Victorian Adult Burns Service Research Articles

Biobrane: A retrospective analysis of outcomes at a specialist adult burns centre

Introduction This study is a retrospective analysis of 168 adult burns patients who received definitive treatment for partial thickness burns with Biobrane at a specialist burns centre. Our aim was to establish whether Biobrane served as a reliable, definitive treatment option or whether further treatment and allocation of surgical and nursing resources was required after application. Methods We conducted a retrospective two year chart review (January 1 2007 and December 31 2008) of patients admitted to the Victorian Adult Burns Service, in Melbourne, Australia. Results Use of Biobrane was associated with the need for further treatment interventions in a total of 74 patients (44%). Of these, Biobrane failure was found to be associated with infection in 28 cases (37.8%) and 48 (65%) patients underwent further surgery. A total of 87 patients (52%) had burns that took greater than three weeks from the time of injury to full re-epithelisation. Factors found to be associated with Biobrane failure were female gender, increasing percentage surface area of Biobrane application and when Biobrane was used in conjunction with split skin grafting to another area. Conclusion The application of Biobrane to burns of mid-dermal or ‘indeterminate’ depth in our institution has resulted in high rates of return to theatre, positive wound cultures and delayed healing, and the recognition of the need to re-conceptualise the principles of use of this product. The use of Biobrane in smaller mid dermal or mixed depth burns may lead to increased operations and use of other hospital resources, without clear evidence of improved outcomes.

Victorian ‘Black Saturday’ Bushfires: The infectious diseases and microbiology response

Background: The Victorian Bushfires in February 2009 were the most severe in Australia's history. Adults with severe burns were admitted to the Victorian Adult Burns Service at The Alfred Hospital, where multidisciplinary teams, including Burns, ICU, and Infectious Diseases (amongst others) managed these patients with complex care needs.

A simple tool for mortality prediction in burns patients: APACHE III score and FTSA

Prediction of outcome for patients with major thermal injury is important to inform clinical decision making, alleviate individual suffering and improve hospital resource allocation. Age and burn size are widely accepted as the two largest contributors of mortality amongst burns patients. The APACHE (Acute Physiology and Chronic Health Evaluation) III-j score, which incorporates patient age, is also useful for mortality prediction, of intensive care populations. Validation for the burns specific cohort is unclear. A retrospective cohort study was performed on patients admitted to the Intensive Care Unit (ICU) via the Victorian Adult Burns Service (VABS), to compare observed mortality with burns specific markers of illness severity and APACHE III-j score. Our primary aim was to develop a mortality prediction tool for the burns population. Between January 1, 2002 and December 31, 2008, 228 patients were admitted to the ICU at The Alfred with acute burns. The mean age was 45.6 years and 81% ( n = 184) were male. Patients had severe injuries: the average percent TBSA (total body surface area) was 28% (IQR 10–40) and percent FTSA (full thickness surface area) was 18% (IQR 10–25). 86% ( n = 197) had airway involvement. Overall mortality in the 7-year period was 12% ( n = 27). Non-survivors were older, had larger and deeper burns, a higher incidence of deliberate self-harm, higher APACHE III-j scores and spent less time in hospital (but similar time in ICU), compared with survivors. Independent risk factors for death were percent FTSA (OR 1.03, 95% CI 1.01–1.05, p = 0.01) and APACHE III-j score (OR 1.04, 95% CI 1.02–1.07, p < 0.001). Mortality prediction based on both of these variables in combination was more specific than either individual variable alone (AUROC 0.85, 95% CI 0.79–0.92). Likelihood of death for patients with severe thermal injury can be predicted with accuracy from APACHE III-j score and percent FTSA. Prospective validation of our model on different burn populations is necessary.

Candida in Burns: Risk Factors and Outcomes

Sepsis due to Candida is an uncommon but a significant cause of death in burns patients. Colonization is common, but consensus guidelines for prophylaxis and empirical therapy do not specifically include this cohort. Our aim was to define predictive factors for candidaemia in a burns unit, to guide protocols for prevention and early treatment. We conducted a 10-year review (July 1998-December 2007) of patients admitted to the Victorian Adult Burns Service, Melbourne, Australia. Of 1929 patients admitted with acute burn injury, 143 had Candida isolated at any site, most commonly Candida albicans. There were 12 episodes of candidaemia. Prior colonization was an important risk factor for candidaemia, and the risk increased substantially with the number of colonized sites; indeed 43% of patients colonized at more than three sites (and not on antifungals) developed candidaemia. Other risk factors were higher total burn surface area, higher full-thickness surface area, prolonged admission, number and duration of intensive care unit admissions, number of visits to the operating theatre, alcohol as a contributing factor to burn, prior treatment with total parenteral nutrition, or certain antibiotics (ceftriaxone, vancomycin, amikacin, co-trimoxazole). The attributable mortality of candidaemia was 15% (n = 2). Initiation of antifungal therapy was often delayed. Our results support early empirical antifungal therapy in septic burns patients who are colonized, before the results of cultures become known. The role of prophylactic antifungals is less clear, but should be strongly considered for patients colonized at multiple sites.

PR18 CANDIDA AND THERMAL INJURY: 10 years EXPERIENCE FROM A SPECIALIST BURNS UNIT

Sepsis due to Candida is a rare but significant cause of death in burns patients. Indications for prophylaxis against invasive Candida infection are unclear in patients with thermal injury. Consensus statements do not specifically include this cohort.We conducted a ten year review of burns patients to the Victorian Adult Burns Service, to identify the extent and clinical significance of Candida infection in a specialist burns unit. Our aim was to define predictive factors for Candidaemia, in order to guide protocols for prevention and early treatment.Between July 1, 1998 and December 31, 2007, 1933 patients were newly admitted with acute burns; of these 143 patients had Candida or Yeast isolated at any site. The most common species was C.albicans. Twelve patients developed 13 episodes of Candidaemia.Prior colonisation was an important risk factor for Candidaemia, and the risk increased substantially with increased number of colonised sites. Other risk factors for Candidaemia were: higher percent TBSA (total burn surface area); increased number of visits to the operating theatre; colonisation of particular sites and prior treatment with TPN and certain antibiotics.The attributable mortality of Candidaemia was 15% (n = 2). Initiation of appropriate antifungal therapy was often delayed.Our results justify early empirical anti‐fungal therapy in septic burns patients who are colonized, before the results of cultures become known. The role of prophylactic antifungals is less clear, but should be strongly considered for high risk patients colonized at multiple sites.

Clinical factors affecting mortality in elderly burn patients admitted to a burns service

Introduction The purpose of this retrospective study was to provide basic probabilistic predictors of mortality to assist in determining appropriate therapeutic aggression in elderly burns population. Method Eighty patients over the age of 70 years were admitted to the Victorian Adult Burns Service in Melbourne, Australia, over a period of 4 years. Retrospective data was analysed, taking into account patient demographics, type, site, depth and area of burn, presence of inhalation injury, number of co-morbidities, survival time and the number of operations performed, withdrawal of care and implementation of comfort measures only. Results Comparing survivors and non-survivors, significant differences were found between age, percentage total burn surface area (TBSA%), percentage full thickness surface area (FTSA%), presence of inhalation injury, site of burn and number of operations. The number of co-morbidities and gender were not significant to outcome. FTSA%, presence of inhalation injury, site of burn, age and number of operations were all significantly related to survival time. When patients who obtained comfort care were excluded from analysis, age and the number of operations were not considered to be significantly related to mortality. Conclusion This study indicates that TBSA%, FTSA%, inhalation injury and age are significant predictors of death in the elderly burns population, although only the first three remain significant when patients who receive comfort care measures only are excluded.