Total Body Surface Area Involvement Research Articles

Bacterial fluorescence imaging as a predictor of skin graft integration in burn wounds

BackgroundSplit-thickness skin graft (STSG)11STSG: Split-thickness skin grafts integration rates are susceptible to improvement. Infection and/or biofilm should be appropriately addressed prior to grafting to improve the likelihood of graft-take. Incorporating technological aids such as fluorescence (FL)22FL: Fluorescence imaging (MolecuLight®), which accurately locates areas of bacterial loads above 104 CFU/gr, for graft site assessment and preparation could yield better outcomes. MethodsThis single-center, prospective observational study included adult burn patients with previously infected wounds that had been deemed clinically and microbiologically clean and were therefore candidates for grafting. Prior to grafting, a FL imaging assessment (blinded to the surgical team) localized areas positive for moderate-high bacterial loads (>104 CFU/gr). Intra-operatively, a standard swab sample from the recipient site was collected by the surgical team. Postoperatively, areas positive/negative for FL and areas of graft take and failure were overlapped and measured (cm2) over a 2D schematic. The performance and accuracy of FL imaging and swab sampling in relation to graft outcomes were assessed. Results38 patients were enrolled in the study. The mean total body surface area (TBSA)33TBSA: Total body surface area involvement was 14.5 ± 12.4 % [range 0.8 – 40.2 %]. 25/38 of the subjects enrolled had complete graft take while 13 had partial graft losses. There were no total losses. FL-imaging was positive in 100 % of losses versus 31 % (4/13) of the swab microbiology. FL-imaging was found to have a sensitivity of 86 %, specificity of 98 %, PPV of 72 %, NPV of 99 %, and an accuracy of 94 % for predicting any type or range of graft loss in the entire cohort. Meanwhile, the sensitivity of microbiology from swab samples was 30 %, with a specificity of 76 %. ConclusionsFL imaging is an accurate method for assessing recipient sites and predicting the outcome of a skin graft among burn patients. These findings suggest that FL imaging can inform better decision-making surrounding grafts that may lead to better outcomes. Level of evidenceLevel IIA, Therapeutic study

High area deprivation index is associated with increased injury severity in pediatric burn patients

BackgroundBurn injuries play a significant role in pediatric injury-related mortality and morbidity. In this study, we aim to explore the relationship between patient demographics, socioeconomic factos and burn severity in pediatric patients. MethodsPatients under age 14 hospitalized at Westchester Medical Center for burn injury between 2015 and 2021 were reviewed. Demographic variables including mechanism of burn, total body surface area (TBSA) involvement, surgical intervention, hospital length of stay (LOS), and LOS per TBSA burn were extracted. The Area Deprivation Index (ADI) was calculated to further assess socioeconomic factors. ResultsWe included 399 patients under the age of 14 hospitalized for burn injuries at our institution between 2015 and 2021. The median age was 2 (IQR 1–6) years old, and 42.6% were female. High ADI (p = 0.018), Caucasian race (p = 0.001), and flame mechanism (p < 0.001) were independently associated with burn TBSA> 5%. LOS per TBSA was shorter in the Caucasian population (p = 0.022). ConclusionIn burn injury patients, further research is necessary to investigate modifiable risk factors in individuals of Caucasian race or lower socioeconomic status to target effective prevention campaigns.

Effect of Burns over Speech: In Context to Dying Declaration

The dying declaration remains important evidence in trials of burned victims in India. However, its evidentiary value is often negated because facial involvement or larger body area involved due to burns may make victims incapable of speaking properly. Hence, this study aimed to study the effect of burn on speech in relation to parameters like age, gender, and total body surface area affected (TBSA). The study included eighty patients having burn injuries over the head, neck, face, and upper chest. They were evaluated longitudinally from the time of infliction of burns at six hourly intervals, at 6 hours, 12 hours, 18 hours, and 24 hours. The speech was assessed using a scale having components of orientation, content, coherence, and articulation. The speech was well preserved in maximally affected age groups (21-40 years); speech was found to be preserved in varying involvement of body surface area. While considering gender and speech, it is observed that speech is relatively unaffected in females; in fact, females can tolerate burns better than males and have well-preserved speech. The above findings were constant at all-time intervals, i.e., at 6 hours, 12 hours, 18 hours, and 24 hours. Overall, the study disproves the notion that burn victims having facial involvement and greater total body surface area (TBSA) involvement cannot give a valid dying declaration.

An alternative model for assessing mortality risk in Stevens Johnson syndrome/toxic epidermal necrolysis using a random forests classifier: A pilot study.

Mortality risk prediction is an important part of the clinical assessment in the Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) patient. The SCORTEN and ABCD-10 scoring systems have been used as predictive clinical tools for assessing this risk. However, some of the metrics required in calculating these scores, such as the total body surface area (TBSA) involvement, are difficult to calculate. In addition, TBSA involvement is calculated in a variety of ways and is observer dependent and subjective. The goal of this study was to develop an alternative method to predict mortality in patients with SJS/TEN. Data was split into training and test datasets and preprocessed. Models were trained using five-fold cross validation. Out of several possible candidates, a random forests model was evaluated as being the most robust in predictive power for this dataset. Upon feature selection, a final random forests model was developed which was used for comparison against SCORTEN. The differences in both accuracy (p = 0.324) and area under the receiver operating characteristic curve (AUROC) (p = 0.318) between the final random forests model and the SCORTEN and ABCD-10 models were not statistically significant. As such, this alternative method performs similarly to SCORTEN while only requiring simple laboratory tests from the day of admission. This new alternative can make the mortality prediction process more efficient, along with providing a seamless implementation of the patient laboratory tests directly into the model from existing electronic health record (EHR) systems. Once the model was developed, a web application was built to deploy the model which integrates with the Epic EHR system on the Fast Healthcare Interoperability Resources (FHIR) Application Programming Interface (API); this only requires the patient medical record number and a date of the lab tests as parameters. This model ultimately allows clinicians to calculate patient mortality risk with only a few clicks. Further studies are needed for validation of this tool.

Predictors of large cell transformation in patients with Sezary Syndrome-A retrospective analysis.

Large cell transformation (LCT) of Sezary Syndrome (SS) is a rare phenomenon. To date, there are no rigorous studies identifying risk factors for its development. Here, we seek to characterize the clinicopathologic risk factors that predispose patients with SS to develop LCT. We retrospectively evaluated all SS patient records available in the Michigan Medicine Cancer Registry from 2010-2021. Clinical and pathologic variables were compared between groups. The Kaplan-Meier method and log-rank test were used to assess overall survival. Of 28 SS patients identified, eight patients experienced LCT, and 20 did not (NLCT). Peak lactate dehydrogenase (LDH) before LCT (p = 0.0012), maximum total body surface area (TBSA) involvement before LCT (p = 0.0114), absolute CD8+ cell count measured on flow cytometry at diagnosis of SS (p = 0.0455) and at the most recent blood draw (p = 0.00736), and ulceration on biopsy (p = 0.0034) were significant clinicopathologic variables identified between the SS patients that developed LCT versus those that did not. Maximum TBSA involvement, peak LDH, presence of ulceration, and decreased levels of CD8+ cells in the peripheral blood may predict the development of LCT in patients with SS.

The CONTROL study: A randomized, double-blind vehicle-controlled phase 2b study of novel topical isotretinoin formulation demonstrates improvement in recessive X-linked and autosomal recessive lamellar congenital ichthyosis

The CONTROL study: A randomized, double-blind vehicle-controlled phase 2b study of novel topical isotretinoin formulation demonstrates improvement in recessive X-linked and autosomal recessive lamellar congenital ichthyosis

Scoring Assessments in Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis.

Epidermal necrolysis, the unifying term for Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), is a severe cutaneous drug reaction associated with high morbidity and mortality. Given the rarity of this disease, large-scale prospective research studies are limited. Significant institutional and geographical variations in treatment practices highlight the need for standardization of clinical assessment scores and prioritization of research outcome measures in epidermal necrolysis. At the present, clinical assessment is typically simplified to total body surface area (BSA) involvement, with little focus on morphology. Validated clinical scoring systems are used as mortality prognostication tools, with SCORTEN being the best-validated tool thus far, although the ABCD-10 has also been recently introduced. These tools are imperfect in that they tend to either overestimate or underestimate mortality in certain populations and are not designed to monitor disease progression. Although mortality is often used as a primary endpoint for epidermal necrolysis studies, this outcome fails to capture more nuanced changes in skin disease such as arrest of disease progression while also lacking a validated skin-directed inclusion criterion to stratify patients based on the severity of skin disease at study entry. In addition to mortality, many studies also use BSA stabilization or time to re-epithelialization as endpoints, although these are not clearly defined morphologically, and inter- and intra-rater reliability are unclear. More specific, validated cutaneous assessment scores are necessary in order advance therapeutic options for epidermal necrolysis. In this review, we summarize the strengths and weaknesses of current clinical assessment practices in epidermal necrolysis and highlight the need for standardized research tools to monitor cutaneous involvement throughout the hospitalization.

Short- and long term hyposmia, hypogeusia, dysphagia and dysphonia after facial burn injury – A prospective matched cohort study

BackgroundFacial burns frequently occur in occupational or household accidents. While dysphagia and dysphonia are known sequelae, little is known about impaired smell and taste after facial burns. MethodsIn a prospective observational controlled study, we evaluated hyposmia via the Sniffin’ Stick Test (SnS), hypogeusia via a taste strip test, and dysphonia and dysphagia via validated questionnaires acutely and one-year after burn, respectively. A matched control group consisting of a convenience sample of healthy volunteers underwent the same assessments. ResultsFifty-five facial burn patients (FB) and 55 healthy controls (CTR) were enrolled. Mean burn size was 11 (IQR: 29) % total body surface area (TBSA); CTR and FB were comparable regarding age, sex and smoking status. Acutely, hyposmia was present in 29% of the FB group (CTR: 9%, p = 0.014) and burn patients scored worse on the SnS than CTR (FB: 10; CTR: 11; IQR: 2; p = 0.013). Hyposmia per SnS correlated with subjective self-assessment. Hyposmia and SnS scores improved over time (FB acute: 10.5 IQR: 2; FB one year: 11; IQR: 2; p = 0.042) and returned to normal at one-year post burn in most patients who completed the study (lost to follow-up: 21 patients). Taste strip scores were comparable between FB and CTR, as was the acute prevalence of dysphagia and dysphonia. ConclusionHyposmia acutely after facial thermal trauma appeared frequently in this study, especially when complicated by inhalation trauma or large TBSA involvement. Of all complete assessments, a fraction of burn patients retained hyposmia after one year while most improved over time to normal. Prevalence of dysphonia, dysphagia and hypogeusia was comparable to healthy controls in this study, perhaps due to overall minor burn severity.

806 Foot burns in diabetic patients: A systematic review

IntroductionPatients with diabetes are prone to foot injuries and burns. Managing burned feet in patients with diabetes can be difficult due to multiple concomitant patient comorbidities that delay wound healing. Burn surgeons tasked with treating these complex foot burns understand that these patients are at risk of developing significant complications, such as infections and non-healing diabetic foot ulcers, which may ultimately lead to amputation. Although there are many studies that examine the causes and outcomes of diabetic foot ulcers and their management, there is a lack of consensus on how to best manage lower extremity burns in patients with diabetes.MethodsA systematic review was performed according to PRISMA criteria and identified 18 articles addressing the management of burned feet in patients with diabetes. Means and standard deviations of scale variables and frequencies derived from nominal and ordinal variables abstracted from the literature were compared between each group. A meta-analysis was attempted but existing data was not of sufficient quality for meaningful analysis, and data aggregation was done where applicable.ResultsThe three-database search identified 726 articles, which yielded 18 full text articles that met inclusion criteria. mean age of patients was 54 years (SD 7), and 80% (n=203) were male. Most (90%, n=179) had type II diabetes, and 10% (n=20) had Type I diabetes. Mean duration of diabetic disease was 11 years (SD 4), and mean A1c at admission was 9% (SD 1). Peripheral neuropathy (64%, n=123) was the most common comorbidity. Median TBSA burned was 2% (IQR 2), and scald (56%, n=155) was the most common mechanism of injury. Full thickness burns (70%, n=102) were most common, followed by partial thickness (28%, n=41), and superficial thickness (2%, n=2). A majority (55%, n=88) had burn wound infection identified at admission. Patients had a median delay in presentation from time of injury to hospital admission of 4 days (IQR 4.5). Sixty percent of patients received surgical treatment via excision and grafting, had a median length-of-stay of 20.5 days despite a median total body surface area involvement of 2%, and experienced sequelae of impaired wound healing such as infections, graft loss, and need for further surgery. Ultimately, 23% of patients had significant wound healing issues that resulted in amputation.ConclusionsExcision and grafting may not be the optimal approach for managing foot burns in patients with diabetes, many of whom are at high risk of amputation. Non-operative management of foot burns in patients with diabetes should be explored as a method to decrease amputations in patients with foot burns.

529 Outcomes of Total Parenteral Nutrition Use in Burn Patients at a Single Institution

IntroductionTotal parenteral nutrition (TPN) has been widely used among critically ill patients. Some of the controversy surrounding parenteral nutrition stems from its early use in the 1980s, which primarily focused on hyperalimentation. In burn patients, nutritional support is a critical aspect of treatment. The metabolic rate in this patient population can be greater than twice the normal rate, and this hypermetabolic response can last more than a year after the burn injury has occurred. The objective of this study was to evaluate the outcomes of patients in our Burn Center who received TPN during their hospitalization.MethodsThis was a single-site, retrospective review using our institutional Burn Center registry. All adult patients (18 years or older) admitted to our Burn Center between July 1, 2015 and June 30, 2021 who had received TPN during their hospitalization were included in this study. Adult patients who had not received TPN were included for comparative purposes. Variables of interest included demographics, burn mechanism, length of stay (LOS), ICU and ventilator days, and mortality.ResultsThere were 20 burn patients who received TPN during their hospitalization. Of those patients who received TPN, 90% were male. The mean age was 45 years, and the mean total body surface area (TBSA) involvement was 32%. The mean resting energy expenditure (REE) was 3,084. On average, the time from day of admission to initiation of TPN was 40 days, and the mean length of TPN administration was 20 days. The overall decrease in patient weight from admission to discharge was 10%. The mean LOS for the TPN group was 118 days. The mean LOS in the ICU was 92 days. The mean ventilator days were 89 days. The overall hospital mortality of patients who received TPN was 20%. When matched with patients who had similar TBSA involvement and who had not received TPN, there was no difference in mortality. However, there was a significant difference in weight loss (4% for non-TPN group), overall LOS (63 days), ICU LOS (29 days), and ventilator days (31 days).ConclusionsBurn patients who received TPN during their hospitalization had a greater decrease in their overall weight, had a longer hospital and ICU length of stay, and were ventilated longer than those patients who did not receive TPN. These findings are to be expected given that patients who receive TPN tend to be more critically ill, and therefore, require more nutritional support.

553 Does COVID-19 Lead to Worse Outcomes in A Burn Center?

IntroductionThe global pandemic caused by severe acute respiratory syndrome coronavirus-2 (COVID-19) has exhausted resources and devastated at-risk populations. Our objective was to determine if COVID-positive patients have worse outcomes compared to COVID-negative patients after burn injury or desquamating skin disorders.MethodsPatients were identified using our institutional Burn Center registry and linked to the clinical and administrative data. All patients admitted between March 1, 2020 and August 31, 2021 were eligible for inclusion. Demographics, length of stay (LOS), co-morbid conditions, and mortality were evaluated. Statistical analysis was performed with Students’ t-test, chi-squared, and Fischer’s exact test.ResultsA total of 1,994 patients were admitted during this period, and of those patients, 1,467 were adults. Twenty-three adults were COVID-positive. There were no significant differences in age, LOS, total body surface area (TBSA) involvement, hospital costs, sex, race or ethnicities of patients. There were no significant differences in percentage of patients presenting for burn or desquamating skin disorders. COVID-positive adult patients had a significantly higher mortality after injury than COVID-negative adults, p=0.003. There were no differences in COVID-positive pediatric patients admitted to our burn center.ConclusionsA positive COVID test is associated with worse outcomes in patients admitted for burn injury or skin-sloughing disorders. Further study is warranted to investigate and mitigate what aspect of their care could be adjusted to improve outcomes.

737 Prevalence and Outcomes of HIV Infection Among Burn Patients at a Single Institution

IntroductionBurn injuries are a significant cause of morbidity and mortality worldwide. Pre-existing conditions may further complicate a patient’s outcome and delay wound healing. Human immunodeficiency virus (HIV) remains an ongoing problem globally and contributes to the morbidity of patients with burn injuries. According to the Centers for Disease Control and Prevention (CDC), the prevalence of individuals with HIV in the United States was 1.2 million in 2018. Burn patients and those with desquamating skin disorders are already in an immunocompromised state, and thus, the effect of HIV on the healing and recovery process can be significant. The objective of this study was to evaluate the prevalence and outcomes of HIV-positive patients admitted to our Burn Center.MethodsThis was a single-site, retrospective review using our institutional Burn Center registry. All adult patients (18 years or older) admitted to our Burn Center between July 1, 2010 and June 30, 2020 who were HIV-positive were included in this study. All adult patients who were HIV-negative and admitted during the same period were included for comparative purposes. Variables of interest included demographics, burn mechanism, length of stay (LOS), cost of hospitalization, and mortality.ResultsThere were 32 HIV-positive burn patients and 16 HIV-positive patients with desquamating skin disorders (e.g., Stevens-Johnson syndrome/Toxic Epidermal Necrolysis). For the burn group, the mean age was 46.9 years +/- 10.6 years, and the mean total body surface area (TBSA) involvement was 3.2% +/- 4.2%. The mean LOS among HIV-positive burn patients was 9.13 days +/- 17.73 days, and the mean cost of hospitalization was $54,613. For the desquamating skin disorders group, the mean age was 47.1 years +/- 13.9 years, and the mean TBSA was 16.2% +/- 29.0%. The mean LOS was 17.25 days +/- 25.26 days, and the mean cost of hospitalization was $138,358. In terms of overall hospital mortality, there were no deaths among HIV-positive burn patients; however, the mortality was 25% among HIV-positive patients with desquamating skin disorders (n = 4). When both groups were compared to HIV-negative patients, overall hospital mortality remained higher among HIV-positive patients with desquamating skin disorders.ConclusionsManagement of HIV-positive burn patients presents a unique challenge for clinicians due to the immunocompromised state of this patient population. The challenge may even be more pronounced in HIV-positive patients with desquamating skin disorders as demonstrated in this study.

128 Mental Health Outcomes in Burn Patients: A Single-site Experience

IntroductionBurn injuries are a leading cause of morbidity and mortality among patients worldwide. Many survivors continue to suffer from psychiatric sequalae long after their physical injuries have healed. This may even be more pronounced in groups who have a history of mental health disorders prior to admission. Common pre-injury mental health problems may include substance abuse disorders, as well as affective, psychotic, and personality disorders. The aim of this study was to explore the outcomes of patients with previously diagnosed mental health disorders who were admitted to our Burn Center.MethodsThis was a single-site, retrospective review using our institutional Burn Center registry. All adult patients (18 years or older) admitted to our Burn Center between January 1, 2014 and June 30, 2021 who had a previous history of mental health disorders were included in this study. All adult patients who did not have any previous history of mental health disorders were also included for comparative purposes. Variables of interest included demographics, burn mechanism, length of stay (LOS), cost of hospitalization, and mortality. A p-value of < 0.05 was considered statistically significant for all analyses.ResultsThere were 7,976 patients included in this study, with 32% of these patients having a previous diagnosis of mental health disorders. The mean age was 43.5 years, and the mean total body surface area (TBSA) involvement was 5.9%. Both the groups with a history of mental health disorders and those without were predominantly male (63.8% versus 68.0%). Most patients were flame-injured in both groups (44.5% versus 40.9%). The mean LOS for those with mental health disorder history was 14.5 days compared to 8.3 days for those without (p < 0.00001). The overall cost of hospitalization was $133,967 for those with mental health disorder history and $65,993 for those without (p < 0.00001). The overall hospital mortality for those with mental health disorder history was 2.3% and 3.4% for those without (p = 0.007).ConclusionsAlthough there was no increase in mortality among patients with pre-existing mental health disorders, we did find that there was an increase in the hospital length of stay, as well as the overall cost of hospitalization. These findings do indicate that individuals with pre-existing mental health disorders do not necessarily have worse outcomes in terms of mortality; however, they may need access to care for longer periods of time, which may contribute to increased medical costs.

702 Outcomes of COPD Patients with Burn Injuries at a Single Institution

IntroductionChronic obstructive pulmonary disease (COPD) is a condition with significant morbidity and mortality. In 2018, about 16 million adults in the United States reported a diagnosis of COPD based on data from the American Lung Association. Home oxygen is often used in more severe cases of COPD, and despite warnings against smoking while using home oxygen, many patients continue to sustain burn injuries. An existing diagnosis of COPD can further complicate management of a burn patient, especially if there is concomitant inhalation injury present. The objective of this study was to explore the outcomes of COPD patients admitted to our Burn Center.MethodsThis was a single-site, retrospective review using our institutional Burn Center registry. All adult patients with flame burns (18 years or older) admitted to our Burn Center between July 1, 2011 and June 30, 2020 who had a history of COPD with and without home oxygen use were included in this study. All adult patients with flame burns, who did not have a history of COPD, were included for comparative purposes. Variables of interest included demographics, burn mechanism, length of stay (LOS), ICU and ventilator days, and mortality.ResultsThere were a total of 4,397 patients with flame burns included in this study, and 515 of those patients were identified to have an existing diagnosis of COPD. The mean age of the COPD group was 45.1 years +/- 13.0 years, and the patient population was predominantly male (60.4%). The mean total body surface area (TBSA) involvement was 5.12% +/- 10.38%. Inhalation injury was present in 10.1% of patients with COPD and in 7.8% of those without COPD. The mean LOS for the COPD group was 11.9 days +/- 19.4 days and 13.4 days +/- 31.0 days for the non-COPD group. The mean ICU LOS for the COPD group was 11.2 days +/- 19.9 days and 18.0 days +/- 37.0 days for the non-COPD group. The mean number of ventilator days was 16.5 days +/- 35.4 days for the COPD group and 26.3 days +/- 42.0 days for the non-COPD group. The overall hospital mortality was 10.3% for the COPD group and 4.3% for the non-COPD group.ConclusionsThis study demonstrates that the overall hospital mortality was highest in the COPD group. Although hospital and ICU length of stay, as well as the number of ventilator days were higher in the non-COPD group, it remains clear that an existing diagnosis of COPD can negatively impact the outcomes of burn patients.

719 Effects of Obesity on Outcomes of Adult Burn Patients at a Single Institution

IntroductionObesity is a global epidemic that continues to worsen. In 2016, more than 1.9 billion adults were considered overweight worldwide and over 650 million were obese. It is well-known that excess adipose tissue may alter inflammatory and immune mediator regulations, which can lead to challenges in managing resuscitation efforts, respiratory support, and thromboprophylaxis of burn patients. The objective of this study was to evaluate the outcomes of burn patients with obesity at our institution.MethodsThis was a single-site, retrospective review using our institutional Burn Center registry. All adult patients (18 years or older) admitted to our Burn Center between July 1, 2013 and June 30, 2021 who were classified as obese (i.e., body mass index > 30.0) were included in this study. All adult patients who were classified as underweight, normal weight, or overweight were also included for comparative purposes. Variables of interest included demographics, burn mechanism, length of stay (LOS), cost of hospitalization, and mortality.ResultsThere were 7,626 patients included in this study, with the largest percentage of patients included in the obese category (38.4%). Among the obese population, most of the patients (53.2%) were classified under ‘Obesity Class I’ (i.e., body mass index 30.0 – 34.9). The majority of patients in each category were male, except in the ‘Obesity Class III’ category (i.e., body mass index > 40.0) where 54.8% of the population were female. The mean age of the entire study sample was 44.9 years +/- 17.5 years, while the mean total body surface area (TBSA) involvement was 5.1% +/- 10.0%. The mean LOS of the entire study population was 10.3 days +/- 22.6 days, with patients in the ‘Obesity Class III’ category having the longest LOS with 14.0 days +/- 36.5 days. The cost of hospitalization was lowest in the overweight group with $82,661, while the highest cost was in the ‘Obesity Class III’ group with $130,683. The overall hospital mortality for the entire study population was 3.0% with the highest mortality noted in the ‘Obesity Class III’ group (4.7%).ConclusionsObesity affects all aspects of a burn patient’s care throughout their hospitalization. In our study, obesity was associated with longer LOS, cost of hospitalization, and mortality; therefore, it is imperative to understand the negative effects that obesity can have on burn patients, not just in terms of their acute management, but also their continued care after hospitalization.

579 Benefits of Licensed Clinical Social Worker Utilization in an Adult Burn Clinic: More Than Just Checking the Box

Abstract Introduction Our burn institution cares for critically ill burn patients and provides post-acute care for a large referral base. The clinic is staffed by a wound certified physical therapist, an advanced practice registered nurse and a licensed clinical social worker (LCSW), with consult access to Trauma/Burn Surgeons. The incidence of acute stress symptoms after burn injury is noted in up to 35% to 40% of patients. Therefore, it is important to identify symptoms of anxiety and depression early and begin symptom management. Burn patients have access to a multi-disciplinary team, and a licensed therapist, that can identify symptoms of acute stress and make recommendations for appropriate treatment in concert with the medical staff. This project seeks to determine the prevalence of acute stress in post-acute burn patients seen in an adult burn clinic and the benefits of utilizing a Licensed Clinical Social Worker to perform screening. Methods For a one-year period all burn patients in the burn clinic were screened by the LCSW. The subjects underwent initial screenings for depression, anxiety, and suicide risk at their first clinic visit. The PHQ-2 and PHQ-9 were utilized to assess depression, the GAD-7 for anxiety and the Columbia Suicide scale to assess suicide risk. Patients were initiated into multi-modal therapies based on specific scoring. These intervention strategies were based on the Depression Screening Protocol which included education on depression, and/or anxiety, with or without participation in a Trauma/Burn Peer Support Group. Patients were prescribed medication per provider discretion, and/or connected to community resources such as, counseling, and psychiatric mental health services. Results During the one-year assessment period screening compliance was &amp;gt;90%. During this period, &amp;gt;50% of patient’s scores were clinically significant for acute stress. Over half of those that screened positive were connected to community resources of counseling services or psychiatric care. 100% of those that screened positive were given education and connection to peer support services. An incidental correlation was noted between increased total body surface area involvement and work-related accidents with increased symptomology. Conclusions The inclusion of an LCSW in the burn clinic has improved the overall care of the burn injured patient. The assessment of depression and anxiety related to the burn injury has led to an increase in peer support participation and an increase in referrals to counseling and/or psychiatric services.

515 Evaluation of growth hormone use in patients with large burns and complex wounds

Abstract Introduction Large burn injuries lead to an extensive and prolonged catabolic state that results in loss of body mass and impaired wound healing. To combat this hypermetabolic response, different strategies have been employed including early excision and grafting, infection control, early nutrition and anabolic therapies such as oxandrolone. Human growth hormone is of interest for burn patients because of its anabolic properties. While its use has been associated with worse outcomes in the critically ill adult with sepsis, it has shown improved outcomes when used in pediatric burn patients. The purpose of this study was to retrospectively evaluate the appropriateness of human growth hormone use, its adverse events and cost in patients with large burns or complex wounds and poor wound healing. Methods This was an IRB approved, retrospective, single center chart review from 2011 to 2019 assessing human growth hormone prescribing patterns in the burn unit. The primary objective was appropriateness of use, defined as documentation of poor wound healing prior to initiation despite adequate nutrition delivery and use of standard anabolic therapies (i.e., oxandrolone). Secondary objectives included perceived benefit, adverse events and median therapy cost per patient of human growth hormone. Results Thirty-eight patients were included in the study, 79% of which were adults, with a median total body surface area involvement of 50% (IQR 40 to 71). Only forty-one per cent of patients receiving human growth hormone met our predefined criteria for appropriateness; this was primarily driven by poor documentation of wound healing. However, 80% of patients were receiving adequate nutrition and oxandrolone, indicating appropriate clinical use. Most adult patients received a dose of 20mg daily, while pediatrics received the weight based 0.2mg/kg daily dose. The median duration of treatment was 24 days (IQR 13–35) and median time from admission to growth hormone initiation was 27 days (IQR 12–34). Overall clinical improvement was noted in 53% of patients, as evident by increased weight, prealbumin and/or documentation of improved wound healing. The most common adverse effect noted was hyperglycemia, followed by new sepsis onset. The median therapy cost per patient was $42,000. Conclusions Human growth hormone may serve as a salvage therapy for large burns with poorly healing wounds. Prior to initiating therapy, nutrition must be optimized and standard, more researched anabolic therapies should be started. While receiving therapy, patients should be monitored for both hyperglycemia and the development of new sepsis.

533 Evaluation of growth hormone use in patients with large burns and complex wounds

Abstract Introduction Large burn injuries lead to an extensive and prolonged catabolic state that results in loss of body mass and impaired wound healing. To combat this hypermetabolic response, different strategies have been employed including early excision and grafting, infection control, early nutrition and anabolic therapies such as oxandrolone. Human growth hormone is of interest for burn patients because of its anabolic properties. While its use has been associated with worse outcomes in the critically ill adult with sepsis, it has shown improved outcomes when used in pediatric burn patients. The purpose of this study was to retrospectively evaluate the appropriateness of human growth hormone use, its adverse events and cost in patients with large burns or complex wounds and poor wound healing. Methods This was an IRB approved, retrospective, single center chart review from 2011 to 2019 assessing human growth hormone prescribing patterns in the burn unit. The primary objective was appropriateness of use, defined as documentation of poor wound healing prior to initiation despite adequate nutrition delivery and use of standard anabolic therapies (i.e. oxandrolone). Secondary objectives included perceived benefit, adverse events and median therapy cost per patient of human growth hormone. Results Thirty-eight patients were included in the study, 79% of which were adults, with a median total body surface area involvement of 50% (IQR 40 to 71). Only forty-one per cent of patients receiving human growth hormone met our predefined criteria for appropriateness; this was primarily driven by poor documentation of wound healing. However, 80% of patients were receiving adequate nutrition and oxandrolone, indicating appropriate clinical use. Most adult patients received a dose of 20mg daily, while pediatrics received the weight based 0.2mg/kg daily dose. The median duration of treatment was 24 days (IQR 13–35) and median time from admission to growth hormone initiation was 27 days (IQR 12–34). Overall clinical improvement was noted in 53% of patients, as evident by increased weight, prealbumin and/or documentation of improved wound healing. The most common adverse effect noted was hyperglycemia, followed by new sepsis onset. The median therapy cost per patient was $42,000. Conclusions Human growth hormone may serve as a salvage therapy for large burns with poorly healing wounds. Prior to initiating therapy, nutrition must be optimized and standard, more researched anabolic therapies should be started. While receiving therapy, patients should be monitored for both hyperglycemia and the development of new sepsis.

Surface Area Graphic Evaluation (SAGE) Diagram Documentation in Burn Patients: Room for Quality Improvement.

BackgroundThe first step in the management of burn patients is an accurate estimation of the total body surface area (TBSA) involvement. Depending on which, burns are categorized as major (>20%) and minor (<20%). This then dictates fluid resuscitation and level of care. At the University of New Mexico Burn Center, we use Surface Area Graphic Evaluation (SAGE) diagramming to objectively estimate the body surface area involvement. We hypothesized patients undergoing SAGE documentation will have better outcomes. MethodsThis is a retrospective study of 320 consecutive patients from 2014-2018 at the University of New Mexico Burn Center. Only patients treated surgically were included. We recorded patient demographics, comorbidities, and burn details. The primary measure of interest was SAGE documentation and the secondary measure of interest was outcomes associated with it.ResultsWe found that a SAGE diagram was only documented for a minority of patients (40%). After comparing patients in the SAGE group vs. No SAGE group, we found that the patients were the same in both groups with regards to demographics, comorbidities, and burn characteristics. The use of a SAGE diagram did not appear to be a significant predictor of complications, including surgical site infections, graft loss, donor site complications, postoperative pneumonia, urinary tract infections, deep vein thrombosis, or myocardial infarction (p=0.254).ConclusionOnly a minority of patients get a SAGE diagram documented. However, our study did not find any improved outcomes with the use of a SAGE diagram. There is a need for prospective studies to validate the utility of SAGE diagramming in predicting adverse outcomes in major burns.

Fluid resuscitation in adult burns

Fluid replacement is an integral part of adult burn care, especially in patients with more than 20% total body surface area involvement. The fluid loss in burns has to be adequately replaced to maintain satisfactory tissue perfusion and prevent shock. Over these years, many different formulas and a variety of fluids have been used to resuscitate these patients. This article reviews the current trends and different approaches in fluid management.