Mean Burn Size Research Articles

Risk factors and the associated limit values for abnormal elevation of extravascular lung water in severely burned adults

BackgroundIncreased extravascular lung water (EVLW) correlates with pulmonary morbidity and mortality in critical illness. The extravascular lung water index (EVLWI), which reflects the degree of EVLW in an individual, increases in the fluid reabsorption stage rather than the initial resuscitation stage in severe burn cases. While many factors contribute to EVLWI variation, the risk factors contributing to its abnormal elevation in severe burns remain unclear. The aim of this study was to identify the risk factors and associated limit values for abnormal elevation of EVLWI during the fluid reabsorption stage in a cohort of severely burned adults. MethodThis prospective, single-center study included only adults with burn sizes≥50% of the total body surface area (TBSA) who were admitted within 24h after burn. Demographic data were collected, and transpulmonary thermodilution (TPTD) measurements and blood biochemistry tests were performed upon admission and up to day (PBD) 9. Risk factors for abnormal EVLWI were analyzed by logistic regression. Receiver operating characteristic (ROC) curves were constructed to determine the optimal cut-offs for each risk factor. ResultsSeventy-two patients were ultimately enrolled, with a mean age of 40.3 years and mean burn size of 69.4% TBSA. EVLWI began to abnormally increase (>7ml/kg) on day 3 and up to PBD 9, indicating that a supranormal EVLWI developed in the fluid reabsorption stage. Several relevant factors were considered, including patient age, burn size, intrathoracic blood volume index (ITBVI), pulmonary vascular permeability index (PVPI), cardiac index (CI), systemic vascular resistance index (SVRI), serum albumin, time of first excision and grafting, and number of operations and daily fluid administration. Among these factors, we found that only burn size and ITBVI were significantly correlated with EVLWI variation and were further identified as the independent risk factors for EVLWI abnormality. ROC analysis showed that the limits for predicting a supranormal EVLWI during the fluid reabsorption stage were 65.5% TBSA for burn size and 845ml/m2 for ITBVI. Patients with burn sizes or ITBVIs higher than the limit showed significantly longer mechanical ventilation time and substantially higher occurrences of acute respiratory distress syndrome (ARDS) and pneumonia within two weeks after burn. ConclusionsBurn size and ITBVI are the independent risk factors for EVLWI abnormality during the fluid reabsorption stage in severely burned adults. The limit values for predicting a supranormal EVLWI in those patients are 65.5% TBSA for burn size and 845ml/m2 for ITBVI.

Virtual reality analgesia for burn joint flexibility: A randomized controlled trial.

We conducted a randomized controlled study to determine the effects of virtual reality (VR) distraction on pain and range of motion (ROM) in patients hospitalized for burn care during active physical therapy exercises. Thirty-nine participants aged 15 to 66 (M = 36) years with significant burn injuries (mean burn size = 14% TBSA) participated. Under therapist supervision, using a within-subjects design, participants performed unassisted active ROM exercises both with and without VR distraction in a randomized order. Therapists provided participants with instructions but did not physically assist with stretches. Maximum active ROM was measured using a goniometer. A 0-100 Graphic Rating Scale (GRS) was used to assess the cognitive, affective, and sensory components of pain. A GRS rating of the amount of "fun" during stretching served as a measure of positive experience. Participants reported lower mean GRS ratings during VR, relative to No VR, for worst pain, pain unpleasantness, and time spent thinking about pain. They also reported having a more positive experience during VR than during No VR. However, patients did not show greater ROM during VR. Immersive VR reduced pain during ROM exercises that were under the control of the patient. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Identification of Cytochrome P450 Polymorphisms in Burn Patients and Impact on Fentanyl Pharmacokinetics: A Pilot Study.

Pain management is critical for burn care. Unfortunately, interindividual variation in pharmacokinetics (PK) due to burn hypermetabolism and genetic polymorphisms can lead to treatment failures in this at-risk population. Analgesics may be affected by genetic polymorphisms affecting cytochrome P450 (CYP) drug metabolizing enzymes. Fentanyl is a common opiate primarily metabolized by CYP3A4 subtypes. Recent studies demonstrate CYP2D6 variants, affecting fentanyl PK. Functional CYP polymorphisms can significantly alter opiate levels resulting in inadequate analgesia or life-threatening toxicity. The goal of our study was to evaluate fentanyl PK and assess associations with CYP polymorphisms. We obtained samples from the previously banked blood of 13 patients (eight males and five females) with >20% TBSA burns. Mean (SD) patient age was 41.7 (14.5) years, and mean burn size was 25.8 (15.3) %TBSA. Plasma fentanyl was quantified, and CYP genotyping was performed. Pharmacokinetic analysis was performed using Monolix software (Lixsoft, France) with a two-compartment population model best-representing fentanyl profiles. Three CYP slow-metabolizing genotypes were identified, which included CYP2D6*9, CYP2D6*29, and CYP3A4*1B. All three patients with variant polymorphisms had increased serum fentanyl concentrations due to impaired clearance. This pilot study supports the need for further research in this topic, and CYP genotyping of individual patients prior to receiving opiate analgesics to inform precision-guided decisions, improve therapeutic efficacy, and, most importantly, increase patient well-being and safety.

Frailty: an independent predictor of burns mortality following in-patient admission

IntroductionBurn injury in the elderly is associated with increased morbidity and mortality. It is not uncommon for biological age, or frailty, to differ from chronological age in this patient group and thus predicting individual clinical outcomes remains challenging. It has been previously shown that Rockwood’s Clinical Frailty Scale, a global clinical measure of fitness and frailty in older people, can be a useful adjunct for predicting outcomes for elderly patients with burns >10% TBSA. We refine our previous work to investigate the impact of frailty on mortality of elderly patients with thermal burns of any size admitted to a burns unit and explore its role as a meaningful adjunct to the modified Baux score. MethodsA retrospective analysis of case notes for all patients ≥65years admitted to our burns centre as an in-patient during an 8-year period was performed with standard demographics, burn injury parameters, length of stay and mortality outcomes collected. Measures of frailty were reviewed and statistically analysed to assess the impact of biological aging on clinical outcome in order to assess how the modified Baux score may be developed for the elderly using Frailty Score. Results239 patients met the inclusion criteria. Mean age was 77years (range: 65–99years) and mean burn size was 14.46% TBSA (Range: 0.1–98% TBSA). The modified Baux and Frailty Score were both independent predictors of mortality (p<0.0001). Increased premorbid Frailty Score was associated with increased in-hospital (OR: 2.33, 95% CI: 1.63–3.34) and one-year mortality (OR: 3.13, 95% CI: 2.22–4.41) independent of burn size compared to the modified Baux Score (IHM OR: 1.09; 95% CI: 1.07–1.13, 1yr M: OR 1.08; 95% CI: 1.05–1.11). The Frailty Score (>3) was a much more sensitive predictor of one-year mortality (Sensitivity: 83.9%; Specificity: 66.4%) than the modified Baux (>97) (Sensitivity: 59.8%; Specificity: 82.9%). A Frailty Score >3 when combined with the modified Baux score demonstrated increased area under ROC curve for both in-hospital (0.89 (95% CI: 0.85–0.94); p=0.02) and one-year (0.88 (95% CI: 0.84–0.92); p=0.02) mortality when compared to the modified Baux alone. ConclusionWe demonstrate that Frailty Score can be used to independently predict in-hospital and one-year mortality for thermal burns of any size in the elderly admitted as an in-patient to a burns unit. We also find that the Frailty Score can be employed in combination with the modified Baux score to improve mortality prediction. We recommend that Frailty Score is integrated into the modified Baux score and used to focus burn care resources appropriately.

Social Interactions and Social Activities After Burn Injury: A Life Impact Burn Recovery Evaluation (LIBRE) Study.

Social interactions and activities are key components of social recovery following burn injuries. The objective of this study is to determine the predictors of these areas of social recovery. This study provides a secondary analysis of a cross-sectional survey of adult burn survivors. The Life Impact Burn Recovery Evaluation-192 was administered to 601 burn survivors for the field-testing of the Life Impact Burn Recovery Evaluation Profile. Survivors aged 18 years and older with injuries ≥5% total BSA or burns to critical areas (hands, feet, face, or genitals) were eligible to participate. Multivariate linear regression analyses were used to determine predictors of the Social Activities and Social Interactions scale scores. A total of 599 people completed the Social Interactions and Social Activities scales. Of these, 77% identified as White Non-Hispanic, 55% were female, 55% were unmarried, and 80% had burns to critical areas. Participants had a mean age of 45 years, a mean time since burn injury of 15 years, and a mean burn size of 41% total BSA. Younger age (P < .01) and being married/living with a significant other (P ≤ .01) were associated with higher Social Activities and Social Interactions scale scores. Individual item responses reveal that survivors had lower scores on items related to participating in outdoor activities (30.4%) or feeling uncomfortable with their appearance (32.4% report dressing to avoid stares). Social interactions and activities are long-term challenges for burn survivors. It is important for clinicians to identify patients who may struggle with social recovery in order to focus on future community-based interventions.

346 Elbow Contracture Severity at Hospital Discharge in Patients with Heterotopic Ossification

Heterotopic ossification (HO), the development of abnormal bone in soft tissue, is an uncommon but significant complication of burn injury. HO most often affects the elbow joint and is associated with reduced range of motion (ROM), pain, and disability. The purpose of this study is to evaluate the association between the presence of HO and severity of elbow contractures. Data was obtained from the Burn Model System National Database. Contracture data was recorded between 1994 and 2003. All patients over 18 years with an elbow contracture at acute discharge were included. Elbow ROM was compared for those with and without radiological evidence of HO. Contracture severity was reported as both mean absolute loss of ROM in degrees and relative percent loss of normal ROM. Elbow ROM was further stratified by total body surface area (TBSA) subgroups (<20, 20–40, >40%) and comparisons were made between the HO and non-HO groups using two-sample t-tests. A p-value of < 0.05 was considered statistically significant. The database included 207 patients (22 with HO, 185 without HO) with 407 instances of elbow contracture. The population was 85.5% male, had a mean (SD) age of 40.2 (14.4) years, and a mean (SD) burn size of 30.1 (19.0)% total body surface area. Elbow contractures in those with HO demonstrated worse elbow flexion compared to those without HO in the whole population (mean absolute loss: 50 vs. 30 degrees, p < 0.0001). Significantly worse elbow flexion outcomes were also noted in the 20–40% TBSA group (62 vs. 28 degrees, p = 0.0003). There were no significant differences between groups (unstratified and stratified by TBSA) in elbow extension. (Table) HO is associated with worse elbow ROM for burn survivors. This study improves our understanding of the impact of HO on elbow contracture severity and association with elbow flexion contractures. The findings of this study highlight the need for additional treatment strategies for those with HO and elbow contractures.

63 The Relation Between Satisfaction with Appearance and Ethnicity

Although the general research on body image has shown that there are associations between ethnicity and perceptions of body image, to our knowledge, no studies have examined the relation between satisfaction with appearance and ethnicity after a burn injury. The purpose of the study was to determine the impact that ethnicity has on satisfaction with appearance; and to determine the impact of satisfaction with appearance on community integration. All participants were part of a larger Burn Model System (BMS) national database. Adult participants completed the Satisfaction with Appearance Scale (SWAP) and the Community Integration Questionnaire (CIQ) at discharge, 6 months, 12 months and 24 months post burn injury. Higher scores on the SWAP indicate lower satisfaction with appearance and higher scores on the CIQ indicate greater integration into the community. A total of 1220 participated in the study but may not have completed the measures at each timepoint. Mean age was 40.1 (sd=13), mean burn size TBSA = 19.5% (sd=18), mean length of stay = 29.5(sd=37), 53% had a head/neck burn and 73% were male. Three sets of linear regression models were completed after adjusting for ethnicity (white, non-Hispanic versus non-white), age, sex and % TBSA. SWAP and CIQ scores between white and non-white participants are significantly different at all three time points (see table 1). On average, white participants reported more satisfaction with their appearance and integrated better into the community than non-white participants. The regression results also indicate that SWAP is significantly associated with CIQ after adjusting for race, sex, age, and burn size at 6, 12, and 24 months. For example, at 12 months, every one unit increase in CIQ was associated with a decrease in SWAP scores of 0.039 points. These results show that burn survivors who identify as non-White are more dissatisfied with their appearance. This dissatisfaction can also affect other outcomes, such as integrating back into the community. Research has shown that those with darker pigmented skin tend to produce more hypertrophic scarring, which may contribute to dissatisfied appearance and impact community re-integration. Cultural differences and degree of acceptance by communities may also impact satisfaction. Interventions on improving body image need to account for the unique ethnic differences of our population and the impact that body image has on other important functional outcomes.

45 Increased Dead Space Fraction in Patients with Inhalation Injury

Inhalation injury increases morbidity and mortality in burn patients. The pathology involves injury to large airways and V/Q mismatch, and differs from ARDS and pneumonia. We noted large differences between end-tidal CO2 (ETCO2) and PaCO2 in patients with inhalation injury. This difference is an indirect measure of dead space. We reviewed our experience with inhalation injury and the correlation of increased dead space with outcomes: mortality, ventilator associated pneumonia (VAP), and ventilator days (VNTd.) Following IRB approval we identified 51 adult patients with burns and inhalation injuries in our admission records from 2011–2015. Data collected includes: demographics, burn size, length of stay (LOS), ventilator days (VNTd), blood gas results, ETCO2, presence of VAP, and mortality. We calculated the dead space fraction (DSF) using the Enghoff-Modified Bohr Equation (difference between PaCO2 and ETCO2, divided by PaCO2.) We also calculated the Modified Baux Score (MBS.) We used Student’s T-tests to compare DSF between survivors and non-survivors, and between patients with and without VAP. We used bivariate correlation analysis to explore the relation between DSF and VNTd, DSF and MBS, and DSF and burn size. Values expressed as mean± SD. The 51 patients had a mean age of 52 ± 16.1 years and a mean burn size of 17.5 ± 25.2% resulting in a mean MBS of 87 ± 26.8. Mean LOS was 11.9 ± 15.0 days. In this sample 10 patients died (19.6%) and 6 developed VAP (11.8%). Mean DSF was 0.38 ± 0.22. Student’s T-tests found the DSF to be significantly lower in survivors (mean 0.34 ± 0.21) compared to non-survivors (mean 0.52 ± 0.24), p=0.027) but not between patients with VAP (mean 0.47 ± 0.31) and without (mean 0.36 ± 0.20, p=0.259.) Bivariate correlation analysis identified a weak correlation between DSF and VNTd, but this was not statistically significant (Pearson correlation coefficient 0.281, p=0.075.) Bivariate analysis identified a significant correlation between DSF and MBS (Pearson coefficient 0.524, p<0.001) and a stronger correlation between DSF and burn size (Pearson coefficient 0.606, p<0.001.) The dead space fraction (DSF) is often increased in patients with inhalation injury. DSF was significantly higher in patients who died with inhalation injury compared to survivors. DSF tended to be higher in patients with VAP, but the difference was not statistically significant. DSF correlates with the MBS and burn size. Further study of DSF and its role in inhalation injury is warranted. Dead space fraction (DSF) is easy to calculate from PaCO2 and ETCO2 and may be useful in measuring the severity of inhalation injury, the patient’s prognosis, and response to treatment.

Fatigue Following Burn Injury: A Burn Model System National Database Study.

Fatigue is a commonly reported but not well-documented symptom following burn injury. This study's objective was to determine the frequency and severity of fatigue over time and to identify predictors of fatigue in the adult burn population. Data from the Burn Model System National Database (April 1997 to January 2006) were analyzed. Individuals over 18 years of age who were alive at discharge were included. The vitality subscale of the Short-Form 36 Item Health Survey was examined at preinjury and discharge and at 6, 12, and 24 months postinjury. Mean and number of low vitality scores were calculated at each time interval. Descriptive statistics were generated for demographic and medical data. Cross-sectional regression models analyzed predictors of vitality at 6, 12, and 24 months postinjury. The study included 945 subjects. The population was 72.5% male and had a mean age of 40.6 years and mean burn size of 17.4%. Fatigue symptoms were present in a majority of the population (74.6%) and were most commonly reported at discharge. Although fewer burn survivors reported fatigue symptoms at each subsequent follow-up (P < .001), approximately one-half (49%) of the population continued to report fatigue symptoms at 24 months postinjury. Larger burn size was the only variable that was significant or approaching significance at all follow-up time points (P < .0167). Fatigue symptoms are common after burns and many burn survivors continue to report symptoms at 2 years postinjury. Burn survivors did not return to preinjury fatigue levels, highlighting the importance of understanding and monitoring fatigue.

Enteral Nutrition Delivery Is Overestimated in Provider Documentation.

Burn-injured patients have the highest metabolic demand of all critically ill patients and are vulnerable to complications of malnutrition. Many burn centers have challenges in achieving prescribed rates of nutrition, despite aggressive algorithms. One possible reason for the discrepancy is inaccurate documentation of volumes. This is a retrospective review of patients requiring tube feeding admitted to a regional burn center between June and August 2015. Demographics were abstracted including gender, type of injury, TBSA, and age. The total feeding volume was recorded from the feeding pump every 24 hours. The values were compared with the enteral nutrition volume charted by the nursing staff and rate prescribed by the physician team. Repeated measures analysis of variance was used to compare continuous variables. Twenty-five patients were observed during the study period providing a total of 105 patient days. The average age was 44 years with 42% TBSA mean burn size. The average volume prescribed by providers was 1,598 ml/d. According to documentation, the average volume given was 1,448 ml/d, a significant difference (P = <.001). The average volume delivered as recorded on the feeding pump was less at 1,287 ml/d. The nourishment provided was significantly less than documented and even more so when compared with the prescribed rate (P < .001 and P < .001, respectively). Overall, 19% of ordered enteral nutrition was not provided. There was a significant discrepancy between ordered, recorded, and delivered volume of enteral nutrition. Potential reasons for the discrepancy may be frequent interruption for repositioning, wound care, linen changes, or other nursing workflow. Burn providers should be aware of the potential for underfeeding patients.

Burn Hand or Finger Goniometric Measurements: Sum of the Isolated Parts and the Composite Whole.

Accurate assessment of hand function following a burn is important for patient impairment determination. Goniometric measurement of hand or finger range of motion (ROM) is typically done measuring individual finger joints with the adjacent joint in extension (isolated) or measuring the joints in a fist position (composite). The purpose of this study was to compare if the total flexion motion of the summed angles of the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints in burned hands were equal when performed in an isolated vs a composite manner. Passive flexion ROM angles were collected prospectively and measured at the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal with the adjacent joints extended to measure isolated angles and with the adjacent joints fully flexed for composite angles. Thumb joints were excluded. ROM for isolated and composite positions of eight fingers was compared individually and as an aggregate. Finger measurements from 145 adult patients were compared. The study population was predominately male (69%) with a mean age of 41 ± 16.6 years. Mean total burn size was 14.2 ± 13.2%. A total of 739 fingers contributed 2217 joint ROM comparisons. Aggregate analysis of isolated ROM was 235.5° ± 52.1° compared with composite ROM of 226.8° ± 53.2° (P < .0001). Individual fingers showed significant differences between the two measurement methods as well (P ≤ .0040). The methods used to measure hand or finger ROM profoundly influence how hand impairment is reported. Measurement of isolated joint angles results in greater ROM values compared with composite angles, which are often more relevant for functional hand positions. Therefore, composite angles are recommended.

Use of porcine acellular dermal matrix following early dermabrasion reduces length of stay in extensive deep dermal burns

ObjectiveExtensive deep partial-thickness burns still seriously challenge the surgeon's abilities. This study aimed to assess the impact of early dermabrasion combined with porcine acellular dermal matrix (ADM) in extensive deep dermal burns. MethodsFrom September 2009 to September 2013, a total of 60 adult patients sustained greater than 50% total body surface area (TBSA) burn by hot water or gas explosion were divided into three groups based on dermabrasion: group A (early dermabrasion and porcine ADM), group B (early dermabrasion and nano-silver dressings), and group C (conservative group). The wound healing time and length of hospital stay were analyzed. Scar assessment was performed at 3 and 12 months after the injury with a modified Vancouver Scar Scale linked with TBSA (mVSS-TBSA). ResultsNo significant difference was found in mean burn size, burn depth, age, male-to-female ratio, or incidence of inhalation injury between the patients in the three groups (p>0.05). Compared with groups B and C, the patients that received early dermabrasion combined with porcine ADM had a shorter wound healing time (p<0.01). The burn patients treated with early dermabrasion and porcine ADM coverage had a mean length of hospital stay of 28.3 days (±7.2), which was significantly shorter than that of groups B and C (p<0.05–0.01). The mVSS-TBSA of patients in group A was significantly improved in comparison with groups B and C at 3 and 12 months after the injury. There was no significant difference in the mortality rate between the three groups (p>0.05). ConclusionEarly dermabrasion combined with porcine ADM coverage facilitates wound healing, reduces the length of hospital stay, and improves esthetic and functional results in extensive deep dermal burns with burn size over 50% TBSA.

A Pilot Study to Validate the Burn Center Pediatric Early Warning Score Tool in Clinical Practice.

The pediatric early warning score (PEWS) tool helps providers to detect subtle clinical deterioration in non-intensive care unit pediatric patients and intervene early to prevent significant adverse outcomes. Although widely used in general pediatrics, limited studies report on its validation; none report on use with burn-injured patients. New York-Presbyterian/Weill Cornell Medical Center modified a general PEWS system to a burn-specific PEWS and integrated its use into standard practice. This study investigated the external validity of the PEWS process in clinical practice. Fifty cases of patients aged 0 to 15.9 years admitted between January 2012 and June 2013, whose length of stay (LOS) more than 3 days were selected for review from this cohort of n equal to 187. Demographics, total PEWS and score changes, and compliance with PEWS documentation and with resultant interventions were reviewed. Continuous variables are presented as mean ± SD, P less than 0.05. Mean age, burn size, and LOS were 3.2 ± 3.3 years, 4.8 ± 5.7%, and 9.8 ± 7.0 days; 26% required grafting, and 50% were male. No mortalities occurred. One thousand six hundred and twelve PEWS from 1745 opportunities were documented (92.4%). For all PEWS (n = 1612) and PEWS greater than 0 (n = 912), means were 0.9 ± 1.2 and 1.6 ± 1.2, respectively. Among the 162 PEWS increase events, intake (54.1%) and output (4.5%) parameters increased most commonly. Of these, 129 PEWS increases (79.6%) were followed by an intervention that most commonly included text notation of score increase (93.7%), physician/physician assistant notification (70.5%), and feeding-tube insertion (25.6%). Patients with PEWS greater than 0 had similar age, LOS, and larger burn size (5.2% vs 1.4%, P < 0.05) than those with PEWS equal to 0. Compliance with PEWS performance and resultant actions based on score increases are high. Data support that even small changes in burn-injury specific PEWS stimulate provider discussion and intervention and support its validation; further studies on its effect on practice are warranted.

Propranolol Dosing Practices in Adult Burn Patients: Implications for Safety and Efficacy.

Studies in children with burn injuries have demonstrated that propranolol improves metabolism and reduces muscle protein wasting. However, safety and efficacy in adults are less well established than in children. The purpose of this study was to determine safety of propranolol use in adult patients with burn injuries. Medical records were reviewed for burn-injured adults receiving propranolol. Patients between 18 and 65 years old and with ≥20% TBSA burn were included. Fifty-four patients met the criteria with mean age of 37 years and mean burn size of 38% TBSA. Propranolol dosages ranged from 0.1 to 3.8 mg/kg/day, with an average maximum dosage of 0.61 mg/kg/day. Mean heart rate decreased by 25% during 4 weeks. Seventy-two percent of patients experienced at least one episode of hypotension and 15% experienced bradycardia. Propranolol doses were most frequently held for low blood pressure; 32% of patients had at least one dose held for hypotension. This retrospective analysis suggests that modest dosing of propranolol results in frequent episodes of hypotension or bradycardia. Our data suggest that adults do not tolerate the higher doses reported in a pediatric population. Despite potential beneficial anti-catabolic effects of propranolol, burn care providers must recognize potential iatrogenic hemodynamic effects of this intervention. Our data support the need for prospective multicenter studies to delineate the safety and efficacy of propranolol in adult burn-injured patients.

Economic burden of burn injuries in the Netherlands: A 3 months follow-up study.

Burn care has rapidly improved in the past decades. However, healthcare innovations can be expensive, demanding careful choices on their implementation. Obtaining knowledge on the extent of the costs of burn injuries is an essential first step for economic evaluations within burn care. The objective of this study was to determine the economic burden of patients with burns admitted to a burn centre and to identify important cost categories until 3 months post-burn. A prospective cohort study was conducted in the burn centre of Maasstad Hospital Rotterdam, the Netherlands, including all patients with acute burn related injuries from August 2011 until July 2012. Total costs were calculated from a societal perspective, until 3 months post injury. Subgroup analyses were performed to examine whether the mean total costs per patient differed by age, aetiology or percentage total body surface area (TBSA) burned. In our population, with a mean burn size of 8%, mean total costs were €26,540 per patient varying from €742 to €235,557. Most important cost categories were burn centre days (62%), surgical interventions (5%) and work absence (20%). Flame burns were significantly more costly than other types of burns, adult patients were significantly more costly than children and adolescents and a higher percentage TBSA burned also corresponded to significantly higher costs. Mean total costs of burn care in the first 3 months post injury were estimated at €26,540 and depended on age, aetiology and TBSA. Mean total costs in our population probably apply to other high-income countries as well, although we should realise that patients with burn injuries are diverse and represent a broad range of total costs. To reduce costs of burn care, future intervention studies should focus on a timely wound healing, reducing length of stay and enabling an early return to work.

Periorbital burns – A 6 year review of management and outcome

IntroductionPeriorbital burns are an infrequent but potentially devastating injury. This study aimed to elucidate the spectrum of such injuries presenting to a UK burns centre and the outcome achieved in the cases requiring periorbital reconstruction for the restoration of function and form. MethodsPatients admitted to a UK regional burns centre between January 2005 and January 2011 with periorbital burns were identified from the Patient Administration System (PAS), theatre logs and the International Burns Injury database (IBID). Multiple parameters were assessed using patient notes, ITU and hospital image databases. ResultsOver 6 years, 167 patients with facial burns requiring surgery were treated, including 103 patients with eyelid burns. The mean burn size was 33% total body surface area. The eyelid burn depth varied; 67% superficial partial thickness, 17% deep dermal and 16% full thickness. Two patients lost complete vision in one eye, one patient underwent amniotic membrane grafting. In total 16 patients required periorbital reconstruction to maintain eye closure, with 1.8 operations on average per patient. Acute surgery was required in 11 patients, whilst late intervention (>3 months) was needed in 5, 2 patients had both acute and delayed surgery. Of the 5 late intervention patients 4 were treated with full thickness skin grafts and 1 with a Z plasty. Average time for final reconstruction with delayed surgery was 4.5 months. ConclusionThe goal in management of periorbital burns is preservation of vision, prevention of future complications and restoration of an acceptable aesthetic outcome. Total visual loss is thankfully rare, but early ophthalmology intervention is vital given the evidence of corneal damage as a brief therapeutic window exists.

Inpatient silver sulphadiazine versus outpatient nanocrystalline silver models of care for pediatric scald burns: A value analysis

Scalds represent the most frequent pediatric burn injury. Inpatient nonsurgical wound management of small or medium-size burns (<20% total body surface area) represents a significant proportion of the cost of care, with nanocrystalline silver (NCS) and silver sulphadiazine (SSD) among the most commonly used dressings. Although several articles have described healing outcomes using these dressings, there are few concurrent economic analyses. To analyze overall health care value (outcomes/cost) in burns not requiring surgery, the authors compared management of scald burns with NCS versus SSD from both a quality perspective and using bottom-up microcosting to determine which dressing option optimizes health care value. A value analysis was performed. Published studies investigating NCS and/or SSD in the treatment of pediatric burns over the past 25 years were analyzed. Healing time, hospital duration and frequency of dressings were chosen as quality metrics. A bottom-up microcosting analysis was performed to estimate costs associated with the two dressing options. Over the 25-year period, 356 studies investigated the use of SSD in burns, while 55 studies evaluated the use of NCS. Mean age and burn size were equivalent. Mean time to healing was 14.9 days for NCS and 17.2 days for SSD. The mean duration of hospital stay was 14.9 days for SSD and 5.9 days for NCS. Dressings were performed twice per week for NCS, and once or twice per day for SSD. The mean total cost per patient to the health care system was estimated to be $61,140 for SSD and $17,220 for NCS. Published outcomes of healing time are equivalent or slightly better using NCS over SSD for pediatric scalds. The financial model illustrated a potential significant cost saving with NCS, primarily as a result of an outpatient model of care. Overall health care value is optimized using NCS for pediatric scalds.

Electrical injury in construction workers: A special focus on injury with electrical power

BackgroundElectrical injury in construction workers due to contact with overhead power lines accounts for an important cause of admission at the emergency department. Due to lack of specific treatment options for this type of injury, prevention remains the mainstay of management. AimsOur study aimed to demonstrate the characteristics of electrical injury in construction workers among one of the largest Iranian population at a burn care hospital. MethodsThrough a retrospective review of hospital data base, patients with electrical injuries admitted to Motahari hospital in Tehran, Iran between March 2011 and June 2012 were included for analysis. Patients were divided into construction workers and other patients. Primary characteristics and final outcomes were then compared between the 2 study groups. ResultsOf 202 patients included in this study, 105 patients (52%) were construction workers and 97 patients (48%) constituted the remainder. There was significant difference between the 2 groups in terms of mean age, gender, and average burn size. In contrast, mean duration of hospitalization and mortality rate did not differ significantly between the 2 study groups (p>0.05). Contacts with over head power-lines accounted for the most common mechanism of injury. There was significant difference between the 2 groups in terms of place of injury and electrical current power. However, total cost of treatment did not differ significantly between the 2 groups (p>0.05). Frequency of severe complications was higher in construction workers and this group underwent more invasive procedures such as limb amputation and fasciotomy. ConclusionThe most common mechanism of electrical injuries in construction workers is due to contact with over head high voltage power-lines at workplace. This type of electrical injury is associated with higher use of fasciotomy, flap and limb amputation.

A Ten-Year Review of Lower Extremity Burns in Diabetics

Diabetes mellitus with its resulting neurovascular changes may lead to an increased risk of burns and impaired wound healing. The purpose of this article is to review 10 years of experience with foot and lower leg burns in patients with diabetes at a single adult burn center. Patients with lower extremity burns and diabetes mellitus, between May 1999 and December 2009, were identified in the Trauma Registry of the American College of Surgeons database, and their charts were reviewed for data related to their outcomes. Sixty-eight diabetic patients, 87% male, with a mean age of 54 years, sustained foot or lower extremity burns with 37 having burns resulting from insensate feet. The pathogenesis included walking on a hot or very cold surface (8), soaking feet in hot water (22), warming feet on or near something hot such as a heater (13), or spilling hot water (7). The majority of patients were taking insulin (59.6%) or oral hyperglycemic medications (34.6%). Blood sugar levels were not well controlled (mean glucose, 215.8 mg/dl; mean hemoglobin A1c, 9.08%). Renal disease was common with admission serum blood urea nitrogen (27.5 mg/dl) and creatinine (2.21 mg/dl), and 13 were on dialysis preinjury. Cardiovascular problems were common with 39 (57%) having hypertension or cardiac disease, 3 having peripheral vascular disease, and 9, previous amputations. The mean burn size was 4.2% TBSA (range, 0.5-15%) with 57% being full thickness. Despite the small burn, the mean length of stay was 15.2 days (range, 1-95), with 5.65 days per 1% TBSA. Inability to heal these wounds was evident in 19 patients requiring readmission (one required 10 operative procedures). At least one patient sustained more than one burn. There were 62 complications with 30 episodes of infection (cellulitis, 28; osteomyelitis, 4; deep plantar infections, 2; ruptured Achilles tendon, 1) and 3 deaths. Eleven patients needed amputations (7 below-knee amputations, 4 transmetatarsal amputations, and 20 toe amputations) with several needing revisions or higher amputations. Patients with diabetes have an increased risk for lower extremity complications, but the risk of burns is not well known. The majority of lower extremity burns result from intentional exposure to sources of heat without recognition for the risk of burns. Once a burn occurs, morbidity and cost to the patient and society are severe. Prevention programs should be initiated to make diabetic patients and their doctors aware of the significant risk for burns.

A Ten-Year Experience With Pediatric Face Grafts

The authors reviewed their 10-year experience of performing face grafts in children with burns. They sought to compare different methods for aesthetic outcome and need for reconstruction. In addition, they determined the efficacy of using allograft skin or Integra as temporary covers. They performed a review of 160 pediatric patients who underwent acute facial excision and grafting for burns between 2000 and 2010. Of the 160 patients with a mean age of 5.8 ± 4.8 years, 96 were males. The mean burn size was 39.4 ± 24.61%, of which 36.5 ± 25.4% was third degree. Overall length of stay was 72.1 days, intensive care unit length of stay was 44.2 days, and the mortality rate was 13.75%. Ninety patients had their entire face burned, 42 burned half, 15 burned their foreheads, and seven had other combinations. The interval between injury and grafting was 13.9 ± 13.19 days. Sixty-three percent patients required one face graft, 23% had two, 8% had three, and 6% four or more. For their initial procedure, 105 patients underwent autografting, 28 had allografting, and 23 received Integra. The authors performed a two-stage procedure in 20.4% and a 1-day procedure in 79.6%. Ten patients had a contiguous "U-shaped" graft wrapped around the face. At least partial regrafting was performed in 21.1%. Allograft and Integra were used for massive burns (69.9 ± 14.5%, 62.6 ± 18.3%, respectively). Of these, 39% died, 17% developed an Integra infection, and 43% required regrafting before autografting. Overall, 24.5% of patients underwent facial reconstruction during their first admission, and 57.1% during subsequent admissions. No difference in the rate of reconstructive surgery was noted between patients receiving Integra or autografting. Autografting face burns as an initial, one-stage procedure works well. The "wrap-around" autograft leads to excellent cosmetic results. When there is a shortage of autograft, allograft or Integra are good options but Integra does not reduce the need for reconstructive surgery.