Victorian Adult Burns Service Research Articles

The obesity paradox in patients with major burn injuries: a single tertiary burn centre review

Introduction: The obesity paradox is a phenomenon described in medical literature where overweight and obese patients have improved survival and better health outcomes. The obesity paradox is of curiosity to many clinicians as the general consensus in medicine has been that a higher body mass index results in poorer health outcomes in both medical and surgical conditions. The aim of this study is to determine whether the obesity paradox exists in our patients with major burn injuries. To our knowledge, this has not been previously investigated in the Australian major burn population. Methods: This is a retrospective study involving patients with major burn injuries > 20 per cent total body surface area admitted to the Victorian Adult Burns Service (Melbourne, Australia) from 1 January 2016 to 31 December 2020 (five-year period). Information collected included patient demographics, weight and height, and nature of burn injuries. Primary outcome of interest was inpatient mortality, and secondary outcomes included hospital length of stay, intensive care unit length of stay, duration of ventilation support required and presence of bacteraemia. Results: A total of 1704 patients were admitted, of whom 165 patients met inclusion criteria for analysis. The vast majority of 31 patients (18.8%) who died during admission were palliated. The obesity paradox did not exist in this study population. Furthermore, although not statistically significant, higher levels of body mass index showed increased risk of mortality. There was no significant association between body mass index and hospital length of stay (p = 0.16), intensive care unit length of stay (p = 0.72), duration of ventilation support (p = 0.62) nor bacteraemia (p = 0.68). Conclusion: The emerging evidence regarding the obesity paradox in the burn surgery literature is inconsistent. We contend that differences in burn management, including palliation of patients with major burn injuries, contribute to these findings.

Venous Thromboembolism in Severe Burns Patients with Intravascular Warming Catheter: A Retrospective Cohort Study

Background: Use of intravascular warming catheters following major burns has been shown to be effective to maintain normothermia, but their use may be associated with complications. The aim of this study was to determine what proportion of patients with an intravascular warming catheter developed a potentially catheter-related venous thromboembolism (VTE) and to identify contributing risk factors. Methods: This was a retrospective cohort study of patients admitted to the Victorian Adult Burns Service January 2013 to July 2018 with major burns (TBSA > 20%) who had an ICYTM intravascular warming catheter. Warming catheter insertion and other details were identified with a manual search of the patients’ medical records by a single author while incidence of VTE was determined by the coding department from a central database. Results: Forty patients had an intravascular warming catheter inserted during the study period. The number of patients in the catheter group that sustained a VTE was eight (20%), of which four (10%) could have been catheter-related due to the anatomical location. In the cases of the four potentially catheter-related VTE, other preventable VTE risk factors including suboptimal prophylactic anticoagulation (n = 2), prolonged catheter duration (n = 1) and prolonged haemoconcentration (n = 2) were identified. Conclusions: We found 20% of major burns patients with an intravascular warming device had significant VTE; however, only half of these may have been related to the catheter. A careful assessment for each patient that balances risks and benefits should be undertaken prior to using intravascular warming devices.

Early Impact of COVID-19 Pandemic on Burn Injuries, Admissions, and Care in a Statewide Burn Service

Anecdotal evidence from specialist burn clinicians suggested patient numbers and workloads increased during lockdown periods. This study aimed to describe the impact of the early COVID-19-related public health control measures (i.e., lockdowns) on burn injuries, hospital admissions, and care in a statewide burn service. We examined admissions data from The Victorian Adult Burns Service (located at the Alfred Hospital) and the Royal Children’s Hospital Burns Service—both of which contribute to the Burns Registry of Australia and New Zealand—during lockdown periods between March and October 2020, compared to the same periods in previous years. There were 714 patients admitted during the control period and 186 during the COVID-19 period. Burns sustained during COVID-19 lockdowns were larger in size. During COVID-19 lockdowns a greater proportion of patients were admitted to intensive care. Although the number of burn-related admissions did not increase during lockdowns, burn injuries that did occur were more severe (i.e., affected a greater percentage of body surface area). These more severe injuries placed an additional and significant burden on an already strained healthcare system. Future public health messaging should include prevention information to minimize the number of injuries occurring during lockdowns and other responses.

Perioperative antibiotic prophylaxis in Australian burns patients

Background: Perioperative antibiotic prophylaxis is perceived to reduce intraoperative bacteraemia and prevent surgical site infections, however, the evidence for its use in burns surgery is limited. Excessive use of perioperative antibiotics has become a growing concern. The authors aimed to audit the prescribing practices of perioperative antibiotic prophylaxis at the Victorian Adult Burns Service and determine whether the duration of antibiotic prophylaxis influenced the risk of postoperative wound infection, bacte-raemia and antibiotic resistance. Methods: This retrospective chart review included all acute adult burns patients who had an operation between November 2018 and November 2019. Basic demographic data, burn specific data and data on perioperative antibiotic use were collected. The outcome measures were wound infection, bacteraemia, other infections and presence of resistant organisms. Results: Results demonstrated that almost all patients (98.6%) received perioperative antibiotic prophylax-is. In comparison, there was no significant difference between the rate of postoperative wound infection, bacteraemia or antibiotic resistance between patients receiving a short or long course of antibiotics. Conclusion: The results of our study demonstrate variable use of perioperative antibiotic prophylaxis with-in one burns unit. There were many cases of unsubstantiated use of long courses of antibiotics without apparent benefit for clinical outcomes of wound infection or bacteraemia. With the growing concern over antibiotic overuse and development of resistance, there is an increasing need for development of clear guidelines for antibiotic use in burns surgery.

Treatment of Anaemia in Patients with Acute Burn Injury: A Study of Blood Transfusion Practices.

Objective: To determine blood transfusion practices, risk factors, and outcomes associated with the use of blood products in the setting of the acute management of burn patients at the Victorian Adult Burn Service. Background: Patients with burn injuries have variable transfusion requirements, based on a multitude of factors. We reviewed all acute admissions to the Victorian Adult Burns Service (VABS) between 2011 and 2017: 1636 patients in total, of whom 948 had surgery and were the focus of our analysis. Method and results: Patient demographics, surgical management, transfusion details, and outcome parameters were collected and analyzed. A total of 175 patients out of the 948 who had surgery also had a blood transfusion, while 52% of transfusions occurred in the perioperative period. The median trigger haemoglobin in perioperative was 80mg/dL (IQR = 76–84.9 mg/dL), and in the non-perioperative setting was 77 mg/dL (IQR = 71.61–80.84 mg/dL). Age, gender, % total body surface area (TBSA) burn, number of surgeries, and intensive care unit and hospital length of stay were associated with transfusion. Conclusions: The use of blood transfusions is an essential component of the surgical management of major burns. As observed in our study, half of these transfusions are related to surgical procedures and may be influenced by the employment of blood conserving strategies. Furthermore, transfusion trigger levels in stable patients may be amenable to review and reduction. Risk adjusted analysis can support the implementation of blood transfusion as a useful quality indicator in burn care.

Burn wound excision within 24 h: A 9-year review

BackgroundSevere burns are accompanied by an acute and prolonged hypermetabolic response typified by elevated levels of proinflammatory cytokines and acute phase proteins. When persistent, this inflammatory response can result in multi-organ dysfunction and death. Regarded as the standard of care, early removal of devitalised tissue and eschar mitigates this hypermetabolic response. Ascertaining the optimal time point for early excision, which remains controversial, has several clinical implications. MethodsThis retrospective observational study included 836 adult thermal burns patients with total burned surface area ≥20% from all Burns Registry of Australia and New Zealand (BRANZ) Hospital sites, including the Victorian Adult Burns Service (VABS), from July 1 2009 to June 30 2018. Patients were divided into two groups, “early” and “delayed”, based on a 24-hour excision cut-off from when the injury occurred. Outcome measurements included mortality, hospital length of stay, intensive care unit length of stay, ventilation requirements and the incidence of positive blood cultures. ResultsAmong all patients at BRANZ sites, excision within 24 h was associated with reduced mean length of ICU stay (6.6 ± 8.1 vs. 9.2 ± 10.6 days; p = 0.008) and lower mean mechanical ventilator hourly use (94.9 ± 160.8 vs. 159.2 ± 219.1 h; p = 0.001) in the 20−29% TBSA sub-group. Beyond this, no significant differences were observed in outcome measurements. ConclusionsWhile it is physiologically important to perform early burn wound excision to mitigate the inflammatory response, delaying excision beyond 24 h for surgical planning, possibly up to 72 h after injury, may be a reasonable approach for certain patient groups.

Venous thromboembolism in burns patients: Are we underestimating the risk and underdosing our prophylaxis?

Burns patients exhibit all factors of Virchow's triad and are thus at high theoretical risk of venous thromboembolism (VTE). At our tertiary referral burns unit, a standard dose of low molecular weight heparin, which acts primarily by inhibiting Factor Xa, is given for thromboprophylaxis. However, the pharmacokinetics of enoxaparin are altered following a burn injury, and thus burns patients are likely underdosed on their thromboprophylaxis. The objectives of this study were to determine the incidence and risk factors for VTE among burns patients at the Victorian Adult Burns Service (VABS) and to determine the adequacy of the current enoxaparin thromboprophylaxis regimen through measurement of anti-factor Xa (AFXa) levels and comparison with established reference ranges. This study consisted of two parts. In part 1, the Burns Registry of Australia and New Zealand (BRANZ) was reviewed for cases of VTE in burns patients admitted to the VABS from 2013 - 2018. Part 2 was a prospective study that determined peak and trough AFXa levels in patients admitted to the VABS with >10% total body surface area (TBSA) burns. Part 1. Totally, 1,475 patients were admitted to the VABS between 2013 - 2018. There were 20 cases of VTE (1.36%). Percent TBSA of burn (OR = 1.04, 95% CI: 1.03 - 1.06), full thickness burns (OR = 2.78, 95% CI: 1.15 - 6.73), ICU admission (OR = 15.08, 95% CI: 5.01 - 45.44), mechanical ventilation (OR = 10.62, 95% CI: 4.05 - 27.91), operative procedures (OR = 1.43, 95% CI: 1.29 - 1.59), and a longer hospital stay (OR = 1.05, 95% CI: 1.04 - 1.07) were all associated with an increased VTE risk. Part 2. A total of 20 participants with >10% TBSA burns were recruited to the prospective study. Peak anti Factor Xa (AFXa) levels were measured for all 20 participants with 15% recording an initial prophylactic peak AFXa level within reference range. Upon subsequent measurements, 50% of participants reached a prophylactic peak AFXa level. Trough AFXa levels were measured for 17 participants with no participant recording an initial or subsequent trough AFXa level at or above the prophylactic threshold. Our study demonstrates a high incidence of VTE among burns patients at the VABS, especially among the major burns patients, and a thromboprophylaxis protocol that is ineffective in achieving prophylactic levels of AFXa level. The evidence suggests a need to evaluate different dosing protocols among burns patients in order to improve AFXa levels, with the aim of decreasing incidence of VTE in high-risk patients.

To intubate or not to intubate? Predictors of inhalation injury in burn-injured patients before arrival at the burn centre.

Inhalation injury occurs in approximately 10-20% of burn patients and is associated with increased mortality. There is no clear method of identifying patients at risk of inhalation injury or requiring intubation in the pre-hospital setting. Our objective was to identify pre-burn centre factors associated with inhalation injury confirmed on bronchoscopy, and to develop a prognostic model for inhalation injury. We analysed acute admissions from the Victorian Adult Burns Service and Ambulance Victoria electronic patient care records for 1 July 2009 to 30 June 2016. We defined inhalation injury as an Abbreviated Injury Scale of >1 on bronchoscopy. A multivariable logistic regression prediction model was developed based on pre-burn centre factors. Emergency medical services transported 1148 patients who were admitted to the burn centre. The median age of patients was 39 years and most patients had <10% total body surface area (%TBSA) burned. The prevalence of confirmed inhalation injury was 11%. Increasing %TBSA burned, flame, enclosed space, face burns, hoarse voice, soot in mouth and shortness of breath were predictive of inhalation injury. The model provided excellent discrimination (area under curve 0.87, 95% confidence interval 0.84-0.91). A lower proportion of patients intubated at a non-burn centre had an inhalation injury (33%) compared to patients intubated by emergency medical services (54%) and in the burn centre (58%). A model to predict inhalation injury in burn-injured patients was developed with excellent discrimination. This model requires prospective testing but could form an integral part of clinician decision-making.

Petrol-related burn injuries presenting to the Victorian Adult Burns Service

Introduction: Burns fuelled by petrol are a major cause of injury in Australia and New Zealand. The same quality of explosive ignition that makes petrol so valuable as a fuel can cause injuries when handled carelessly or used for a purpose for which it was not intended.&#x0D; Methods: This was a retrospective cohort study that examined the epidemiology of patients admitted to the Victorian Adult Burns Service (VABS) based at the Alfred Hospital, Melbourne. Data were extracted from the VABS Database on patients presenting over a seven-year period, between 1st July 2009 to 30th June 2016. &#x0D; Results: During the study period, 378 out of 1927 burns (19.6%) admissions were related to petrol use. Males aged 20 – 29 years were most at risk, contributing to 25.4% of petrol related burn injuries. A large portion of burns, 31.0%, occurred during a leisure activity. The mean total body surface area burnt in this cohort was 19.3% and surgery was required in 70.4% of cases. Petrol related burns injuries is estimated to cost AU$ 5,484,834 annually and had a mortality rate of 7.4%.&#x0D; Conclusion: Misuse of petrol contributed to a substantial injury burden to Victorians. Raising community awareness through preventive strategies targeted at high-risk groups of at-risk behaviours is warranted to reduce the incidence of petrol related burn injuries.

The psychosocial complexities of acute burn patients in an Australian trauma hospital

IntroductionPsychosocial risk and protective factors specific to acute burn patients have been shown to impact on longer-term health outcomes. Yet the nature and impact of such factors throughout the acute hospital admission phase have not been extensively examined to date. This study analysed the psychosocial pre-admission, hospitalisation and discharge factors for a sample of burn patients at an Australian specialist acute burns unit (The Alfred) and the relationship with their admission length. MethodsA retrospective audit was undertaken of psychosocial factors documented in patient medical records, Victorian Adult Burns Service registry data, and social work files (January–December 2014). ResultsTwo hundred and forty-nine patients were identified, with a mean age of 42.83 years and a preponderance of men (73.9%). The majority (71%) had a low burn severity (<10%), and an average of eight psychosocial factors. Independent of the severity of the burn, two psychosocial domains were strongly predictive of length of stay — coping with treatment and discharge planning — along with pre-existing psychosocial factors and family support. ConclusionA diversity of psychosocial factors was identified, highlighting the clinical complexity of this patient group. Given three domains of admission-related psychosocial factors were predictive of the length of patient stay, more targeted psychosocial interventions in these areas may ensure patients and their families are supported more effectively throughout an admission, and length of stay costs may also be reduced.

Wound healing after cultured epithelial autografting in patients with massive burn injury: A cohort study

Last century, our laboratory produced Cultured Epithelial Autograft (CEA) for clinical use by the affiliated adult burn service and other burn units across the country. Production of CEA for clinical use was discontinued after several years because of a low success rate and subsequent low demand. Recently, at our burns unit, a cell culture program was reintroduced as a direct response to the need for improvement in ongoing deficiencies and clinical requirements in burn wound closure. The aim of this study was to validate the laboratory processes and clinical algorithms established and share our recent clinical experiences involving CEA. This observational cohort study recruited patients with burns exceeding 35% TBSA admitted to the Victorian Adult Burns Service at The Alfred (December 2013-December 2016). Autologous keratinocytes were expanded and delivered through sheets of fibrin carrier. Twelve patients were recruited to participate in the study. Thirty-two sites were treated with CEA. CEA applied in combination with widely meshed SSG led to the highest take rate (90.1%) at 7-10 days. Further, debridement and grafting were necessary in sixteen of thirty-two sites treated, all involving wound beds prepared with Cuono method or sites treated with CEA only. It is important to address the problem of wound bed contamination, either through increased resistance on the part of the construct or wound bed sterilization. Improved understanding of the relative importance of vascularization, control of cell behavior, the extracellular matrix, immune function, and intrinsic antimicrobial capacity for graft take would then inform a more targeted approach to skin tissue engineering for wound closure in severe burns.

Recovery in the first six months after hand and upper limb burns: A prospective cohort study.

Hands are commonly involved in burn trauma. Occupational therapy in the acute phase aims to reduce the risk of deformities and facilitate return to usual occupations. This study aimed to describe usual occupational therapy care at a major adult burns service, and measure recovery from hand burns in the first six months post-acute hospital discharge. To describe usual occupational therapy care, an audit of patient contact statistics over six months was undertaken, and occupational therapy staff were interviewed. To measure recovery, a prospective cohort study recruited adults hospitalised with hand/upper limb burns at the Victorian Adult Burns Service. Recruitment occurred over a four month period. Functional recovery was measured at three time points: discharge, three and six months post-discharge. Instruments included the Quick Disabilities of the Arm, Shoulder and Hand and the Functional Assessment for Burns. Usual care was calculated to be one 30minute session of daily occupational therapy. Interventions were described using the Template for Intervention Description and Replication. Participants (N=10) were aged 22-65years and were treated for burns ranging from 2% to 40% total body surface area. Scores on the Functional Assessment for Burns suggested high functional independence at discharge. Quick Disabilities of the Arm, Shoulder and Hand scores improved significantly at each time point, with most substantial improvement occurring between discharge and three months. Involvement of the first web-space was associated with poorer recovery in the first three months post-discharge (P=0.04). Six participants (60%) had returned to work at the three month follow-up, and seven (70%) at six months. The Quick Disabilities of the Arm, Shoulder and Hand was responsive to recovery in the post-discharge period. Further research into upper limb recovery following burns is needed, including exploration of the relationship between recovery and first web space hand burns.

Building a Nurse Practitioner model at Victorian Adult Burns Service (VABS)

The Victorian Adult Burns Service (VABS) at Alfred Health provides a state wide service of multidisciplinary burns care for 300 inpatients and 2000 outpatients per year.

Effective use of Biobrane as a temporary wound dressing prior to definitive split-skin graft in the treatment of severe burn: A retrospective analysis

AimsTo report on the use of Biobrane, a synthetic skin substitute, as a temporary wound cover in patients with severe burn. In particular we wished to examine the role of Biobrane in maintaining a healthy wound bed following surgical excision and identify factors associated with regrafting. MethodsA retrospective case series review was performed on patients with severe burns (≥20% TBSA), admitted to the Victorian Adult Burns Service, in Melbourne, from January 2009 to June 2012. Logistic regression analysis was performed to identify factors associated with regrafting. ResultsOut of 58 patients with median %TBSA burn of 30%, 22 patients (37.9%) required regrafting of at least one area previously treated with Biobrane and split-skin graft. On univariate analysis, need for regrafting was significantly associated with increasing %TBSA (OR 1.04, 95% CI: 1.01–1.08; p=0.02); and after multivariate analysis to adjust for this effect, hospital LOS (OR 1.04, 95% CI: 1.02–1.07; p=0.001); total operative time (OR 1.16, 95% CI; 1.06–1.28; p=0.002) and total number of surgeries (OR 1.69, 95% CI: 1.27–2.26, p<0.001) remained significantly associated with regrafting. Age, gender, time to surgical debridement and Biobrane application, and anatomical region were not found to be associated with regraft. ConclusionAt our institution, Biobrane has emerged as an alternative option to maintain a healthy wound bed after burn excision and prior to grafting. Our small number of extensive graft failures, small areas of regrafting and low infection rate following Biobrane application reflects our current experience with Biobrane. Precise indications and most appropriate methods for Biobrane use are yet to be established.

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

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

Early and late complications of ocular burn injuries

Ocular involvement in facial burns may lead to significant long-term morbidity. The aims of this study were to analyse the epidemiology, management and outcomes of ocular burn injuries, as well as to identify risk factors for developing early and late ocular complications. A retrospective medical chart review was conducted for 125 patients with ocular burns who were admitted to the Victorian Adult Burns Service (VABS), from November 2000 to January 2010. Univariate analyses was utilised to identify demographic and injury related variables associated with early and late complications. The majority of patients were male (n=101, 80.8%), and the mean (range) age was 40.7 (15-86) years. The most common mechanism was flame burns (n=77, 61.6%), and most were accidental (n=114, 91.2%). Early ocular complications occurred in 50 (40.0% [95% CI: 31.3%-49.1%]) patients, with the commonest being visual loss (n=39, 31.2%). Chemical burns, ocular discomfort, peri-orbital oedema, corneal injury, as well as eyelid and facial burns of increasing severity were associated with developing an early complication. Late ocular complications occurred in 19 (15.2% [95% CI: 9.4%-22.7%]) patients, with visual loss being the most frequent (n=13, 10.4%). Chemical burns, ocular discomfort, corneal injury of increasing severity, visual loss on presentation, ectropion, as well as eyelid burns of increasing depth were associated with late morbidity. Chemical burns, ocular discomfort, as well as corneal injury and eyelid burns of increasing severity were risk factors for both early and late ocular complications. III (retrospective comparative study).

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

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

Secondary bacterial infection and empirical antibiotic use in toxic epidermal necrolysis patients.

The objective of this study was to determine rates of positive bacterial cultures in patients with extensive toxic epidermal necrolysis, the rate of bacteremia, whether empirical antibiotics had been commenced, and their effectiveness when commenced. The authors conducted a retrospective chart review of patients with extensive toxic epidermal necrolysis between January 2001 and December 2012 admitted to the Victorian Adult Burns Service, Melbourne, Australia, with respect to the amount of positive cultures, number and type of organisms identified, whether empirical antibiotics had been commenced, and whether antibiotics were effective against organisms cultured. A total of 27 patients were admitted over the study period of 11 years. Seventeen of these patients developed at least one positive bacterial culture. Patients who grew positive cultures had a longer length of stay in intensive care unit and in hospital overall compared with patients who did not grow positive cultures. Thirty-five positive cultures were collected overall, with empirical antibiotics commenced in 22 cases. In terms of sensitivity, antibiotics were appropriate in 19 cases. Four patients developed bacteremia, two of whom died. This study does not dispute the generally accepted practice of avoiding prophylactic antibiotics in toxic epidermal necrolysis patients, but in the context of a relatively low rate of bacteremia in this patient population, advises appropriate and targeted empirical antibiotic use where clinical infection is suspected.

Hospital management and clinical factors associated with ophthalmic involvement in Toxic Epidermal Necrolysis

BackgroundToxic Epidermal Necrolysis (TEN) is characterized by an exfoliative rash resembling widespread burns. It is often considered on the same spectrum of disease as Stevens Johnson Syndrome but is distinguished by epidermal detachment of >30% of total body surface area (TBSA). Ocular involvement of TEN may result in complications requiring intensive topical, systemic or operative treatment. This study aimed to identify the current hospital management of, and factors associated with, ophthalmic involvement in adult TEN patients. MethodsAll adult TEN patients admitted to the Victorian Adult Burns Service over an 12-year period were included. Retrospective data analyzed included patient demographics, site of TEN involvement, % TBSA, complications, duration of ocular follow up and visual outcomes. ResultsTEN patients with and without ocular involvement were compared. Cutaneous involvement of the head and neck was found to be significantly associated with ocular involvement of TEN. Age, TBSA involvement, presence of a prodrome, and presence of comorbidities were not found to be significantly associated with ocular involvement. Management of ophthalmic involvement of TEN varied between patients. ConclusionsClinicians should have a high index of suspicion for ocular involvement when exfoliation of the head and neck is present and should seek ophthalmological advice early in the course of disease.

Multidisciplinary team response to a mass burn casualty event: outcomes and implications

To describe the characteristics of patients with burn injury admitted to a major trauma hospital in Melbourne following the Black Saturday bushfires of 7 February 2009, and to provide a detailed analysis of the hospital's response to the crisis. A retrospective chart review of ambulance and hospital records of patients admitted to the Victorian Adult Burns Service (VABS) at The Alfred Hospital (The Alfred) following the bushfires. Patient characteristics and outcomes: age, sex, total and full thickness body surface area burnt, type and site of burn, hospital and intensive care unit length of stay (LOS) and receipt of standard burn care practices. Estimated glomerular filtration rate, theatre time and LOS data for the bushfire cohort compared with corresponding data for historical cohorts from VABS and from a similar institution in New Zealand. Nineteen patients were admitted to VABS over the first 48 hours after the bushfires. Of these, nine patients were subsequently admitted to The Alfred's intensive care unit. Most patients (74%) were men with a mean age of 52.7 years (SD, 12.4 years). Seventeen patients (89%) underwent at least one surgical procedure, which resulted in 4355 minutes of theatre time for the bushfire cohort in the first week. Hospital LOS was similar for the bushfire and New Zealand cohorts. Compared with the VABS historical cohort, there was a higher incidence of abnormal renal function among the bushfire cohort patients. Although relatively few patients with severe burns were admitted to VABS, significant increases in resource allocation were required to manage them in terms of additional theatre time, consumables and staffing. The experience of VABS may aid planning for future mass burns casualty events.