Major Burn Patients Research Articles

A modified culture strategy of human keratinocytes to shorten the primary culture time.

Shortening time from biopsy to graft preparation is crucial for the coverage of extensive burn wound in major burn patients. This study was aimed to shorten the culture time of keratinocytes by means of one modified cell culture method. Three factors (temperature of dispase, area of skin, and age of patient) that might have impacts on cell behavior were evaluated. The results showed that cells isolated with dispase at 37°C exhibited an improved cell activity than being isolated at 4°C. The time that cells reached subconfluence with various skin areas was in order of 3 cm(2) < 2 cm(2) < 1 cm(2) (120.07 ± 5.03 h, 141.33 ± 4.16 h, and 193.33 ± 6.11 h, respectively). Furthermore, compared with the young and middle-aged groups, proliferation of keratinocytes isolated from children skin tissue was better. These results indicated that 3 cm(2) skin biopsy from a young patient, isolated with dispase at 37°C, was a promising strategy to shorten the cultivation of keratinocytes.

Uso de sugamadex no paciente queimado: estudo descritivo

ObjectivesThe burn patient is a challenge for the anesthesiologist, undergoing several surgeries during admission, and requiring general anesthesia and muscle relaxation most of the times. They have respiratory system impairment and a response to muscle relaxants that differs from the healthy patient, thus proper monitoring and reversal is crucial. We analyzed sugammadex effectiveness and safety in this population. Material and methodsProspectively descriptive study including four patients, all of them considered major burn patients, who underwent escharotomy with general anesthesia and neuromuscular relaxation. The main variable was the time for recovery of a TOF higher than 0.9 after the administration of sugammadex before extubation. ResultsMean time of recovery from a TOF ratio higher than 0.9 following the administration of Sugammadex was of 4.95minutes 95% CI (3.25‐6.64, p=.53); ConclusionsThe reversion of neuromuscular relaxation with sugammadex appears to be effective and safe in the burn patient. More analytical, comparative studies, of larger populations would be necessary to confirm this data.

Use of sugammadex on burn patients: descriptive study

ObjectivesA burn patient is a challenge for any anesthesiologist, undergoing several surgeries during admission, and requiring general anesthesia and muscle relaxation most of the times. The victim may have respiratory system impairment and a response to muscle relaxants that differs from the healthy patient, thus proper monitoring and reversal is crucial. We analyzed sugammadex effectiveness and safety in this population. Materials and methodsIt was a prospectively descriptive study, including 4 patients, and all of them were considered major burn patients, who underwent escharotomy with general anesthesia and neuromuscular relaxation. The main variable was the time for recovery of a TOF higher than 0.9 after the administration of sugammadex before extubation. ResultsMean time of recovery from a TOF ratio higher than 0.9 following the administration of Sugammadex was of 4.95min 95% CI (3.25–6.64, p=.53). ConclusionsThe reversion of neuromuscular relaxation with sugammadex appears to be effective and safe in the burn patient. More analytical, comparative studies of larger populations would be necessary to confirm these data.

El reto de las transferencias de colgajos libres en pacientes quemados: ¿cuál es el momento para la cirugía?

Free flap transfer is an essential tool within the reconstructive repertoire for the surgical treatment of major burn patients. For a long time there has bee...

Serum cystatin C and microalbuminuria in burn patients with acute kidney injury.

This study was aimed at evaluating the effectiveness of serum cystatin C and microalbuminuria as diagnostic markers for acute kidney injury (AKI) in major burn patients. Major burn adult patients admitted to the burn intensive care unit within 24 h from the onset of injury were enrolled. Serum cystatin C and microalbuminuria (albumin-creatinine ratio, ACR) were obtained at postburn days 1, 3, 7, 14, 21 and 28. The patients were divided into two groups of the AKI group and the nonacute kidney injury group. A total of 97 patients were enrolled in this study. Acute kidney injury was diagnosed in 40 patients (41.2%) at postburn day 17.3 ± 7.9. The area under the curve of the receiver operating characteristic curve for serum cystatin C was 0.808 (95% CI, 0.711-0.905, P < 0.001) at postburn day 7 and 0.908 (95% CI, 0.843-0.973, P < 0.001) at postburn day 14. The results were 0.610 (95% CI, 0.497-0.724, P = 0.069) for ACR at postburn day 7 and 0.694 (95% CI, 0.589-0.798, P = 0.001) at postburn day 14. The optimal cut-off value of serum cystatin C at postburn day 14 and ACR at postburn day 14 were 0.85 mg/L (sensitivity, 89.5%; specificity, 82.5%) and 41.51 mg/g cre (sensitivity, 60.5%; specificity, 61.4%), respectively. Serum cystatin C at postburn day 14 was the only significant factor in relation to AKI. Serum cystatin C is a valuable diagnostic marker, whereas microalbuminuria is a relatively less significant marker for AKI in major burn patients.

Utilización del sugammadex en el paciente quemado: estudio descriptivo

ObjectivesThe burn patient is a challenge for the anesthesiologist, undergoing several surgeries during admission, and requiring general anesthesia and muscle relaxation most of the times. They have respiratory system impairment and a response to muscle relaxants that differs from the healthy patient, thus proper monitoring and reversal is crucial. We analyzed sugammadex effectiveness and safety in this population. Material and methodsProspectively descriptive study including 4 patients, all of them considered major burn patients, who underwent escharotomy with general anesthesia and neuromuscular relaxation. The main variable was the time for recovery of a TOF higher than 0.9 after the administration of sugammadex before extubation. ResultsMean time of recovery from a TOF ratio higher than 0.9 following the administration of Sugammadex was of 4.95min 95% CI (3.25-6.64, P=.53); Conclusionsthe reversion of neuromuscular relaxation with sugammadex appears to be effective and safe in the burn patient. More analytical, comparative studies, of larger populations would be necessary to confirm this data.

A novel subpopulation of peripheral blood mononuclear cells presents in major burn patients

Hypertrophic scars (HTS) are generally believed to result from proliferation and activation of resident connective tissue fibroblasts after burns. To demonstrate a potential role of blood-borne cells, the peripheral blood mononuclear cells (PBMCs) and the effect of PBMCs on dermal fibroblast behavior was investigated.Flow cytometry was used to analyze the surface and intracellular protein expression of PBMCs and fibroblasts. Transwell migration assay, enzyme-linked immunosorbent assay and real-time reverse transcription polymerase chain reaction was performed to assess fibroblast functions.We identified a novel subpopulation of PBMCs in burn patients in vivo that appears at an early stage following major thermal injuries, which primarily express procollagen 1, leukocyte specific protein 1, CD204, toll-like receptor 4 and stromal cell-derived factor 1 (SDF-1) receptor CXCR4. In vitro, the conditioned media from burn patient PBMCs up-regulated the expression of fibrotic growth factors and extracellular matrix molecules, down-regulated antifibrotic factor decorin, enhanced cell chemotaxis and promoted cell differentiation into contractile myofibroblasts in dermal fibroblasts.After thermal injury, this novel subpopulation of PBMCs is systemically triggered and attracted to the wounds under SDF-1/CXCR4 signaling where they appear to modulate the functions of resident connective tissue cells and thus contribute to the development of HTS.

Clinical differences between major burns patients deemed survivable and non-survivable on admission

IntroductionDespite advances in burn care, there is still a group of patients with serious burn injury who fail to respond to therapies or for whom active treatments are unsuccessful. As the demographic and causative factors of burn related mortality may differ between treating units and countries, we aimed to investigate clinical aspects of patients that die whose injuries are considered either survivable or non-survivable on admission. MethodsA retrospective 11-year medical record review (2000–2011) of patients admitted to the Victorian Adult Burns Service (VABS), Melbourne, Australia, with a fatal burn injury was undertaken. Patient characteristics such as age, gender, total body surface area (TBSA%) burned, type and site of burn, hospital length of stay, receipt of burn care treatments and when withdrawal of care (WOC) took place were identified using hospital databases. For the purposes of categorization, two categories of patients were defined retrospectively. ‘Early WOC’ patients were those for whom a decision was made within the first 24h following admission that a patient injury was likely non-survivable, or that survival was incompatible with a meaningful quality of life. ‘Late WOC’ patients were those patients for whom a decision was made within the first 24h following admission that a patient injury was survivable and potentially compatible with a meaningful quality of life. ResultsIn a study analyzing 70 patients, the average TBSA% burned in the ‘Early WOC’ group (n=43) was significantly higher with the ‘Late WOC’ cohort (n=27) (85% vs. 45%; p=0.001) compared. A higher incidence of accelerant use (60% vs. 35%; p=0.07) and facial burns (74% vs. 44%; p=0.02) was found in the ‘Early WOC’ patients. In the ‘Late WOC’ group, 92.6% of patients required mechanical ventilation and 78.6% of patients underwent operative intervention (median surgical time 9.25h, inter-quartile range 6.5–18.5). ConclusionA number of clinical differences in major burn patients can be observed at admission between patients for whom a decision is made as to whether an injury is survivable or non-survivable. These differences may influence the degree of therapeutic aggression or conservatism as determined by the treating clinical team. As a matter of maintaining standards amongst the burns community, reporting mortality data such as this may also provide a benchmark by which other burns units can assess their own data regarding end-of-life decision-making.

Evaluation of diagnostic biomarkers for acute kidney injury in major burn patients.

PurposeAcute kidney injury (AKI) in major burn patients is a common complication with high morbidity and mortality. The mainstream treatment is early diagnosis and rapid termination and prevention of the underlying insult. Therefore, it's essential to identify early biomarkers predicting AKI.MethodsA total of 85 patients who were admitted to the burn intensive care unit from June 2012 to July 2013 were included in this prospective cohort study. Ten biomarkers (blood urea nitrogen, serum creatinine, urine creatinine, cystatin C, cystatin C glomerular filtration rate, AST, lacate dehydrogenase [LD], creatine kinase, lactic acid, and myoglobin) were obtained at time of admission and evaluated as diagnostic biomarkers to predicting AKI and early AKI.ResultsOut of 85 patients, 35 patients were dead and overall mortality was 41.2%. The mean age was 49.4 years and mean percentage of total body surface area was 53.2%. Area under the curve (AUC) of receiver operating characteristic curve of biomarkers on predicting AKI were 0.746, 0.718, and 0.717 in LD, lactic acid, and serum creatinine, respectively. AUC of cystatin C predicting AKI was much lower at 0.555. AUC of biomarkers on predicting early AKI were 0.833, 0.816, 0.790, and 0.759 in LD, serum creatinine, AST, and serum myoglobin.ConclusionLD, lactic acid and serum creatinine were acceptable as diagnostic biomarkers of AKI and LD, serum creatinine, AST, and serum myoglobin were reasonable as diagnostic biomarkers of early AKI. However, cystatin C was an unfavorable biomarker in major burn patients.

The Brief Fatigue Inventory is reliable and valid for the burn patient cohort

ObjectiveAfter burn, patients are at risk of fatigue which may influence negatively their capacity to participate in activity, rehabilitation and other treatments. Fatigue may stem from the wound healing and systemic responses to burn which drive a hypermetabolic state that may persist for months. However, an established method is not available for objectively measuring fatigue after burns. The Brief Fatigue Inventory (BFI) was hypothesised to be an appropriate option for assessments following severe burn. The primary aim of the study was to establish if the BFI was reliable and valid in a burn patient sample. MethodsAdult patients admitted between 2009 and 2013 to Royal Perth Hospital Burn Center were included. Patients completed the BFI and Burns Specific Health Scale Brief (BSHS-B) in tandem at one, three, six and 12 months after burn. Reliability was assessed using Cronbach's alpha; construct validity using factor analysis and multi-variable regression of BFI; and, criterion validity with longitudinal regression of BFI with BSHS-B. ResultsThe sample (n=587) had a median TBSA of 3% (range=<1–75%). The BFI demonstrated excellent reliability (α>0.90). The factor analysis confirmed a single-domain construct, centred around the first scale item. Good correlation between BFI and BSHS-B scores (p<0.001) on longitudinal analysis confirmed criterion validity. There was a significant difference in fatigue scores between minor and major burn patients and a significant association of fatigue levels over time with TBSA. ConclusionThe BFI is a reliable and valid tool for fatigue measurement in patients during the first 12 months after burn.

Nursing research on a first aid model of double personnel for major burn patients.

This study explored the effect of a first aid model employing two nurses on the efficient rescue operation time and the efficient resuscitation time for major burn patients. A two-nurse model of first aid was designed for major burn patients. The model includes a division of labor between the first aid nurses and the re-organization of emergency carts. The clinical effectiveness of the process was examined in a retrospective chart review of 156 cases of major burn patients, experiencing shock and low blood volume, who were admitted to the intensive care unit of the department of burn surgery between November 2009 and June 2013. Of the 156 major burn cases, 87 patients who received first aid using the double personnel model were assigned to the test group and the 69 patients who received first aid using the standard first aid model were assigned to the control group. The efficient rescue operation time and the efficient resuscitation time for the patients were compared between the two groups. Student's t tests were used to the compare the mean difference between the groups. Statistically significant differences between the two groups were found on both measures (P's < 0.05), with the test group having lower times than the control group. The efficient rescue operation time was 14.90 ± 3.31 min in the test group and 30.42 ± 5.65 min in the control group. The efficient resuscitation time was 7.4 ± 3.2 h in the test group and 9.5 ± 2.7 h in the control group. A two-nurse first aid model based on scientifically validated procedures and a reasonable division of labor can shorten the efficient rescue operation time and the efficient resuscitation time for major burn patients. Given these findings, the model appears to be worthy of clinical application.

Epidemiological trends and risk factors in major burns patients in South Korea: A 10-year experience

PurposeTo determine epidemiological trends among burns patients admitted to our burns center during 2003–2012, and the usefulness of the Abbreviated Burns Severity Index (ABSI) for predicting burns-related mortality. MethodsWe retrospectively reviewed the data of 4481 burns patients. We analyzed the epidemiological trends and ABSI scores using Student t-test and one-way analysis of variance (continuous variables), chi-square test (categorical variables) and stepwise logistic-regression analysis (predictors of mortality). ResultsThe mean age and male-to-female ratio were 39.9±19.7 years and 2.88, respectively. ABSI scores decreased from 7.7±3.0 in 2003 to 6.9±3.0 in 2012. Mortality rate improved from 24.5% in 2003 to 15.8% in 2012. Burns were caused by flames (67.3%), scalding (22.0%) and electrical (7.5%), chemical (1.6%) and contact (1.5%) injuries. Scalding and flames were the most common causes in patients aged ≤20 years and ≥21 years, respectively. Female sex, inhalation injury, full-thickness burns, large total body surface area (TBSA) burned and old age predicted mortality. ABSI scores <4 and >14 were associated with 0.7% and >90% mortality, respectively. ConclusionsThe mortality of major burns has decreased but remains high. ABSI scores predict burns-related mortality.

Comparing mortality outcomes of major burns and toxic epidermal necrolysis in a tertiary burns centre

IntroductionOur aim was to provide descriptive information to burn clinicians, who have extensive experience treating major burns and determining prognosis, as to whether significant differences in mortality exist between major burns injuries and the comparatively less common toxic epidermal necrolysis for a given age and total body surface area percentage. MethodsRetrospective data was analyzed of all deceased patients admitted to the Victorian Adult Burns Service in Melbourne, Australia over a period of 10 years with greater than 30% total body surface area burned or greater than 30% total body surface area epidermal detachment in the case of toxic epidermal necrolysis. Retrospective data was also collected on all patients, survivors and deceased, with toxic epidermal necrolysis and these patients were matched with burns patients by age and % total body surface area burned. Comparisons in outcomes were performed with mortality being the primary variable of interest. ResultsToxic epidermal necrolysis patients that died were older (median: 68.5 vs 57 yrs; P=0.04), had a longer length of hospital stay (36.5 vs 0.8 days; P=0.001) and significantly longer periods of mechanical ventilation (1404 vs 14.5h; P=0.011) than major burns patients that died. When toxic epidermal necrolysis patients were matched to major burns patients by age and total body surface area burned, there were no significant differences between the two groups with respect to mortality. ConclusionPalliative care approaches are more frequently administered at the time of presentation for major burns patients in comparison to toxic epidermal necrolysis patients. This may be due to a perception that if toxic epidermal necrolysis patients can survive their initial systemic injury, they are likely to survive, as opposed to major burns patients who often undergo extensive surgery and for whom other factors should be taken into account in the context of end-of-life decision making.

Guideline for diagnosis, prophylaxis and treatment of invasive fungal infection post burn injury in China 2013.

Invasive fungal infection is one of the major complication of severe burns which can induce local or systemic inflammatory response and cause serious substantial damage to the patient. The incidence of fungal infection for burn victims is increasing dramatically during recent years. This guideline, organized by Chinese Society of Burn Surgeons, aims to standardize the diagnosis, prevention and treatment of burn invasive fungal infection. It can be used as one of the tools for treatment of major burn patients.

Outcome analysis of major burn patients after admission to the burns intensive care unit in a tertiary regional referral center

Outcome analysis of major burn patients after admission to the burns intensive care unit in a tertiary regional referral center

Le glottiscope AWS-Pentax™, alternative à la fibroscopie dans deux cas d’intubation difficile prévue du brûlé grave

Intubating patients with facial burn is difficult to most anesthesiologists. Awake flexible fiberoptic intubation is the gold standard for management of anticipated difficult tracheal intubation. However, serious facial burn and dysmorphic syndrome can make fiberoptic intubation more difficult or impossible. We report the use of awake oral intubation using the Pentax-Airway Scope (AWS) in two major burn patients with facial injury, in whom awake fiberoptic intubation was impossible. As shown in morbidly obese patient and in patients with unstable necks, AWS could be useful to facilitate tracheal intubation in awake, facial burn patients presenting with a potentially difficult airway. Awake AWS intubation seems as a potential alternative to awake fiberoptic intubation.

The prevalence of human endogenous retroviruses in the plasma of major burn patients

BackgroundApproximately 8% of the human genome is composed of retroviral sequences, which are known as human endogenous retroviruses (HERVs) and, have been implicated in both health status and disease. Recently, indirect evidence for a possible role of retroviral elements in the systemic response to stress signals has been provided by several studies. In the present study, we sought to evaluate the relationship between HERVs and major burn in humans. MethodWe investigated the prevalence of HERV families by reverse transcriptase PCR (RT-PCR) in cell-free plasma samples from patients with burns and from normal individuals. ResultsDifferent prevalences of HERV families were observed in the plasma samples from the burn patient group and normal group. Compared with the prevalences of HERV-W and HERV-K in the normal group, in the burn patient group, the prevalence of HERV-W was significantly lower (P<0.001), but the prevalence of HERV-K was higher (P=0.059). ConclusionsOur study of the prevalences of HERVs revealed that the activation of certain HERV families may be influenced not only by burns but also by the initial treatments that were used to address these injuries.

Population pharmacokinetic analysis of fluconazole to predict therapeutic outcome in burn patients with Candida infection.

The pharmacokinetic (PK) property of fluconazole might be significantly altered in major burn patients by medical interventions and physiologic changes. In this study, our aims were to investigate fluconazole PK in burn patients using a population approach and to recommend the optimal fluconazole regimen based upon the predicted therapeutic outcome. At steady state, blood samples for PK analysis were obtained from 60 burn patients receiving between 100 and ~400 mg fluconazole daily. A mixed-effect modeling was performed and the therapeutic outcome of antifungal therapy was predicted for 10,000 virtual patients using NONMEM (version 7.2). MIC values were sampled from the MIC distribution at the study site. An area under the free drug concentration-time curve (fAUC)/MIC measurement of >25 h was used as the criterion for therapeutic success. When the same dose was given, the plasma concentration of fluconazole was predicted to be lower in burn patients compared to the nonburn population because of the large PK parameter (clearance, volume of distribution) estimates and continuous renal replacement therapy (CRRT). This tendency was particularly predominant when the patients were within 30 postburn days. Based upon our findings, 400 mg/day fluconazole is recommended to obtain therapeutic successes in major burn patients.

Enzymatic debridement of large burn wounds with papain–urea: Is it safe?

IntroductionEnzymatic debridement is a method by which burn wounds can be prepared for coverage by skin grafts in patients presenting late. Many agents have been used in the past but none of them have been thoroughly evaluated. The present study was undertaken to assess the efficacy of Debridace, a commonly available debriding agent with papain and urea as its constituents. Material and methodsA prospective descriptive study design was used to evaluate our experience. Almost symmetrical areas of the burnt surface were assessed and used for comparison. On one half of the wound, Debridace was applied while on the other silver sulphadiazine was used. The primary end point of this study was the extent of the achieved debridement at the end of the study period. Secondary outcomes were the presence of adverse effects such as pain and fever. All patients with sepsis were excluded from the study. ResultsThe age of the subjects ranged from 9 to 80 years with an SD of 16. Large areas ranging from 5% to 20% body surface area with an SD of 4.27 were debrided by Debridace. Only two patients (3.33%) could complete the study. The rest of the recruited patients either had high fever (63.33%), excruciating pain (13.33%) or both (16.66%), which brought an end to enzymatic debridement. ConclusionDebridace, a papain–urea product, cannot be considered safe as an enzymatic debriding agent in its present form for use in major burn patients who present late with deep burn wounds that are large in size.

Multiple Organ Dysfunction Syndrome In Major Burns Patients

Organ dysfunctions are frequent after major burn trauma. Development of MODS in severely burned patients is highly fatal. The present study was conducted to elucidate the etiology and quantify the Multiple Organ Dysfunction (MODS) in major burn patients. “Multiple organ dysfunctions in major burnt patients” was a prospective analytic study. A total of thirty patients were included in the study, which was conducted in the Burn and Plastic Surgery unit, Bir Hospital, Kathmondu, Nepal over the period of eighteen months from January 2002 to June 2003. Patients with acute major burn i.e. 24 hours from the time of injury were admitted and included in the study. All patients were initially treated in the ICU of burn unit. Among 30 patients, 25 patients were in the age group 15-30 years and 5 patients were in the 31- 60 years age group. 12 patients were male and 18 were female. 93.3% of patients in this study had sustained flame burn and the chief mode of burn injury was accidental 50% whereas 46.7% were suicidal. 66.7% of the patients had 20% - 50%TBSA and 33.3% had sustained 50% - 90% TBSA burn. Majority of the patients were under went early excision and SSG with regular dressing. 63.3 % (19 patients) develop multiple organ dysfunctions and most frequently involved organ was kidneys and followed by lungs, liver and pancreas. Among the multiple organ failure patients, 10 had developed septicemia. None of the patients were found to have developed cardiac failure. The mortality in the study population was 46.7%, all of them had MODS and 9 of them had inhalation injury. It was also seen that MODS can Medicine Today 2010 Volume 22 Number 02 Page 75-79 DOI: http://dx.doi.org/10.3329/medtoday.v22i2.12438