Large Burn Wounds Research Articles

Effect of Low-Temperature Argon Plasma and Ultrasonic Cavitation on the Course of Burn Wound Healing

Background: Various physical phenomena come into use in medicine; however, to date, universal physical methods have not been developed to optimize the course of the wound healing at all treatment stages. In combustiology, the first stage of burn treatment is debridement; then it is important to create an optimal biological environment, normalize blood circulation, suppress pathogenic flora, and stimulate proliferative processes in the wound.Objective: To determine the effectiveness of low-temperature argon plasma (LTAP) and ultrasonic cavitation in deep burn wound treatment based on clinical observations and cytological findings.Materials and methods: We studied impression smears from burn wounds of 36 patients with deep burns of various etiologies who were treated using LTAP and ultrasonic cavitation in the Thermal Injuries Unit at the Saint Petersburg I.I. Dzhanelidze Research Institute of Emergency Medicine (Saint Petersburg, Russian Federation) between 2022 and 2023.Results: We found that cytogram findings in the study area changed from the inflammatory type to the regenerative-inflammatory one on day 3-7 when LTAP and ultrasonic cavitation were used, while such change in the control area was observed only after 10 days of treatment. Thanks to the use of LTAP and ultrasound after necrosectomy for deep dermal burns, the wound preparation for autologous skin grafting takes less time than it does with standard methods of local burn wound care. Ultrasonic cavitation should be used in cases of severe exudation and slough, whereas LTAP should be used when reparative processes in a burn wound slow down.Conclusions: Burn wound treatment using ultrasonic cavitation and LTAP enables to prepare the wound surface for autologous skin grafting with a high engraftment rate. The procedure allows to effectively and atraumatically debride the wound and suppress pathogenic microflora. Further research is planned in patients with large deep burn wounds.

The Application of a Synthetic Biodegradable Temporizing Matrix in Extensive Burn Injury: A Unicenter Experience of 175 Cases.

Objectives: Addressing extensive and deep burn wounds poses considerable challenges for both patients and surgeons. The NovoSorb® Biodegradable Temporizing Matrix (BTM) emerged as a novel dermal substitute and has been subjected to evaluation in large burn wound cases, with a specific focus on identifying risk factors associated with suboptimal take rates. Methods: All patients with burn wounds greater than 10% body surface that underwent BTM treatment between March 2020 and November 2023 were eligible for inclusion. Univariate analyses and linear regression models were employed to discern risk factors and predictors influencing the take rates of both the BTM and split-thickness skin grafts (STSGs). Results: A total of 175 patients (mean age 56.2 ± 19.8 years, 70.3% male) were evaluated. The mean take rates of the BTM and STSGs were 82.0 ± 24.7% and 87.3 ± 19.0%, respectively. There were significant negative correlations between BTM take and the number of surgeries before BTM application (r = -0.19, p = 0.01), %TBSA and STSG take (r = -0.36, p = <0.001) and significant positive correlations between BTM and STSG take (r = 0.41, p ≤ 0.001) in addition to NPWT and STSG take (r = 0.21, p = 0.01). Multivariate regression analyses showed that a larger number of surgeries prior to BTM application (OR -3.41, 95% CI -6.82, -0.03, p = 0.04) was associated with poorer BTM take. Allograft treatment before BTM application (OR -14.7, 95% CI -23.0, -6.43,p = 0.01) and failed treatment with STSG before BTM application (OR -20.8, 95% CI -36.3, -5.23, p ≤ 0.01) were associated with poorer STSG take, whereas higher BTM take rates were associated with overall higher STSG take (OR -0.15, 95% 0.05, 0.26, p = 0.01). The Meek technique was used in 24 patients and showed similar take rates (BTM: 76.3 ± 28.0%, p = 0.22; STSG: 80.7 ± 21.1, p = 0.07). Conclusions: This study summarizes our findings on the application of a BTM in the context of large burn wounds. The results demonstrate that successful treatment can be achieved even in patients with extensive burns, resulting in satisfying take rates for both the BTM and STSG. The data underscore the importance of promptly applying a BTM to debrided wounds and indicate good results when using Meek.

20 Large Burn Injury Leads to Pathological Alteration of Hematopoietic Stem and Progenitor Cell Lineage Commitment

20 Large Burn Injury Leads to Pathological Alteration of Hematopoietic Stem and Progenitor Cell Lineage Commitment

Celecoxib to improve scar quality following acute burn injury: Lessons learned after premature termination of a randomised trial

BackgroundPre-clinical studies suggest that non-steroidal anti-inflammatory therapy may reduce acute inflammation and modulate scar formation after burn injury. The objective of this trial was to determine if celecoxib administered soon after acute burn improved scar quality. MethodsA single centre, parallel group, placebo-controlled, randomised, superiority trial. Adults with non-major acute burn injury were eligible for recruitment. Participants within 48 h of admission for acute burn injury received either six weeks of celecoxib 200 mg twice daily or identically packaged placebo capsules. The primary outcome was participant-reported Patient Observer Scar Assessment Scale (POSAS) at day 42 following burn injury. The best possible score using this assessment is 7 and the worst 70. Key safety outcomes included study drug side effects. ResultsRestrictions imposed during the COVID-19 pandemic resulted in slow recruitment and early termination after 59 of the 150 planned participants were enrolled. The primary outcome was available for 21/30 (70 %) participants in the celecoxib arm and for 23/29 (79 %) who received placebo. There was no significant difference in the primary outcome between treatment groups with a mean POSAS of 33.4 (standard deviation 12.7) in the celecoxib arm and 36.9 (13.7) in the control arm giving a difference of −3.49 (95 % CI [-11.57, 4.59], p =.39). Gastrointestinal symptoms occurred in 3/30 (10 %) allocated celecoxib and in none allocated placebo. Secondary outcomes including graft loss and delayed healing were similar between groups. ConclusionsAnti-inflammatory therapy did not improve scar quality. Due to early trial termination and significant loss to follow up these findings should be interpreted cautiously. To improve generalisability and to attain recruitment targets, future trials should apply different approaches to improve participant retention as well as including patients with larger burn injuries and an older population.Trial registration: ACTRN12618000732280.

Sepsis in surgical patients: Burn sepsis

Patients with large burn injuries remain a challenge. The loss of skin barrier integrity and induced immunosuppression after injury increases their vulnerability to infection. Sepsis remains the primary cause of death for burn-injured patients who survive their acute injury and resuscitation. The objective of this work is to describe the current understanding and management of sepsis in the burn-injured patient and newer strategies to approach its management. Current understanding of the systemic inflammatory response to burn injury and sepsis, preventative strategies, and novel research will be discussed. Understanding the origin of burn sepsis from wounds themselves is key to understanding current paradigms. Infection control and management begins from the time of injury and continues throughout the patient’s hospital course. The use of personal protective equipment, burn unit design considerations, and optimization of prevention protocols and catheter care all play a role in burn sepsis prevention and management. The emergence of drug-resistant pathogens poses a particular challenge for burn patients due to the chronicity with which their wounds are sometimes open. The difficulty of systemic antibiotics to reach wounds has underscored the need to anticipate resistant organisms moving forward. Antibiotic strategies and newer approaches, such as phage therapy, will be discussed. Multi-omics approaches to understanding burn sepsis have developed in hopes of identifying patients more susceptible or at risk of developing burn sepsis. As with many aspects of burn care, a multidisciplinary, proactive approach to the management of burn sepsis is key to minimizing the morbidity and mortality associated with this complication.

Auxetic incisions with alternating slit shapes: a promising technique for enhancing synthetic skin grafts expansion

Split thickness skin grafts are widely used in treating burn injuries. To date, with limited availability of donor skin and minimal expansions offered by conventional skin grafting, it is challenging to cover large and severe burns. In this study, novel synthetic skin grafts with alternating slit (AS) shaped cut patterns were developed and tested to evaluate the expansion potentials offered by auxetic or negative Poisson’s ratio structures in skin grafting. A range of auxetic incision patterns were designed with varying unit cell dimensions, and these were projected onto skin using 3D printing. The mechanical properties and digital image correlation of the created synthetic skin grafts were used to determine stress, effective Poisson’s ratio, meshing ratio (MR), and generated strains for strain loadings of up to 150%. The AS graft simulant with equal slit lengths and low slit spacings exhibited the maximum negative Poisson’s effect, expansion, and Mr Expansions were inversely related with the spacing between slits. The lowest value for the MR and highest stress was observed with high spacing, high horizontal slit length, and low vertical slit length. The expansions were highly sensitive to the applied strain, with low strains exhibiting high auxeticity. Such an extensive experimental investigation of the expansion potentials and stress estimations of skin grafts with varying AS dimensional parameters have not been conducted previously. The findings would be crucial for advancing research on mitigation of large burn injuries using high expansion skin grafts.

96 A Quality Improvement Study of Routine Mattress Exchange to Reduce Microbial Recontamination

Abstract Introduction It is industry standard for a patient to maintain a single mattress throughout admission, which may be problematic with burn injuries. Significant burn injuries are high exudate wounds which provide challenging care, including frequent dressing changes and environmental contamination. As part of an infection prevention process improvement (PI) including routine air mattress (AM) exchanges throughout admission, the purpose of this study was to examine microbial contamination of mattresses before and after utilization. Methods This single center, retrospective study was conducted in an ABA-verified burn center. Routine AM exchanges began in November 8, 2020, including logging serial numbers of incoming/outgoing AM and periodic environmental cultures. Pre- and post-occupation AM environmental cultures (EC) (outside and inside the top cover and baffles) were compared with patient culture data. All patients were admitted to the Burn Center. Results During the 91 weeks, a total of 635 AM were exchanged. A total of 34 AM were cultured with 20 (59%) being post- and 14 being the pre-occupation. For the pre-occupation AM cultures, all 14 outer and inner surfaces cultured sterile. Regarding post-occupation AM, 80% had a positive EC of the outside surface, while 58% had positive environmental culture from inside the sealed AM. The median time of AM utilization prior to culturing was 6 (6, 7) days. All microbes isolated from post-occupation AM matched culture data from each patient’s hospital course. There were a total of 42 microbes isolated from environmental swabs taken from the outside cover with the most common: S.epidermidis 38%, S.aureus 14%, and P.aeruginosa 12%. A total of 40 microbes were isolated from inside the sealed AM with the most common: S.epidermidis 25%, Acinetobacter spp. 13%, Enterobacter spp. 10%, and Pseudomonas spp. 10%. There were 5 different EC taken from inside the sealed AM resulting in fungal growth. The 34 EC were taken from AM of 9 patients during the 91 week period. The median age was 48 (22, 66) years with 42 (21.25, 44) %TBSA burned. The median weight was 92 (76, 98) kg with body mass index of 27.47 (23.72, 37.11) kg/m2. Two of the 9 patients were below 20 % TBSA burned (9 and 19.5%) while the remaining 7 patients had greater that 20% TBSA burns. There was an inverse signals between size of burn and amount of wound closure and contamination. Conclusions AM are not impervious to the heavy exudate of patients with large burn injuries. Over time, the mattress becomes contaminated with microorganisms specific to the patient. This study justifies the infection prevention practice of routine mattress exchanges during admission for patients with large, open burn wounds. We do not send patients back from the operatory theater or hydrotherapy with reused dressing. Given these findings mattresses should be no different. Applicability of Research to Practice First study to analyze infectious mitigation potential of routine AM exchanges in burn patients.

37 The Epidemiology of Burn Injury in A Large Southern Geographic Area

Abstract Introduction Given the resource-intense nature of treatment for burn injuries and the knowledge of at-risk populations, a public health approach to reducing individual and societal burden is indicated. To accomplish this, it is critical to understand the regional distribution of these injuries and the risk factors influencing one’s susceptibility to being burned. We hypothesize that there are common sociodemographic trends in burn injuries in a large southern geographic area. Methods Data was retrospectively reviewed for all burn patients admitted between 08/2013 and 12/2021 at a major burn center in a large southern geographic area. Sociodemographic data, burn characteristics and outcomes were analyzed. Patients with isolated inhalation injuries were excluded. One-way ANOVA was used for continuous variables with a P-value &amp;lt; 0.05. Binary logistic regression was used to evaluate independent risk factors for mortality. GIS software mapped injury locations alongside census data to augment statistics with visuospatial analysis. Results 1753 patients were included with an annual incidence rate of 36 per 100,000 person-years. Most were male (68%), Caucasian (60%) and non-Hispanic (67%). The most common etiology was cooking-related (14%), with scald and flame burns collectively making up 80%. Flame burns were significantly larger when compared to scald, electrical and chemical mechanisms (p&amp;lt; 0.05). Those between 19 and 45 years old were the largest age group (40%) with significantly larger burns compared to those 0-18 and 46-64 (p&amp;lt; 0.05), but not those &amp;gt; 65. Non-Hispanic patients had significantly larger burns than their Hispanic counterparts (p&amp;lt; 0.05) but no difference in mortality (p=.306). Patients utilizing Medicare/Medicaid were over three times more likely to die compared to those with commercial insurance. Conclusions In this cohort, male patients are injured at higher rates, however, they do not have more severe burns. The larger burns are distributed in a bimodal fashion between those 19-45 and those &amp;gt; 65, with hispanic ethnicity protective against larger burn injuries. This suggests separate mechanisms mediating larger burns in these two groups, and warrants further investigation. Insurance type, a surrogate for socioeconomic status (SES), is not associated with TBSA or LOS, however it does confer an increase in mortality in those with Medicare/Medicaid. GIS mapping verifies neighborhoods concentrated in more urban areas with lower median household incomes have higher injury rates. This highlights populations worth targeting for injury prevention, namely those between 19 and 45 of lower SES, particularly in the setting of cooking and food preparation. Applicability of Research to Practice Understanding regional trends in burn injury can target prevention efforts and identify at risk populations where further resources might be best allocated to ease the burden of burn injury.

752 Burn Rehab Guidelines Following Application of Cultured Epithelial Autografts For Closure of Large Burn Wounds

Abstract Introduction As the use of CEA by burn surgeons becomes more widespread, the existence of an experienced and dedicated burn therapy team, educated in post-operative care and treatment of CEA, is essential to short and long-term success of patients post-CEA, and their ability to achieve and maintain maximum functional status. Early mobilization of patients is an important aspect of treatment in the BICU, and has demonstrated a positive effect on patient outcomes throughout the continuum of care. However, postoperative treatment practices following application of CEA vary across burn centers, depending on experience and perceptions of CEA fragility and expense. The objective of this case series is to review one burn center’s therapy treatment plan before and after CEA application, and short and long-term outcomes in response to early implementation of therapy interventions. The hypothesis is early mobilization of patients after CEA can be achieved without negative consequence of graft loss. Methods This single-center, retrospective case series utilized electronic chart review to assess patients admitted between Apr '15 and Apr '20 who received CEA. Demographics, injury characteristics, surgical procedures collected. Therapy interventions and outcomes also collected, including postoperative therapy treatment plans, functional status at and following discharge, and occurrence of graft loss and contracture formation. Data collected analyzed with descriptive statistics. Results 8 patients met inclusion criteria for the case series. Median post-operative day for initiating positioning techniques post CEA application was POD0 (0,0); POD6.5 (3.75,7) for active, passive elongation; POD12 (11,15) for out of bed mobilization, functional mobility training; POD25 (17.75,25) for return to treatment in therapy clinic. All 8 patients demonstrated 0% occurence of graft loss and 0% contracture formation; none of the patients required reconstructive surgical procedures as a result of decreased joint mobility. In addition, 6 out of the 8 patients were admitted to the burn-specific inpatient rehab program, and all achieved a functional status of independent community locomotor upon discharge, including return to work and leisure activity. Conclusions Early implementation of therapy interventions by burn therapists trained in post-op treatment of CEA resulted in optimal short and long-term functional patient outcomes following closure with CEA. Early mobilization of patients in the BICU post-CEA did not result in any graft loss related to therapy treatment, despite the increased risk for shearing due to the physiological structure of CEA. 75% of patients reviewed in this case series achieved functional mobility skills required for independent living upon discharge, as well as return to work or leisure activities, after receiving treatment in a burn-specific inpatient rehabilitation facility within the burn center. Applicability of Research to Practice n/a

295 Topical Tranexamic Acid in Burn Surgery – A Randomized Controlled Trial

Abstract Introduction Early excision and grafting of large burn wounds can result in considerable bleeding. Systemic use of tranexamic acid (TXA) generally reduces surgical bleeding by 30-40%, but its safety in burn surgery has not been studied. Topical use may provide a sufficient wound concentration with negligible risk of systemic adverse events. However, it is unclear whether topical use may delay wound re-epithelialization. This pilot double-blinded randomized controlled trial aimed to evaluate the therapeutic potential of topical TXA for reducing blood loss and the effect on wound re-epithelialization in burn surgery. Methods Between Jan 2021 – April 2022, burn patients at a single national burn center who needed at least two separate donor sites for split-thickness skin grafting were included. In total, 36 wound pairs in similar anatomical areas were made in 23 patients. Donor sites were infiltrated with tumescence containing epinephrine before harvesting. Paired wounds were randomized to topical application of standard epinephrine solution, with or without added TXA 25 mg/ml, before coverage with vaseline and dry gauze. Endpoints were time to re-epithelialization and surrogate bleeding estimates defined as net weight gain of dressings per cm2 wound area, bloodstain area per wound area, and visual rating of the amount of blood in dressings on the first postoperative day. Results There was no difference in healing time between wounds. The results trended towards less increase in dressing weight gain per cm2 of wound area in the TXA group, though not significant (p=0.12). However, when dividing the results in two at the median bleeding volume, there was a significant reduction in bleeding in the high-bleed group (p=0.012). Similar observations were made for the other two bleeding endpoints, but the differences did not reach statistical significance. Conclusions Moistening a superficial wound surface with TXA 25 mg/ml does not impair wound re-epithelialization. Topical TXA may reduce bleeding from graft donor sites with low risk of systemic complications. Applicability of Research to Practice This pilot study suggests that topical TXA is of value in reducing bleeding in burn surgery without delaying donor site healing. The effect may be larger in wounds not prepared with epinephrine infiltration. More research is warranted regarding the optimal mode of topical drug delivery and systemic concentrations after topical application in burns. Furthermore, it remains to investigate whether topical TXA affects graft take.

Core temperature responses in well-healed burn survivors during exercise heat stress: effect of cooling modalities

Introduction: Every year, ~150,000 patients are treated in the United States with burn-related injuries. Previously, our group has shown that ~75% of burn survivors have a maximal aerobic capacity in the lowest 20th percentile rankings, relative to sex and age-adjusted non-burned individuals. This level of impairment is strongly associated with cardiovascular-specific, as well as all cause, morbidity, and mortality. Moreover, burn injuries that require grafting impair thermoregulation, and the subsequent increases in skin and core temperature may dissuade these individuals from engaging in exercise and/or physical activity. Low-energy cooling strategies have potential to attenuate increases in core temperature in burn survivors, which may promote regular physical activity. Thus, the purpose of this study was to evaluate the efficacy of low-energy cooling modalities on thermoregulatory responses during physical activity in the heat. Methods: Twenty-four adults with NO-BURN (n = 9), MODERATE burns (20-40% body surface area burned, n = 7), or LARGE burns (&gt; 40% body surface area burned, n = 8) walked for one hour at a moderate intensity (rate of metabolic heat production of 4.5 W/kg body mass) in an environmental chamber (39°C, 40% RH). Burn survivors were at least 2 years post-injury. Participants performed this activity four times, with the following modalities randomly applied throughout each trial on separate days: no cooling (i.e., control), fan at 4 m/s (FAN), water spray (WS, minimum 10-50 g every 5 min, scaled to burn area size), or WS+FAN. Core temperature (Tcore) was recorded throughout each trial via a telemetric pill. Final Tcore values for each cooling modality were compared against the no cooling condition. Results: For the LARGE burn group, WS reduced end-exercise Tcore by 0.37°C (range 0.09 to 0.66°C) compared with no cooling ( p = 0.01). FAN and WS+FAN did not impact end-exercise Tcore for the LARGE burn group ( p ≥ 0.48). No cooling modality affected Tcore for the MODERATE burn group ( p ≥ 0.12) or the NO-BURN group (p ≥ 0.55). Conclusion: At the assessed workload and environmental condition, the efficacy of the applied cooling modalities on Tcore responses for burn survivors appears to be dependent on both the selected modality and the size of the burn surface area. Namely, WS attenuated the increases in Tcore in participants with LARGE burn injuries, but FAN and WS+FAN did not attenuate Tcore responses in any group. Supported by NIHGrant R01GM068865 This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Development of novel hierarchical designs for skin graft simulants with high expansion potential

Skin graft designs play an essential role in healing severe burn injuries. Split-thickness skin grafting (STSG) is one of the commonly used techniques for treating large burn injuries. In STSG, parallel cuts are projected onto a small portion of excised healthy skin for expansion and covering a larger burn area. To date, expansions reported for STSG are very low and insufficient to cover large burn areas. In this work, novel traditional and auxetic hierarchical cuts were designed on skin graft simulants, which were mechanically tested to study their expansion potential. Additive manufacturing and a two-part polymeric material were employed to fabricate the skin graft simulants. The nonlinear mechanical behavior of the hierarchical skin graft simulants was characterized using hyperelastic models. The effective Poisson’s ratio, meshing ratios, and induced stresses in first and second-order hierarchical cut patterns were estimated across all skin graft simulants for up to 300% strain. Also, Statistical analysis was performed to calculate the significance among the groups. From the analysis, the skin graft simulants with second-order auxetic incision patterns were found to exhibit the lowest induced stresses and maximum expansion of approximately four times, at 300% strain. To date, traditional skin grafts have only been able to achieve up to three times expansion. Therefore, the expansions realized with the novel hierarchical skin graft simulants is unprecedented, with the potential to generate ground-breaking advances in burn injury treatment.

High Expansion Auxetic Skin Graft Simulants for Severe Burn Injury Mitigation

Burn injuries are commonly treated with split-thickness skin grafting. However, low expansions offered by spilt-thickness skin grafting inhibit the treatment of large and severe burn injuries when limited donor skin is available. To overcome this gap, in this work, it was attempted to study the expansion potential of skin grafts with novel auxetic incisions with rotating rectangle (RR), honeycomb (HC), alternating slit (AS), H-shaped (HS), Y-shaped (YS), and I-shaped (IS) unit cells, through development of skin graft simulants. Clinically relevant biaxial load testing was conducted to estimate the stress–strain response, void area, and meshing ratio. Moreover, hyperelastic constitutive models were employed to characterize the non-linear biomechanical behavior of the skin graft simulants. The maximum void area increase was observed in the HS skin graft simulant, indicating low skin cover. Overall, the IS auxetic skin graft design exhibited meshing ratio higher than traditional grafts (&gt;3:1), low void area and stresses, which can be beneficial for large skin cover and burn wound healing. With further optimization and clinical tests, the auxetic skin graft designs may find a place with the graft manufacturers for fabrication of grafts with better surgical outcomes for severe burn injuries.

Engineered multi-functional, pro-angiogenic collagen-based scaffolds loaded with endothelial cells promote large deep burn wound healing.

The lack of vascularization associated with deep burns delays the construction of wound beds, increases the risks of infection, and leads to the formation of hypertrophic scars or disfigurement. To address this challenge, we have fabricated a multi-functional pro-angiogenic molecule by grafting integrin αvβ3 ligand LXW7 and collagen-binding peptide (SILY) to a dermatan sulfate (DS) glycosaminoglycan backbone, named LXW7-DS-SILY (LDS), and further employed this to functionalize collagen-based Integra scaffolds. Using a large deep burn wound model in C57/BLK6 mice (8-10weeks old, 26-32g, n = 39), we demonstrated that LDS-modified collagen-based Integra scaffolds loaded with endothelial cells (ECs) accelerate wound healing rate, re-epithelialization, vascularization, and collagen deposition. Specifically, a 2 cm × 3cm full-thickness skin burn wound was created 48h after the burn, and then wounds were treated with four groups of different dressing scaffolds, including Integra + ECs, Integra + LDS, and Integra + LDS + ECs with Integra-only as the control. Digital photos were taken for wound healing measurement on post-treatment days 1, 7, 14, 21, 28, and 35. Post-treatment photos revealed that treatment with the Intgera + LDS + ECs scaffold exhibited a higher wound healing rate in the proliferation phase. Histology results showed significantly increased re-epithelialization, increased collagen deposition, increased thin and mixed collagen fiber content, increased angiogenesis, and shorter wound length within the Integra + LDS + ECs group at Day 35. On Day 14, the Integra + LDS + ECs group showed the same trend. The relative proportions of collagen changed from Day 14 to Day 35 in the Integra + LDS + ECs and Integra + ECs groups demonstrated decreased thick collagen fiber deposition and greater thin and mixed collagen fiber deposition. LDS-modified Integra scaffolds represent a promising novel treatment to accelerate deep burn wound healing, thereby potentially reducing the morbidity associated with open burn wounds. These scaffolds can also potentially reduce the need for autografting and morbidity in patients with already limited areas of harvestable skin.

A textile device for the therapy of patients with burn wounds by the use of a drug delivery from a hydrogel to dermis

The paper proposes a textile device for patients with large area burn wounds consisting of an assembly made up of a knitted backing layer, a hydrogel, with an antibiotic content, as a second layer and a membrane with controlled porosity located directly at the interface with the wound. The knit is the material support with a supporting clothing role, but also as a solution tank. The hydrogel has a keratin structure obtained from human hair with advanced swelling capacity and porosity. The study proposes the use of silver sulfadiazine (SSD), an antibiotic used in the topical therapy of burn wounds. The work optimizes the degree of swelling, evaluates the porosity of the hydrogel and designs the support garment for wound therapy. The optimal parameters to obtain the maximal swelling degree are: duration of hydrolytic reaction 180 min, volume of hydrogen peroxide 3.7 mL and duration of oxidation 90–125 min. Based on these optimal parameters one can obtain swelling degrees higher than 1000%. The device proposed is reusable and supports the SSD diffusion to wound.

Advances in Skin Tissue Engineering and Regenerative Medicine.

There are an estimated 500,000 patients treated with full-thickness wounds in the United States every year. Fire-related burn injuries are among the most common and devastating types of wounds that require advanced clinical treatment. Autologous split-thickness skin grafting is the clinical gold standard for the treatment of large burn wounds. However, skin grafting has several limitations, particularly in large burn wounds, where there may be a limited area of non-wounded skin to use for grafting. Non-cellular dermal substitutes have been developed but have their own challenges; they are expensive to produce, may require immunosuppression depending on design and allogenic cell inclusion. There is a need for more advanced treatments for devastating burns and wounds. This manuscript provides a brief overview of some recent advances in wound care, including the use of advanced biomaterials, cell-based therapies for wound healing, biological skin substitutes, biological scaffolds, spray on skin and skin bioprinting. Finally, we provide insight into the future of wound care and technological areas that need to be addressed to support the development and incorporation of these technologies.

Comparative effectiveness analysis of deep low heat burns in the shin surgical approaches: Outcomes and cost for wound rehabilitation.

A variety of surgical techniques exist for deep burn wounds in the shin at low temperature reconstruction after appropriate debridement, but limited high-quality data exist to inform treatment strategies. Using multi-institutional data, the authors evaluated the length of healing time, cost, and outcomes of three common surgical reconstructive modalities. All subjects with deep burn wounds in the shin caused by low temperature who received direct suture repair, skin grafting, or local flap reconstruction were retrospectively reviewed (from 2015.01 to 2021.03). Mean operation time, mean blood loss in operation, postoperative healing time, whether there is scar depression after operation were the primary outcomes; patient satisfaction score, Vancouver scar scale (VSS) score and average costs were secondary outcomes. Two hundred subjects (68 suture, 87 skin-grafting, and 45 local flap coverage patients) were evaluated. Matched patients (n=200; 3/groups) were analysed. The average operation time, average operation blood loss, and postoperative healing time were statistically significant differences (P< 0.05). Readmissions and reoperations were greater for direct suture and local flaps, if achievable, direct suture provided success at low cost. Skin grafting was effective with large burn wounds but at higher costs and longer length of stay. Local flaps successfully treated smaller burn wounds unable to suture directly, with less pigmentation and scars, even suitable for older patients. Deep low heat burn wounds in the shin healing can be performed effectively using multiple modalities with varying degrees of success and costs. Direct suture or local skin flap reconstruction, if achievable, provides successful coverage at minimal costs, no skin contractures, and reducing length of hospital stay.

456: A CHALLENGING CASE OF RAPID-ONSET MULTISYSTEM ORGAN FAILURE IN A BURN PATIENT

Introduction: Burns are significant injuries that cause a cascade of inflammatory responses. Patients with large burns and inhalation injury often experience respiratory failure, renal failure, liver dysfunction, and sepsis. The COVID-19 virus has added a unique challenge as a current or recent COVID-19 infection seems to lend to worse outcomes, However, we do not yet have enough data to understand the full implication of COVID-19 on burn patients. Description: A 41-year-old man with no remarkable medical history was admitted to the Burn Intensive Care Unit (BICU) with 58% body surface area burns with smoke inhalation. He was given appropriate burn resuscitation and placed on the volumetric diffusive respirator (VDR). Admission COVID-19 PCR was negative, and COVID-19 Spike IgG was 12 IU/mL. Both labs and vital signs remained stable and he went to the OR on hospital day 4 for excision and grafting and the first 24 hours post-op were unremarkable. On post-op day 1, he had an abrupt rise in lactate with worsening acidosis. Sepsis guidelines were followed and he required initiation of renal replacement therapy (CRRT) along with bedside laparotomy with no significant findings. Repeat lab work showed a COVID-19 Spike IgG level >800. Patient’s conditioned worsened despite maximal medical intervention, and he died on hospital day 8. Since the sudden, rapid decline in patient’s condition at this point in his hospitalization is somewhat atypical, we theorize that patient was either admitted with COVID-19 infection that was undetectable, or this was a nosocomial infection. Though he had no significant comorbidities, it certainly seems that this new infection unduly stressed his immune system, leading to multi-system organ failure and death. Discussion: Large burn injuries are often challenging to manage, but improved therapies and treatments have led to increasingly good outcomes. The addition of current or recent COVID-19 infection adds a new challenge which needs further study as we learn more about the inflammatory and long-term implications of this disease on lung function and immune systems. Our experience of rapid onset organ failure and death in a burn patient with likely new COVID-19 infection presented a unique burn and critical care management challenge that needs further study.

Antibacterial silk sericin/poly (vinyl alcohol) hydrogel with antifungal property for potential infected large burn wound healing: Systemic evaluation

Hydrogel-based burn wound dressings with excellent antibacterial, antifungal, and mechanical properties are ideal biomaterials to promote infected large burn wound healing. In this study, the hydrogel synthesized by repetitive freezing-thawing consists of poly (vinyl alcohol) (PVA), silk sericin (SS), and azithromycin (AZM), with genipin (GNP) as crosslinker. The FTIR showed that all hydrogel components were successfully blended. The swelling ratio, porosity, cell attachment, and proliferation improved with SS incorporation, while increased PVA content enhanced the mechanical performance of the hydrogel. The inclusion of AZM improved the antimicrobial property of the hydrogel towards Staphylococcus aureus, Pseudomonas aeruginosa, Escherichia coli, and Candida albicans. The hydrogel showed sustained SS and AZM releases as well as cytocompatibility on keratinocytes and fibroblasts. Furthermore, the hydrogel displays skin adhesion ability when freeze-dried. In the in vivo study using an infected mouse full-thickness burn model with a 10% total body surface area, it was shown that burn injury led to increased inflammatory cytokine responses and macroscopic and microscopic alterations in the spleen and liver. The kidneys, on the other hand, revealed neither change. Interestingly, the prepared hydrogel had a better burn wound healing effect than the commercial Tegaderm™ film dressing, minimizing systemic burn effects. Hence, this novel hydrogel is projected to be a promising candidate for accelerated healing of infected burn wounds.

Evidence for Chronotropic Incompetence in Well-healed Burn Survivors.

Due to various pathophysiological responses associated with a severe burn injury, we hypothesized that burn survivors exhibit chronotropic incompetence. To test this hypothesis, a graded peak oxygen consumption (V̇O2peak) test was performed in 94 adults (34 nonburned, 31 burn survivors with 14-35% body surface area grafted, and 29 burn survivors with >35% body surface area grafted). The threshold of 35% body surface area grafted was determined by receiver operating characteristic (ROC) curve analysis. Peak exercise heart rates (HRmax) were compared against age-predicted HRmax within each group. The proportion of individuals not meeting their age-predicted HRmax (within 5 b/min) were compared between groups. Age-predicted HRmax was not different from measured HRmax in the nonburned and moderate burn groups (P = .09 and .22, respectively). However, measured HRmax was 10 ± 6 b/min lower than the age-predicted HRmax in those with a large burn injury (P < .001). While 56 and 65% of individuals in the nonburned and moderate burn group achieved a measured HRmax within 5 b/min or greater of age-predicted HRmax, only 21% of those in the large burn group met this criterion (P < .001). These data provide preliminary evidence of chronotropic incompetence in individuals with severe burn injury covering >35% body surface area.