Modern Burn Care Research Articles

Fighting A New Front On An Old Battlefield: Examining the Development of Topical Antimicrobial Care to Control Burn Wound Sepsis.

Recognition of invasive burn wound sepsis as a major cause of morbidity and mortality in burn injured patients has profoundly changed the management of burn wounds and its associated complications. The development of effective topical antimicrobial therapy is one of the last major developments of modern burn care and has been driven by major world events and scientific breakthroughs. Topical antimicrobial burn care has evolved from the use of anecdotal remedies to scientific breakthroughs such as Moyer's successful dilution of silver nitrate solution, Fox's described benefit of silver sulfadiazine use in animal models, and Pruitt's dramatic improvement in post-burn mortality using topical mafenide acetate in burn wounds. The objective of this manuscript is to review the definition of burn wound sepsis and highlight the major developments and breakthroughs in topical burn wound care throughout history. This includes historical events like major wars or domestic fires that have influenced or impacted the understanding and treatment of burn wounds. Newer advances in topical antimicrobial care such as nanosilvers and dressing technologies that improve the morbidity and mortality associated with burn wound sepsis and novel approaches to management will also be discussed. To improve burn care, it is prudent to look to the past and learn from the experiences of those who contributed to the control of burn wound sepsis.

Investigating the Impact of Wound Edge Approximation with Skin Grafting on Hypertrophic Scar Reduction: A Randomized Controlled Clinical Trial.

In modern burn care, the focus extends beyond mere patient survival to encompass long-term functional and cosmetic outcomes. Research suggests that the technique and manner of suturing during skin grafting play a significant role in scar formation. This study aimed to explore the effectiveness of wound edge approximation with skin grafting compared to the conventional approach, where the graft edge exclusively interacts with the wound edge, in reducing hypertrophic scar development. Seventy-four burn unit patients eligible for grafting were randomly allocated into two groups: those receiving grafts with overlapping edges (Group A) and those receiving grafts with edges tailored to the burn wound (Group B). Evaluation of graft sites occurred immediately post-surgery and at 1 and 6 months post-operatively using the standardized Vancouver Scar Scale (VSS) administered by trained surgeons. The findings of this study revealed that there was no statistically significant difference between the two examined groups regarding the average duration of hospitalization and the mean thickness of wounds (P>0.05). Similarly, the mean scores for pain, vascular index, and pigmentation index immediately post-surgery, at 1 month, and 6 months later, as well as the scar height index and flexibility immediately and at 1 month post-surgery, and the Vancouver Scar Scale index at the study's conclusion, showed no significant variation between the two groups (P>0.05). However, at the 6-month follow-up, the mean scar height score (P=0.004) in the overlapping group and the mean flexibility score (P=0.017) in the non-overlapping group were significantly lower compared to the respective alternative group. This indicates a notable improvement in scar height and wound flexibility in the overlapping group over the non-overlapping group after 6 months.

734 Use of the Burn Care Quality Platform (BCQP) for Modern Burn Care Benchmarking

734 Use of the Burn Care Quality Platform (BCQP) for Modern Burn Care Benchmarking

YANIK YARALANMASI OLAN HASTANEYE YATIRILAN ERİŞKİN HASTALARDA AĞRI KESİCİ KULLANMA ALIŞKANLIKLARI

Objectives: Modern burn care is dependent on the effective management of burn pain. Although opioids remain the cornerstone of treatment, their adverse effects remain serious. In this study, we investigated non-opioid painkillers, including acetaminophen and dexketoprofen, which are commonly used in the clinical practice for adult burn inpatients who do not require admission to an intensive care unit.
 Methods: Thirteen consecutive inpatients with burns were included in this study. During the six-day period, the patients self-administered painkillers as needed. The time of medication intake was recorded, and a visual analog scale was used to assess pain. Thereafter, statistical analyses were performed.
 Results: No significant differences were observed between age and sex groups. As the percentage of burns increased, the number of painkillers used also increased. It was found that the patients took painkillers most frequently at 11 o'clock (when the wound dressing was changed) and least frequently at 14 o'clock. No significant difference was observed between the effects of dexketoprofen and paracetamol in reducing pain.
 Conclusions: The need for painkillers in patients with burns varies throughout the day. The effectiveness of acetominophen and dexketoprofen during the day was higher than that during dressing changes. The total body surface area should be considered with regards to the amount and frequency of painkiller administered.

722 Select Survey of Human Cadaver Skin Allograft Utilization by 21 Senior Academic Burn Surgeons

Abstract Introduction As of 2022, cryopreserved human cadaver skin allograft remains the gold standard by which all other skin substitutes used for burn care are compared. The 2015 Taiwan Color Dust Explosion burn mass casualty engendered the transfer of emergency tranches of skin allograft from reserves in both the US and EU to Taiwan. HHS/ASPR/BARDA/CBRN led an after-action fact-finding mission to Taiwan and concluded that skin allograft would still play a central role as a safety net in US national burn care preparedness, even as BARDA invested in the development of other burn medical countermeasures that would be part of the preparedness strategy. However, before investments in a skin allograft based national strategy could be built, it was critical that the leaders of the Disaster Committee and Organization and Delivery of Burn Care (ODBC) Committee of the American Burn Association (ABA) commission a survey to verify current practice patterns of senior academic burn surgeons on the use of skin allograft. Methods The committee chairs curated a list of 21 leading academic burn surgeons in North America. These surgeons’ credentials included having been an ABA president, a member of the ABA Board of Trustees, or having chaired a standing committee of the ABA. All 21 surgeons were actively practicing burn care daily. The survey contained 18 questions and was intentionally kept brief (Survey to be provided as Appendix). Results Of the 21 surgeons selected, there was 100% participation and completion of the survey. Most were in practice >15 years (62%) and manage >200 patients surgically per year (71%). The predominant use of allograft is to temporize the wound bed when there are inadequate donor sites (48% “Almost Always”). It is “Often” (48%) used to temporize wound beds prior to autografting. However, most are looking for alternatives to allograft (43% “Sometimes”, 43% “Often”). With ongoing development of skin substitutes, most indicated their allograft use will likely decrease, with only 19% indicating “Probably Not”. Conclusions Human skin allograft continues to play a central role in surgical burn care management. For the foreseeable future, new technologies are not likely to displace allograft use but rather blend with its use. This brief, select survey is not powered but provides a snapshot of the current role of skin allograft. In the future, we may conduct a broader survey to obtain a validated and more granular view of the use of allograft in modern burn care. Applicability of Research to Practice Armed with this information, the US Federal Government acted to increase preparedness after a burn mass casualty. In February 2022, a Request for Proposals for a large vendor-managed inventory of human cryopreserved skin allograft was answered by two separate tissue banks. As of September 2022, $38M was awarded to two partners for procurement and expansion of a vendor managed inventory of cryopreserved human skin allograft to ensure preparedness for rapid response to a burn mass casualty incident.

503 The Accuracy of the Revised Baux Score in Predicting Burn Mortality: A Systematic Review

Abstract Introduction Osler et al. revised the Baux score in 2010 to include inhalation injury, attempting to improve upon the original 1961 model given the significant advances in modern burn care. Other predictive models of burn mortality have similarly been developed using use an assortment of other variables, however there is no consensus on the preferred formula to use. This systematic review aims to investigate the accuracy of the revised Baux (rBaux) score in comparison to other models when determining mortality risk in patients with burn injuries. Methods A systematic review was performed by two independent reviewers using electronic databases (PubMed, EMBASE, Scopus) from March 1, 2010 to May 22, 2022. The majority of studies were classified as “high” quality and no studies were excluded due to risk of bias. Articles were included if they were published in English and assessed risk of mortality from burns using the rBaux model and an alternative model. The PRISMA statement was followed, and all the PROBAST quality appraisal checklist was used during data extraction. Results The search identified 79 non-duplicate citations, of which 33 underwent full-text review, and 21 met inclusion criteria. They assessed the predictive ability of the rBaux score in comparison to the original Baux score, Belgian Outcome for Burn Injury, Abbreviated Burn Severity Index, APACHE II, Sequential Organ Failure Assessment score, Boston Group/Ryan scores, the FLAMES model, the Prognostic Burn Index, and several other equations that have not been externally validated. The accuracy of mortality prediction (area under ROC curves) for the rBaux score ranged from 0.68 to 0.99 and 14 studies found a value greater than 0.90. These ROC values were found to be lowest in the two studies with subgroupings for age, demonstrating an ROC of 0.01 in children, and 0.68 and 0.92 in the elderly. Eleven studies described sensitivity, specificity, or both, with sensitivity ranging from 12% to 96%, and specificity ranging from 80% to 100%. Conclusions The rBaux score offers a relatively easy method to rapidly assess the mortality risk from burn injury in a broad range of patient populations based on age, percent total body surface area burned, and presence/absence of an inhalation injury. This tool remains valid despite the exclusion of patient comorbidities and other injury-related factors. However, this study also identified the rBaux’s ability to predict mortality risk was limited when applied to patients at the extremes of age, highlighting an important area for future research. At present, given its relative simplicity and generalizability, the rBaux score remains a useful clinical tool for predicting mortality. Applicability of Research to Practice The rBaux score remains a simple yet powerful predictor of mortality in burn patients, which can be applied at the bedside on initial presentation across diverse patient populations.

740 Implementation and Retrospective Assessment of a Modified Graft Loss Grading System

Abstract Introduction Success of split-thickness skin grafting (STSG) is a cornerstone of modern burn care and sets the stage for success in acute, rehabilitative and reconstructive care. Shupp et al, proposed a graft loss grading system, which the authors then modified to reflect true clinical practice and changes in management. Purpose of the quality improvement (QI) project was to design, implement and assess this grading system. Methods A modified graft loss grading system was developed and implemented. Burn patients requiring STSG were tracked over a five month period, and initial (first takedown) and subsequent (either outpatient or 7 days after initial assessment) graft loss grades and contributing factors were noted. Assessments were performed an APP and burn surgeon with agreement of an assigned grade. Patient demographic data was recorded. Results 63 patients underwent 66 STSG procedures during the review period (44 males, 19 females). Average age was 33.3 years (range: 1-86). Average % TBSA burn was 10.2% (range 0.2-67%). Obesity was present in 33.3% of patients, cardiac disease (hypertension, coronary artery disease or congestive heart failure) in 21.2%, DM in 21.2% and 24.2% of patients were active smokers. Flame burns represented the etiology in the majority (51.5%) of patients. Overall, 10 patients (16%) on initial assessment and 18 patients (29%) on subsequent assessment had evidence of graft loss. Etiology of graft loss included wound bed viability - the default etiology (10 patients/55%), infection (3 patients/17%) and hematoma/seroma (4 patients/22%). Of the 18 patients, 5 (28%) required re-grafting. Of patients with graft loss, 89% had a comorbidity including DM (28%) and smoking history (28%). Malnutrition was felt to contribute in 3 (17%) of patients. Conclusions A graft loss grading system is a beneficial quality improvement project to characterize the surgical results of burn patients undergoing STSG. This modified grading system better characterizes graft loss outcomes and subsequent changes in management if applicable. Wound bed viability remains a major factor in graft loss, although the majority of these patients had a contributing comorbidity. Applicability of Research to Practice Implementation of a graft loss grading system can be a valuable quality improvement tool that can be employed by burn centers to assessment surgical results.

In-hospital outcomes of paediatric burn injuries managed in children’s hospitals compared to general hospitals

IntroductionIn Australia and New Zealand, children with burn injuries are cared for in either general hospitals which cater to both adult and paediatric burn injuries or in children’s hospitals. Few publications have attempted to analyse modern burn care and outcomes as a function of treating facilities. AimThe aim of this study was to compare in-hospital outcomes of paediatric burn injuries managed in children’s hospitals to those treated in general hospitals that regularly treated both adult and paediatric burn patients. MethodsA retrospective cohort study of cases was undertaken using data from the Burns Registry of Australia and New Zealand (BRANZ). All paediatric patients with data for an acute or transfer admission to a BRANZ hospital and registered with BRANZ with a date of admission between 1 July 2016 and 30 June 2020 were included in the study. The primary outcome of interest was the acute admission length of stay. Secondary outcome measures of interest included admission to the intensive care unit and readmission to a specialist burn service within 28 days. The Alfred Hospital Ethics Committee granted ethical approval for this study (project 629/21). ResultsA total of 4630 paediatric burn patients were included in the analysis. Approximately three quarters of this cohort (n = 3510, 75.8%) were admitted to a paediatric only hospital, while the remaining quarter (n = 1120, 24.2%) were admitted to a general hospital. A greater proportion of patients admitted to general hospitals underwent burn wound management procedures in the operating theatre (general hospitals 83.9%, children’s hospitals 71.4%, p < 0.001). Patients admitted to children’s hospitals had a longer median time to their first episode of grafting (children’s hospitals 12.4 days, general hospitals 8.3 days, p < 0.001). The adjusted regression model for hospital LOS indicate that patients admitted to general hospitals had a 23% shorter hospital LOS, compared to patients admitted to children’s hospitals. Neither the unadjusted or adjusted model for intensive care unit admission was significant. After accounting for relevant confounding factors, there was no association between service type and hospital readmission rates. ConclusionsComparing children’s hospitals and general hospitals, different models of care seem to exist. Burn services in children’s hospitals adopted a more conservative approach and were more inclined to facilitate healing by secondary intention rather than surgical debridement and grafting. General hospitals are more “aggressive” in managing burn wounds in theatre early, and debriding and grafting the burn wounds whenever considered necessary.

Burn Wound Bed Management.

Critical to the success of modern burn care is the management of the burn wound. Timely and complete removal of nonviable tissue is complicated by the irreplaceable nature of the tissue lost either through the burn injury or as "collateral damage" as part of the treatment. Challenges in distinguishing between viable and nonviable tissue and "replacing the irreplaceable" are discussed alongside potential disruptive technologies which could fundamentally change how burn care is delivered. Advances in burn wound bed management forms the foundation on which the goal of zero preventable death and disability after burn injury can be achieved.

48 Metformin Rescues the Aging-induced Failure of Post-burn White Adipose Browning

IntroductionSevere burns are responsible for an estimated 300,000 deaths per year worldwide. While modern burn care has markedly improved survival for pediatric and adult patients, this is sadly not the case for one population: the elderly. Despite being the fastest-growing demographic in North America, burn patients over the age of 60 years have the highest mortality and morbidity rates. Recent evidence suggests that progressive aging induces several structural and functional alterations which impair the capacity of older trauma patients to adequately respond to stress. Indeed, it was discovered that reduced survival in elderly burn patients is associated with the failure to initiate the browning of white adipose tissue (WAT) —a hallmark of the systemic response to injury commonly observed in adults. Interestingly, the widely used hypoglycemic drug metformin has been found to protect against aging-induced metabolic decline in various pathological conditions. Thus, we investigated the anti-aging effects of metformin on the metabolic deterioration of post-burn WAT responses in elderly patients and mice after injury.MethodsHuman WAT was obtained from elderly patients admitted to our burn center. Elderly (75-week) mice received a full-thickness scald burn and/or daily intraperitoneal injections of metformin (100 mg/kg) for 7 days. The inguinal WAT was harvested for histological analyses. Mitochondrial respiration was measured via Seahorse XF96. Gene and protein expression was assessed via RT-PCR and western blot, respectively.ResultsPost-burn metformin treatment restores the thermogenic activation of WAT in elderly patients and mice, reflected by the increased expression of key browning markers, UCP-1 and PGC-1α (p< 0.05). This was accompanied by higher mitochondrial respiration, improved lipolysis (p< 0.05) and increased fat wasting (p< 0.01) relative to control counterparts. The anti-aging effects of metformin appeared to be mediated by AMPK, which consequently increased [NAD+] (p< 0.01), thereby promoting activation of the longevity-specific enzyme Sirt-1 (p< 0.05).ConclusionsHere, we show that post-burn metformin treatment effectively rejuvenates adaptive metabolic responses in elderly WAT by targeting key longevity pathways which rescue the age-dependent loss of being back to youthful levels. Our findings support the potential of anti-aging modalities to improve care and outcomes in elderly burned patients.

513 Fluid Over-Resuscitation in Burn Patients After Initial 24-Hours of Care is Associated with Increased Mortality

IntroductionFluid resuscitation is a cornerstone of modern burn care. Despite the use of well-established formulae to determine the appropriate amount of fluid resuscitation for the first 24 hours of care, there is increasing recognition that patients receive fluids in excess of predicted volumes, a phenomenon termed fluid creep. Underscoring the significance of this phenomenon is the association between large volumes of fluid resuscitation and adverse outcomes. Although research in non-burn ICU patients reveals a clear association between overall fluid intake and increased morbidity, minimal burn-related literature exists regarding fluid patterns after the initial 24-hour period and their impact on outcomes. We hypothesized that increased fluid administration after the standard initial resuscitation period is associated with increased morbidity and mortality.MethodsA retrospective chart review was performed for 113 patients with ≥20% TBSA burns admitted to an American Burn Association-verified burn center between 2010 and 2020. Patients admitted with Stevens-Johnson Syndrome and/or Toxic Epidermal Necrolysis, with length of stay ≤ 72 hours, who required renal replacement therapy (RRT) within 72 hours of admission, and those with withdrawal of care ≤ 7 days of admission were excluded. Univariate and multivariate logistic regression was used to determine the association between the primary outcome of in-hospital mortality and secondary outcomes of increased ventilator days, acute kidney injury, need for RRT, and hospital length of stay, with increasing total and net fluid volumes from days 2 through 7 of treatment. Additionally, the association between first OR day and total fluid volumes in the first week were assessed.ResultsMedian age was 41 years (IQR 23-55) and TBSA was 31% (IQR 24-43). 21 patients (18.6%) died during hospitalization. Increase in net fluid balance from days 2-7 were associated with increased mortality (OR 1.016, 95% CI 1.00 – 1.03, p = 0.013). Increasing total fluid volumes were significantly associated with increased ventilator days (OR 1.027, 95% CI 1.008-1.047, p = 0.006) and acute kidney injury (OR 1.003, 95% CI 1.000-1.006, p = 0.017). Early first OR day was associated with decreased net fluid balance between hospital days 2-7 (OR 0.993, 95% CI 0.989-0.997, p = 0.001).ConclusionsSimilar to studies on other ICU populations, increasing total fluid volumes and net fluid balance is associated with adverse outcomes in critically ill burn patients. Additionally, earlier initial OR is associated with less total fluid volumes and lower net fluid balance in the first week of hospitalization. Further investigation is needed to elucidate optimal markers of resuscitation in burn patients in an effort to decrease adverse fluid administration.

Geriatric Burn Injuries: Prevalence, Management and Clinical Outcome

Burns are a significant public health issue that result in more than 180 000 fatalities annually. For specialized burn care, the geriatric burn population is a sensitive and usually challenging group. Despite the fact that all age groups have shown advances in burn care, geriatrics still have worse survival rates. Burn severity, treatment, and outcomes are impacted in geriatrics because of the physiological differences between them and younger adult burn patients. The atrophic skin of the elderly results in deeper burns, or a higher ratio of full-thickness total body surface area compared to younger patients, but it also hinders the healing of both donor sites and burns. The purpose of this research is to review the available information about geriatric burn injuries: prevalence, management and clinical outcome. Elderly people are more susceptible to complications such pneumonia, congestive heart failure, and pulmonary edema. The morbidity and mortality seen in geriatric burn patients are also attributed to altered immunological and inflammatory response driven by age leading to increased hospital stays and more severe complications. Management of geriatric burn patients involves two concepts. the revolutionary theory of eschar excision and wound closure within the first week of hospitalization, and the conventional strategy of reducing physiologic stress by delaying surgery in the early post-burn stage while the development of effective fluid resuscitation protocols, which has most significantly boosted patient survival, is one of the pillars of modern burn care. The epidemiology of burn injuries in geriatrics is quite variable and demands further research.

Sepsis in Burns-Lessons Learnt from Developments in the Management of Septic Shock.

After surviving the acute phase of resuscitation, septic shock is the cause of death in the majority of burn patients. Therefore, the management of septic shock is a cornerstone in modern burn care. Whereas sepsis therapy in general has undergone remarkable developments in the past decade, the management of septic shock in burn patients still has a long way to go. Instead, the differences of burn patients with septic shock versus general patients have been emphasized and thus, burn patients were excluded in every sepsis study which are the basis for modern sepsis therapy. However, due to the lack of evidence in burn patients, the standards of procedure for general sepsis therapy have been adopted in burn care. This review identifies the differences of burn patients with sepsis versus other septic patients and summarizes the scientific basis for modern sepsis therapy in general ICU patients and burn patients. Consequently, the results in general sepsis research should be transferred to burn care, which means the implementation of effective screening, early resuscitation, and efficient antimicrobial treatment. Therefore, on the basis of past developments and in the light of the current update of the Surviving Sepsis Campaign guidelines, this review introduces the “Burn SOFA score” and the “3 H’s of burn sepsis” as a screening tool for early sepsis recognition in burn patients.

Nurse Staffing, the Clinical Work Environment, and Burn Patient Mortality.

The complexity of modern burn care requires an integrated team of specialty providers working together to achieve the best possible outcome for each burn survivor. Nurses are central to many aspects of a burn survivor's care, including physiologic monitoring, fluid resuscitation, pain management, infection prevention, complex wound care, and rehabilitation. Research suggests that in general, hospital nursing resources, defined as nurse staffing and the quality of the work environment, relate to patient mortality. Still, the relationship between those resources and burn mortality has not been previously examined. This study used a multivariable risk-adjusted regression model and a linked, cross-sectional claims database of more than 14,000 adults (≥18 years) thermal burn patients admitted to 653 hospitals to evaluate these relationships. Hospital nursing resources were independently reported by more than 29,000 bedside nurses working in the study hospitals. In the high burn patient-volume hospitals (≥100/y) that care for the most severe burn injuries, each additional patient added to a nurse's workload is associated with 30% higher odds of mortality (P < .05, 95% CI: 1.02-1.94), and improving the work environment is associated with 28% lower odds of death (P < .05, 95% CI: 0.07-0.99). Nursing resources are vital in the care of burn patients and are a critical, yet previously omitted, variable in the evaluation of burn outcomes. Attention to nurse staffing and improvement to the nurse work environment is warranted to promote optimal recovery for burn survivors. Given the influence of nursing on mortality, future research evaluating burn patient outcomes should account for nursing resources.

T4 Nursing Matters! Better Nurse Staffing and Work Environments Associated with Lower Burn Patient Mortality

Abstract Introduction The complexity of modern burn care requires an integrated team of clinicians working together to achieve the best possible outcome for each survivor. Nurses are central to many aspects of a burn survivor’s care including physiologic monitoring, fluid resuscitation, pain management, infection prevention, complex wound care, and rehabilitation. Previous research suggests that hospital nursing resources such as staffing, education, and the quality of the work environment relate to overall patient mortality, but the relationship between those resources and burn mortality has not been previously examined. Due to their unique and complex care needs, burn patients are likely highly sensitive to nursing resources. Methods This study examined whether patient-to-nurse ratios, nurse education, and features of the clinical work environment are associated with burn patient in-hospital mortality. A multivariable regression model using a linked, cross-sectional claims database of 14,064 adult (&amp;gt;18 yrs.) burn patients admitted to 653 hospitals was employed. Mortality was risk-adjusted for age, burn size, the presence of mechanical ventilation, co-morbidities, and hospital characteristics such as burn patient volume, technological capabilities, and teaching status. Nursing resources were independently reported by 29,586 bedside nurses working in the study hospitals. The work environment was assessed using the National Quality Forum-endorsed Practice Environment Scale. Nursing resources differ in the high vs. low-volume hospitals, so the final model includes an interaction term for each nursing resource and hospital burn patient volume. Results In the risk-adjusted main-effects model, the patient’s age, burn size, presence of mechanical ventilation, comorbidities, and hospital burn patient volume were all significantly associated with in-hospital mortality. The full model including interaction terms suggests that in high burn patient volume hospitals (&amp;gt;100 patients / yr.) each additional patient added to a nurse’s workload is associated with 30% higher odds of mortality (p&amp;lt; 0.05, 95% CI [1.02, 1.94]), and improvements in the nurse work environment are associated with 28% lower odds of mortality (p&amp;lt; 0.05, 95%CI [0.07, 0.99]). Conclusions Nurse staffing and the nurse work environment significantly relate to burn patient mortality in high-volume burn hospitals where the most complex burn patients often receive care. Applicability of Research to Practice Nursing resources are critical to the survival of the most complex burn patients, and are a significant, yet previously unmeasured variable in the evaluation of burn outcomes. To promote optimal recovery for burn survivors, attention to nurse staffing and the work environment is warranted. Future evaluations of burn patient outcomes should account for hospital nursing resources.

Geospatial Mapping as a Guide for Resource Allocation Among Burn Centers in India.

Timely treatment is essential for optimal outcomes after burn injury, but the method of resource distribution to ensure access to proper care in developing countries remains unclear. We therefore sought to examine access to burn care and the presence/absence of resources for burn care in India. We surveyed all eligible burn centers (n = 67) in India to evaluate burn care resources at each facility. We then performed a cross-sectional geospatial analysis using geocoding software (ArcGIS 10.3) and publicly available hospital-level data (WorldStreetMap, WorldPop database) to predict the time required to access care at the nearest burn center. Our primary outcome was the time required to reach a burn facility within India. Descriptive statistics were used to present our results. Of the 67 burn centers that completed the survey, 45% were government funded. More than 1 billion (75.1%) Indian citizens live within 2 hours of a burn center, but only 221.9 million (15.9%) live within 2 hours of a burn center with both an intensive care unit (ICU) and a skin bank. Burn units are staffed primarily by plastic surgeons (n = 62, 93%) with an average of 5.8 physicians per unit. Most burn units (n = 53, 79%) have access to hemodialysis. While many Indian citizens live within 2 hours of a burn center, most centers do not offer ICU and skin bank services that are essential for modern burn care. Reallocation of resources to improve transportation and availability of ICU and skin bank services is necessary to improve burn care in India.

Tissue Inflammatory Markers and Oxidative Stress in Swine Subjected to a 40% TBSA Burn Injury

Burn injury is well known to induce a robust inflammatory response and hypermetabolic state. Intravenous (IV) crystalloid fluid resuscitation of burn patients is the foundation of modern burn care to improve tissue perfusion and outcomes. However, under military scenarios of far‐forward burn care or under civilian mass casualty situations, the availability of large volumes of such fluids for IV burn resuscitation will be logistically challenging and definitive burn care may be delayed for days. More recently, enteral resuscitation of burns has received renewed attention and some evidence suggests that it may reduce IV fluid requirements to support urine output. The present study investigated the early response of tissue inflammatory markers and evidence for oxidative stress in swine subjected to a 40% burn and resuscitated with enteral fluids compared to no fluids or a standard of care IV fluid regimen. Anesthetized Yorkshire swine (n=6 per group) were subjected to a 40% full thickness total body surface area (TBSA) burn with brass probes heated to 100°C. They were then randomized to 4 groups: 1) no fluid (NF), 2) 15 ml/kg/d WHO oral rehydration solution (ORS) (15‐ORS), 3) 70 ml/kg ORS (70‐ORS) or 4) 2 ml/kg/% burn IV lactated Ringer's (Modified Brooke (MB) formula‐ a standard of care). After 48 h, animals were euthanized and heart, liver, kidney, lung and small intestine collected and analyzed for tissue cytokine levels and indices of oxidative stress. As expected, urine output was higher in the 70‐ORS and MB groups than the NF group (p&lt;0.01). Although plasma creatinine and BUN peaked 6 h after burn, levels returned to baseline by 48 h in all groups except 15‐ORS and NF. In the kidney, levels of IL‐1β, IL‐6 and TNF‐α tended to be higher in the 70‐ORS and MB groups, whereas IL‐10 levels were similar among groups. In liver, heart and jejunum, only IL‐1β levels tended to be higher in MB than the other groups, with a similar trend in IL‐10 concentrations. With regard to oxidant status in kidney, total antioxidant levels, glutathione reductase (GR) and glutathione peroxidase activities were higher in 70‐ORS than the other groups. Mn‐superoxide dismutase (SOD) activity was higher in both 70‐ORS and MB groups, with no differences in catalase activity or nitric oxide levels. In liver, the lowest levels of total antioxidants, SOD, GR and catalase activities were observed in the NF groups compared to the others. No significant differences in indices of antioxidant status were observed in jejunum, heart or lung among groups. Typically, these variables in 15‐ORS were similar to the NF group in all tissues. The results of this study indicate that enteral fluids may be as effective as a standard of care IV fluid regimen in maintaining antioxidant status in vital organs without major changes in pro‐inflammatory cytokines. As such, this oral resuscitation may prove lifesaving in resource poor environments and reduce potential IVfluid‐related complications until definitive clinical care is available.Support or Funding InformationFunded by US Army MRMCThis abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Enteral resuscitation with oral rehydration solution to reduce acute kidney injury in burn victims: Evidence from a porcine model.

Intravenous (IV) resuscitation of burn patients has greatly improved outcomes and become a cornerstone of modern burn care. However, the heavy fluids and vascular access required may not be feasible in austere environments, mass casualty, or delayed transport scenarios. Enteral resuscitation has been proposed for these situations; we sought to examine the effectiveness of this strategy on improving burn-induced kidney injury. Anesthetized Yorkshire swine sustaining 40% TBSA full-thickness contact burns were randomized to three groups (n = 6/group): fluid deprivation, ad libitum water access, or 70 mL/kg/d Oral Rehydration Salt solution (ORS). Urine and blood were collected at baseline (BL), 6, 12, 24, 32, and 48h post-burn, at which point tissue was harvested and CT angiography performed. Although fluid consumption by ad libitum and ORS groups were matched (132±54mL/kg versus 120±24mL/kg, respectively), ORS intake increased urine output compared with water and no water (47.3±9.0 mL/kg versus 16.1±2.5 mL/kg, and 24.5±1.7 mL/kg respectively). Plasma creatinine peaked 6h following burn (1.67±0.07mg/dL) in all animals, but at 48h was comparable to BL in animals receiving water (1.23±0.06mg/dL) and ORS (1.30±0.09mg/dL), but not fluid deprived animals (1.56±0.05mg/dL) (P<0.05). Circulating levels of blood urea nitrogen steadily increased, but also decreased by 48h in animals receiving enteral fluids (P<0.05). Water deprivation reduced renal artery diameter (-1.4±0.17mm), whereas resuscitation with water (-0.44±0.14 mm) or ORS maintained it (-0.63±0.20 mm;P< 0.02). Circulating cytokines IL-1β, IL-6, IFNγ, and GM-CSF were moderately elevated in the fluid-deprived group. Taken together, the data suggest that enteral resuscitation with ORS rescues kidney function following burn injury. Incorporating enteral fluids may improve outcomes in resource-poor environments and possibly reduce IV fluid requirements to prevent co-morbidities associated with over-resuscitation. Studies into different volumes/types of enteral fluids are warranted. While ORS has saved many lives in cholera-associated dehydration, it should be investigated further for use in burn patients.

Swelling of the Subcutaneous Adipose, but not the Dermis, in Burn Wound Edema is Exacerbated by IV Fluids

Intravenous (IV) resuscitation of burn patients has greatly improved outcomes and become a cornerstone of modern burn care. However, the large volumes of crystalloid given can lead to various comorbidities such as compartment syndromes and acute respiratory distress syndrome. Simultaneously, it is well established that vascular leak leads to significant edema in the severely burned patient. The objective of this study was to begin to examine the interaction of edema of burn wounds and IV fluids. Anesthetized Yorkshire swine sustained 40% total body surface area (TBSA) full‐thickness contact burns with brass probes heated to 100°C placed on the skin for 30 seconds. Animals were recovered from anesthesia and randomized to one of four treatment groups: no IV fluids (n=6), IV lactated Ringer's (LR) resuscitation with the modified Brooke formula (MB; 2 ml/kg/%TBSA, n=6), 15 mL/kg/d of IV LR (LR: n=6), or 15 mL/kg/d fresh frozen plasma (FFP: n=6). Unburned sham animals (n=4) and injured animals were assessed for 48 hours, at which point animals were humanely euthanized and dorsal and ventral dermis was taken to determine wet to dry weight ratios. Additionally, 3 biopsies to include dermis and the entire subcutaneous fat were taken from both the dorsal and ventral aspects of the animal for histological determination of tissue thickness. Burn wound edema was demonstrated by a significantly higher wet:dry ratio in all groups compared to sham animals for dorsal (P=0.017) and ventral (P=0.044) dermis. However, there was no difference amongst the various IV regimens. Moreover, neither burn nor IV fluids induced a difference in the thickness of the dermis on dorsal or ventral locations. In contrast, the thickness of the subcutaneous fat was significantly elevated in both dorsal (P=0.028) and ventral (P=0.0045) samples, depending on IV fluid regimen. Thickness of the dorsal fat layer was 1865 ± 327 μm, 2170 ± 205 μm, 3466 ± 421 μm, 2452 ± 271 μm, and 2707 ± 302 μm for Sham, no IV, MB, LR, and FFP groups, respectively. Thickness of the ventral fat layer was 1557 ± 164 μm, 2728 ± 184 μm, 2618 ± 172 μm, 2368 ± 236 μm, and 3329 ± 352 μm for Sham, no IV, MB, LR, and FFP groups, respectively. Collectively, these data demonstrate that volumes and types of IV fluids can alter burn‐induced edema in an anatomically‐dependent manner. Elucidating the specific drivers of burn wound edema may lead to personalized medicine approaches that can minimize comorbidities associated with over/under resuscitation of the burn patient.Support or Funding InformationThis study was supported by Military Burn Research Program Award# W81XWH‐16‐2‐0041.This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

A Review of the First Seminar That Set the Stage for the Creation of the American Burn Association.

As the first civilian burn center in the United States, the Evans-Haynes burn center shares a rich history with the American Burn Association. This is evidenced by a review of Dr. B.W. Haynes Jr's personal notes, which were shared with us by his daughter. Dr. Haynes states, in his own hand writing, that this 1959 burn seminar led to the formation of the American Burn Association. The manuscript contains a meticulous collection of discussions among leaders in the development of modern burn care. These discussions range from debates about burn resuscitation and the early use of antibiotics to the reconstruction of large burn defects and release of burn scars. We propose a detailed discussion of Dr. Haynes's notes. In addition, we include a review of the participants in this event as well as some of their accomplishments. In conclusion, this article provides a rare insight into the history of burn management and highlights the many challenges that remain in modern burn care.