Modern burn care

Comparison of Albumin and Fresh Frozen Plasma as Colloid Therapy in Patients With Major Burns

BACKGROUND

Burn injuries are one of the main causes of morbidity and mortality throughout the world, and burn patients have higher chances of recovery if they are treated with effective fluid and colloid management. Fresh frozen plasma (FFP) and albumin suspension used as a colloid treatment agent are very useful for the treatment of severe burns.

METHODS

This retrospective clinical trial was conducted at the Numune Education and Research Hospital Burn Center, Ankara, Turkey. Two hundred and nine patients who had severe burns that involved more than 30% of their total body surface area (TBSA) were studied. After the first 24 hours, 13 patients were deceased, leaving 196 patients remaining in the study, including 139 patients in the fresh frozen plasma group and 57 patients in the albumin group. Both the fresh frozen plasma and albumin groups received the standard therapy of the burn center, which was based on a standard protocol. Then, these patients were compared according to their clinical findings and mortality.

RESULTS

There were no significant differences between the groups with respect to age, gender, and comorbidities. The laboratory findings, blood, urine, and wound culture results were also similar between groups. The mortality rate was higher in the group receiving albumin than in the group receiving fresh frozen plasma (78.9% and 33.8%, respectively; p=0.0007).

CONCLUSIONS

According to this study, there was a significant relationship between the improvement in mortality and the mode of colloid treatment in patients with major burns.

High-Voltage, Pulsed Electric Fields Eliminate Pseudomonas aeruginosa Stable Infection in a Mouse Burn Model

Objective: The incidence of severe infectious complications after burn injury increases mortality by 40%. However, traditional approaches for managing burn infections are not always effective. High-voltage, pulsed electric field (PEF) treatment shortly after a burn injury has demonstrated an antimicrobial effect in vivo; however, the working parameters and long-term effects of PEF treatment have not yet been investigated. Approach: Nine sets of PEF parameters were investigated to optimize the applied voltage, pulse duration, and frequency or pulse repetition for disinfection of Pseudomonas aeruginosa infection in a stable mouse burn wound model. The bacterial load after PEF administration was monitored for 3 days through bioluminescence imaging. Histological assessments and inflammation response analyses were performed at 1 and 24 h after the therapy. Results: Among all tested PEF parameters, the best disinfection efficacy of P. aeruginosa infection was achieved with a combination of 500 V, 100 μs, and 200 pulses delivered at 3 Hz through two plate electrodes positioned 1 mm apart for up to 3 days after the injury. Histological examinations revealed fewer inflammatory signs in PEF-treated wounds compared with untreated infected burns. Moreover, the expression levels of multiple inflammatory-related cytokines (interleukin [IL]-1α/β, IL-6, IL-10, leukemia inhibitory factor [LIF], and tumor necrosis factor-alpha [TNF-α]), chemokines (macrophage inflammatory protein [MIP]-1α/β and monocyte chemoattractant protein-1 [MCP-1]), and inflammation-related factors (vascular endothelial growth factor [VEGF], macrophage colony-stimulating factor [M-CSF], and granulocyte-macrophage colony-stimulating factor [G-CSF]) were significantly decreased in the infected burn wound after PEF treatment. Innovation: We showed that PEF treatment on infected wounds reduces the P. aeruginosa load and modulates inflammatory responses. Conclusion: The data presented in this study suggest that PEF treatment is a potent candidate for antimicrobial therapy for P. aeruginosa burn infections.

Patient-reported scar quality of donor-sites following split-skin grafting in burn patients: Long-term results of a prospective cohort study

BACKGROUND

Skin grafting is the current gold standard for treatment of deeper burns. How patients appraise the donor-site scar is poorly investigated. The aim of this study was to evaluate long-term patient-reported quality of donor-site scars after split skin grafting and identify possible predictors.

METHODS

A prospective cohort study was conducted. Patients were included in a Dutch burn centre during one year. Patient-reported quality of donor-site scars and their worst burn scar was assessed at 12 months using the Patient and Observer Scar Assessment Scale (POSAS). Mixed model analyses were used to identify predictors of scar quality.

RESULTS

This study included 115 donor-site scars of 72 patients with a mean TBSA burned of 11.2%. The vast majority of the donor-site scars (84.4%) were rated as having at least minor differences with normal skin (POSAS item score ≥2) on one or more scar characteristics and the overall opinion on 80.9% of the donor-site scars was that they deviated from normal skin 12 months after surgery. The overall opinion on the donor-site scar was 3.2 ± 2.1 vs. 5.1 ± 2.4 on the burn scar. A younger age, female gender, a darker skin type, and location on the lower leg were predictors of reduced donor-site scar quality. In addition, time to re-epithelization was associated with scar quality.

CONCLUSION

This study provided new insights in long-term scar quality of donor-sites. Donor-site scars differed from normal skin in a large part of the population 12 months after surgery. Results of this study can be used to inform patients on the long-term outcomes of their scars and to tailor preventive or therapeutic treatment options.

Enzymatic Debridement of Porcine Burn Wounds via a Novel Protease, SN514

Necrotic tissue generated by a thermal injury is typically removed via surgical debridement. However, this procedure is commonly associated with blood loss and the removal of viable healthy tissue. For some patients and contexts such as extended care on the battlefield, it would be preferable to remove devitalized tissue with a nonsurgical debridement agent. In this paper, a proprietary debridement gel (SN514) was evaluated for the ability to debride both deep-partial thickness (DPT) and full-thickness burn wounds using an established porcine thermal injury model. Burn wounds were treated daily for 4 days and visualized with both digital imaging and laser speckle imaging. Strip biopsies were taken at the end of the procedure. Histological analyses confirmed a greater debridement of the porcine burn wounds by SN514 than the vehicle-treated controls. Laser speckle imaging detected significant increases in the perfusion status after 4 days of SN514 treatment on DPT wounds. Importantly, histological analyses and clinical observations suggest that SN514 gel treatment did not damage uninjured tissue as no edema, erythema, or inflammation was observed on intact skin surrounding the treated wounds. A blinded evaluation of the digital images by a burn surgeon indicated that SN514 debrided more necrotic tissue than the control groups after 1, 2, and 3 days of treatment. Additionally, SN514 gel was evaluated using an in vitro burn model that used human discarded skin. Treatment of human burned tissue with SN514 gel resulted in greater than 80% weight reduction compared with untreated samples. Together, these data demonstrate that SN514 gel is capable of debriding necrotic tissue and suggest that SN514 gel could be a useful option for austere conditions, such as military multi-domain operations and prolonged field care scenarios.

Fast and safe fabrication of a free-standing chitosan/alginate nanomembrane to promote stem cell delivery and wound healing

Polymeric ultrathin membranes that are compatible with cells offer tremendous advantages for tissue engineering. In this article, we report a free-standing nanomembrane that was developed using a layer-by-layer self-assembly technique with a safe and sacrificial substrate method. After ionization, two oppositely charged polyelectrolytes, alginate and chitosan, were alternately deposited on a substrate of a solidified gelatin block to form an ultrathin nanomembrane. The space between the two adjacent layers was ∼200 nm. The thickness of the nanomembrane was proportional to the number of layers. The temperature-sensitive gelatin gel served as a sacrificial template at 37°C. The free-standing nanomembrane promoted bone marrow stem cell adhesion and proliferation. Fluorescence-activated cell sorting was used to analyze green-fluorescent-protein-positive mesenchymal stem cells from the wounds, which showed a significantly high survival and proliferation from the nanomembrane when cells were transplanted to mouse dorsal skin that had a full-thickness burn. The bone-marrow-stem-cell-loaded nanomembrane also accelerated wound contraction and epidermalization. Therefore, this methodology provides a fast and facile approach to construct free-standing ultrathin scaffolds for tissue engineering. The biocompatibility and free-standing nature of the fabricated nanomembrane may be particularly useful for stem cell delivery and wound healing.

Predictive Value of IL-8 for Sepsis and Severe Infections After Burn Injury: A Clinical Study

The inflammatory response induced by burn injury contributes to increased incidence of infections, sepsis, organ failure, and mortality. Thus, monitoring postburn inflammation is of paramount importance but, so far, there are no reliable biomarkers available to monitor and/or predict infectious complications after burn. As interleukin 8 (IL-8) is a major mediator for inflammatory responses, the aim of our study was to determine whether IL-8 expression can be used to predict postburn sepsis, infections, and mortality. Plasma cytokines, acute-phase proteins, constitutive proteins, and hormones were analyzed during the first 60 days after injury from 468 pediatric burn patients. Demographics and clinical outcome variables (length of stay, infection, sepsis, multiorgan failure [MOF], and mortality) were recorded. A cutoff level for IL-8 was determined using receiver operating characteristic analysis. Statistical significance is set at P < 0.05. Receiver operating characteristic analysis identified a cutoff level of 234 pg/mL for IL-8 for survival. Patients were grouped according to their average IL-8 levels relative to this cutoff and stratified into high (H) (n = 133) and low (L) (n = 335) groups. In the L group, regression analysis revealed a significant predictive value of IL-8 to percent of total body surface area burned and incidence of MOF (P < 0.001). In the H group, IL-8 levels were able to predict sepsis (P < 0.002). In the H group, elevated IL-8 was associated with increased inflammatory and acute-phase responses compared with the L group (P < 0.05). High levels of IL-8 correlated with increased MOF, sepsis, and mortality. These data suggest that serum levels of IL-8 may be a valid biomarker for monitoring sepsis, infections, and mortality in burn patients.

Intensive care organisation: Should there be a separate intensive care unit for critically injured patients?

In the last two decennia, the mixed population general intensive care unit (ICU) with a “closed format” setting has gained in favour compared to the specialized critical care units with an “open format” setting. However, there are still questions whether surgical patients benefit from a general mixed ICU. Trauma is a significant cause of morbidity and mortality throughout the world. Major or severe trauma requiring immediate surgical intervention and/or intensive care treatment. The role and type of the ICU has received very little attention in the literature when analyzing outcomes from critical injuries. Severely injured patients require the years of experience in complex trauma care that only a surgery/trauma ICU can provide. Should a trauma center have the capability of a separate specialized ICU for trauma patients (“closed format”) next to its standard general mixed ICU

α-Tocopherol adipose tissue stores are depleted after burn injury in pediatric patients

BACKGROUND

We previously showed that thermal injury depletes plasma vitamin E in pediatric burn patients; however, plasma changes may reflect immediate alterations in vitamin E nutriture. Adipose tissue α-tocopherol concentrations are generally accepted to reflect long-term vitamin E status.

OBJECTIVE

To test the hypothesis that thermal injury depletes body stores of vitamin E, α-tocopherol concentrations were measured in adipose tissue samples.

DESIGN

Pediatric patients (n = 8) were followed up to 1 y after burn injury. Surgically obtained samples were collected at various intervals and stored at -80°C in a biorepository. α- and γ-Tocopherols, cholesterol, and triglycerides were measured in the same tissue aliquot.

RESULTS

During the first week after injury, adipose tissue α-tocopherol concentrations were within the expected normal range of 199 ± 40 nmol/g adipose tissue but were substantially lower at weeks 2 and 3 (133 ± 13 and 109 ± 8 nmol/g adipose tissue, respectively). Individual rates of decrease, estimated by linear regression, showed that adipose tissue α-tocopherol decreased by an average of 6.1 ± 0.6 nmol/g daily. During the first month after injury, adipose tissue triglyceride concentrations also decreased, whereas no changes in cholesterol concentrations occurred.

CONCLUSIONS

These data emphasize that the burn injury experienced by these pediatric patients altered their metabolism such that vitamin E status diminished during the month after injury. Further studies are needed to evaluate the mechanism and consequences of the observed vitamin E depletion. This trial was registered at clinicaltrials.gov as NCT00675714.

Infection control in the burn unit

The survival rates for burn patients have improved substantially in the past few decades due to advances in modern medical care in specialized burn centers. Burn wound infections are one of the most important and potentially serious complications that occur in the acute period following injury. In addition to the nature and extent of the thermal injury influencing infections, the type and quantity of microorganisms that colonize the burn wound appear to influence the future risk of invasive wound infection. The focus of medical care needs to be to prevent infection. The value of infection prevention has been acknowledged in organized burn care since its establishment and is of crucial importance. This review focuses on modern aspects of the epidemiology, diagnosis, management, and prevention of burn wound infections and sepsis.

Bench-to-bedside review: Burn-induced cerebral inflammation--a neglected entity?

Severe burn injury remains a major burden on patients and healthcare systems. Following severe burns, the injured tissues mount a local inflammatory response aiming to restore homeostasis. With excessive burn load, the immune response becomes disproportionate and patients may develop an overshooting systemic inflammatory response, compromising multiple physiological barriers in the lung, kidney, liver, and brain. If the blood–brain barrier is breached, systemic inflammatory molecules and phagocytes readily enter the brain and activate sessile cells of the central nervous system. Copious amounts of reactive oxygen species, reactive nitrogen species, proteases, cytokines/chemokines, and complement proteins are being released by these inflammatory cells, resulting in additional neuronal damage and life-threatening cerebral edema. Despite the correlation between cerebral complications in severe burn victims with mortality, burn-induced neuroinflammation continues to fly under the radar as an underestimated entity in the critically ill burn patient. In this paper, we illustrate the molecular events leading to blood–brain barrier breakdown, with a focus on the subsequent neuroinflammatory changes leading to cerebral edema in patients with severe burns.

Effects of a 12-week rehabilitation program with music & exercise groups on range of motion in young children with severe burns

Previous studies indicate that rehabilitation programs supplemented with a strength and endurance-based exercise program improve lean body mass, pulmonary function, endurance, strength, and functional outcomes in severely burned children over the age of 7-years when compared with standard of care (SOC). To date, supplemental exercise programming for severely burned children under the age of 7-years has not yet been explored. The purpose of this study was to determine if a 12-week rehabilitation program supplemented with music & exercise, was more effective in improving functional outcomes than the SOC alone. This is a descriptive study that measured elbow and knee range of motion (ROM) in 24 severely burned children between ages 2 and 6 years. Groups were compared for demographics as well as active and passive ROM to bilateral elbows and knees. A total of 15 patients completed the rehabilitation with supplemental music and exercise, and data was compared with 9 patients who received SOC. Patients receiving the 12-week program significantly improved ROM in all joints assessed except for one. Patients receiving SOC showed a significant improvement in only one of the joints assessed. Providing a structured supplemental music and exercise program in conjunction with occupational and physical therapy seems to improve both passive and active ROM to a greater extent than the SOC alone.

[Importance of proper initial treatment of moderate and major burns]

BACKGROUND/AIM

Burns are common injuries with frequency depending on human factors, development of protection, industry and traffic, eventual wars. Organized treatment of major burn injuries has tremendous medical, social and economic importance. The aim of this study was to analyze initial treatment of major and moderate burns, to compare it with the current recommendations and to signify the importance of organized management of burns.

METHODS

In a prospective study 547 adult patients with major burns were analyzed, covering a period of eight years, with the emphasis on the initial hospital admission and emergency care for burns greater than 10% of total body surface area (TBSA).

RESULTS

In the different groups of major burns, the percentage of hospital admission was: 81.5 in burns greater than 10% TBSA, 37.7 in burns of the functional areas, 54.5 in the III degree burns, 81.6 in electrical burns, 55.9 in chemical burns, 61.9 in inhalation injury, 41.0 in burns in patients with the greater risk and 100 in burns with a concomitant trauma. In the group of 145 patients with burns greater than 10% TBSA, intravenous fluids were given in 87 patients, analgesics in 45, corticosteroids in 29, antibiotics in 23 and oxygen administration in 14. In the same group, wound irrigation was done in 14.4%, removing of the clothing and shoes in 29.6%, elevation of the legs in 8.9% and prevention of hypothermia in 7.6% of the victims. There were no initial estimations of burn extent (percentage of a burn), notes about the patient and injury and tetanus immunizations.

CONCLUSION

Based on these findings, it is concluded that there should be much more initial hospital admissions of major burns, and also, necessary steps in the emergency care of burns greater than 10% TBSA should be taken more frequently. On the other side, unnecessary or wrong steps should be avoided in the initial burn treatment.

Assessment of muscle function in severely burned children

INTRODUCTION

The posttraumatic response to a severe burn leads to marked and prolonged skeletal muscle catabolism and weakness, which persist despite standard rehabilitation programs of occupational and physical therapy. We investigated the degree to which the prolonged skeletal muscle catabolism affects the muscle function of children 6 months after severe burn.

METHODS

Burned children, with >40% total body surface area burned, were assessed at 6 months after burn in respect to lean body mass and leg muscle strength at 150 degrees /s. Lean body mass was assessed using dual-energy X-ray absorptiometry. Leg muscle strength was assessed using isokinetic dynamometry. Nonburned children were assessed similarly, and served as controls.

RESULTS

We found that severely burned children (n=33), relative to nonburned children (n=46) had significantly lower lean body mass. Additionally they had significantly lower peak torque as well total work performance using the extensors of the thigh.

CONCLUSIONS

Our results serve as an objective and a practical clinical approach for assessing muscle function and also aid in establishing potential rehabilitation goals, and monitoring progress towards these goals in burned children.

Infection in patients with severe burns: causes and prevention thereof

The better understanding of burn pathophysiology has resulted in effective fluid resuscitation in the acute stage, but the morbidity and mortality of burn patients are mostly linked to the burn wound consequences. Once the initial acute phase is over, the burn wound becomes the source of virtually all ill effects, local and systemic. The dysfunction of the immune system, a large cutaneous bacterial load, the possibility of gastrointestinal bacterial translocation, prolonged hospitalization, and invasive diagnostic and therapeutic procedures all contribute to infectious complications. Wound infection may lead to septicemia that may not only consume additional resources but is associated with significant morbidity and mortality despite the advances in burn care.

A role for long chain myosin light chain kinase (MLCK-210) in microvascular hyperpermeability during severe burns

Microvascular leakage has been implicated in the pathogenesis of multiple organ dysfunction during trauma. Previous studies suggest the involvement of myosin light chain (MLC) phosphorylation-triggered endothelial contraction in the development of microvascular hyperpermeability. Myosin light chain kinase (MLCK) plays a key role in the control of MLC-phosphorylation status; thus, it is thought to modulate barrier function through its regulation of intracellular contractile machinery. The aim of this study was to further investigate the endothelial mechanism of MLC-dependent barrier injury in burns, focusing on the long isoform of MLCK (MLCK-210) that has recently been identified as the predominant isoform expressed in vascular endothelial cells. An MLCK-210 knockout mouse model was subjected to third-degree scald burn covering 25% total body surface area. The mesenteric microcirculation was observed using intravital microscopy, and the microvascular permeability was assessed by measuring the transvenular flux of fluorescein isothiocyanate-albumin. In a separate experiment, in vivo mesenteric hydraulic conductivity (Lp) was measured using the modified Landis technique. The injury caused a profound microvascular leakage, as indicated by a 2-fold increase in albumin flux and 4-fold increase in Lp at the early stages, which was associated with a high mortality within the 24-h period. Compared with wild-type control, the MLCK-210-deficient mice displayed a significantly improved survival with a greatly attenuated microvascular hyperpermeability response to albumin and fluid. These results provide direct evidence for a role of MLCK-210 in mediating burn-induced microvascular barrier injury and validate MLCK-210 as a potential therapeutic target in the treatment of burn edema.

Burn injuries

PURPOSE OF REVIEW

To summarize new advances and research findings that relate to the treatment of burn victims.

RECENT FINDINGS

Recent advances in burn resuscitation and critical care reflect a better understanding of the acute phase pathophysiology of severe burns. Aggressive management of the unstable burn airway is always the most important clinical priority. Emphasis has been placed on the early identification of inhalation injury and its impact on fluid resuscitation, as well as on a protective lung strategy to reduce the development of pulmonary edema, acute lung injury and pneumonia, and to reduce the risk of barotrauma. New blood markers, such as serum cholinesterase and inflammatory cytokines, have been introduced to assist in the prognosis of morbidity and mortality, beyond the traditional vital signs. At this time, however, these are available only for research purposes. Finally, early burn wound excision and coverage with new biodegradable materials results in less pain and more rapid healing for the patient.

SUMMARY

The combination of innovative approaches and a dedicated burn team is expected to continue to improve survival in the next few years even in the most severe cases.

Burn and smoke inhalation injury in sheep depletes vitamin E: kinetic studies using deuterated tocopherols

To test the hypothesis that burn and smoke injury will deplete tissue alpha-tocopherol and cause its faster plasma disappearance, deuterium-labeled vitamin E was administered to sheep exposed to both surface skin burn and smoke insufflation, which cause injuries similar to those of human victims of fire accidents. Two different protocols were used: (1) deuterated vitamin E was administered orally with food at time 0 (just before injury) or (2) the labeled vitamin E was administered orally with food the day before injury. The animals, which had been operatively prepared seven days before, were anesthetized and then received both 40% body surface area third-degree burn and 48 breaths of cotton smoke or sham injuries. All were resuscitated with Ringer's lactate solution (4 ml/kg/% BSA burn/24 h) and mechanically ventilated. Blood samples were collected at various times after vitamin E dosing. In both studies the depletion of plasma alpha-tocopherol was faster in the injured sheep. The sheep given deuterated vitamin E 24 h before injury had similar maximum alpha-tocopherol concentrations at similar times. The exponential rates of alpha-tocopherol disappearance were 1.5 times greater and half-lives were 12 h shorter (p < 0.05) in the injured sheep. In separate studies, various tissues were obtained from sheep that were sacrificed from 4 to 48 h after injury. The liver alpha-tocopherol concentrations in sheep killed at various times after injury seem to show a linear decrease at a rate of 0.1 nmol alpha-tocopherol/g liver per hour, suggesting that the liver is supplying alpha-tocopherol to maintain the plasma and lung alpha-tocopherol concentrations, but that this injury is so severe the liver is unable to maintain lung alpha-tocopherol concentrations. These findings suggest that alpha-tocopherol should be administered to burn patients to prevent vitamin E depletion and to protect against oxidative stress from burn injury.

Cultured epithelial autograft (CEA) in burn treatment: three decades later

Methods for handling burn wounds have changed in recent decades and increasingly aggressive surgical approach with early tangential excision and wound closure is being applied. Split-thickness skin (STSG) autografts are the "gold standard" for burn wound closure and remain the mainstay of treatment to provide permanent wound coverage and achieve healing. In some massively burned patients, however, the burns are so extensive that donor site availability is limited. Fortunately, considerable progress has been made in the culture of human keratinocytes and it is now possible to obtain large amounts of cultured epithelium from a small skin biopsy within 3-4 weeks. Questions related to optimal cell type for culture, culture techniques, transplantation of confluent sheets or non-confluent cells, immediate and late final take, carrier and transfer modality, as well as final outcome, ability to generate an epithelium after transplantation, and scar quality are still not fully answered. Progress accomplished since Reinwald and Green first described their keratinocyte culture technique is reviewed.

Vitamin E attenuates acute lung injury in sheep with burn and smoke inhalation injury

INTRODUCTION

A decrease in alpha-tocopherol (vitamin E) plasma levels in burn patients is typically associated with increased mortality. We hypothesized that vitamin E supplementation (alpha-tocopherol) would attenuate acute lung injury induced by burn and smoke inhalation injury.

MATERIALS AND METHODS

Under deep anesthesia, sheep (33 +/- 5 kg) were subjected to a flame burn (40% total body surface area, third degree) and inhalation injury (48 breaths of cotton smoke, < 40 degrees C). Half of the injured group received alpha-tocopherol (1000 IU vitamin E) orally, 24 h prior to injury. The sham group was neither injured nor given vitamin E. All three groups (n = 5 per group) were resuscitated with Ringer's lactate solution (4 ml/kg/%burn/24 h), and placed on a ventilator (PEEP = 5 cmH2O; tidal volume = 15 ml/kg) for 48 h.

RESULTS

Plasma alpha-tocopherol per lipids doubled in the vitamin E treated sheep. Vitamin E treatment prior to injury largely prevented the increase in pulmonary permeability index and moderated the increase in lung lymph flow (52.6 +/- 6.2 ml/min, compared with 27.3 +/- 6.0 ml/min, respectively), increased the PaO2/FiO2 ratio, ameliorated both peak and pause airway pressure increases, and decreased plasma conjugated dienes and nitrotyrosine.

CONCLUSIONS

Pretreatment with vitamin E ameliorated the acute lung injury caused by burn and smoke inhalation exposure.

Burn wound infections

Burns are one of the most common and devastating forms of trauma. Patients with serious thermal injury require immediate specialized care in order to minimize morbidity and mortality. Significant thermal injuries induce a state of immunosuppression that predisposes burn patients to infectious complications. A current summary of the classifications of burn wound infections, including their diagnosis, treatment, and prevention, is given. Early excision of the eschar has substantially decreased the incidence of invasive burn wound infection and secondary sepsis, but most deaths in severely burn-injured patients are still due to burn wound sepsis or complications due to inhalation injury. Burn patients are also at risk for developing sepsis secondary to pneumonia, catheter-related infections, and suppurative thrombophlebitis. The introduction of silver-impregnated devices (e.g., central lines and Foley urinary catheters) may reduce the incidence of nosocomial infections due to prolonged placement of these devices. Improved outcomes for severely burned patients have been attributed to medical advances in fluid resuscitation, nutritional support, pulmonary and burn wound care, and infection control practices.

Burn wound infections

Burns are one of the most common and devastating forms of trauma. Patients with serious thermal injury require immediate specialized care in order to minimize morbidity and mortality. Significant thermal injuries induce a state of immunosuppression that predisposes burn patients to infectious complications. A current summary of the classifications of burn wound infections, including their diagnosis, treatment, and prevention, is given. Early excision of the eschar has substantially decreased the incidence of invasive burn wound infection and secondary sepsis, but most deaths in severely burn-injured patients are still due to burn wound sepsis or complications due to inhalation injury. Burn patients are also at risk for developing sepsis secondary to pneumonia, catheter-related infections, and suppurative thrombophlebitis. The introduction of silver-impregnated devices (e.g., central lines and Foley urinary catheters) may reduce the incidence of nosocomial infections due to prolonged placement of these devices. Improved outcomes for severely burned patients have been attributed to medical advances in fluid resuscitation, nutritional support, pulmonary and burn wound care, and infection control practices.

A qualitative and quantitative analysis of protein loss in human burn wounds

INTRODUCTION

It is well known that in patients suffering from major burn injuries of more than 15% of total body surface area (TBSA), capillary leak and loss of proteins including immunoglobulins (Ig) lead to cardiovascular failure and significantly elevated risk of infections. However, knowledge of the resulting protein profiles is limited. In order to elucidate quantitative and qualitative protein loss in human burn wounds we compared wound fluid (WF) protein content with serum protein levels.

MATERIAL AND METHODS

Eleven patients suffering from second degree burns of 18-68% TBSA were enrolled in the study. Immediately after admission burn wounds were enclosed in cutaneous vinyl wound chambers covering a 2.25 cm(2) wound surface area. WF and serum samples were harvested every 8 h with a follow up of 48 h and analyzed for total protein content, albumin and the immunoglobulins A, E, G and M.

RESULTS

Protein levels in serum were significantly lower as compared to physiological levels while WF protein levels were elevated and remained high. Total protein (TP) and albumin (AL) accumulated in high concentrations on the wound surface (average accumulation on 10% burnt TBSA within 8 h: TP=16.59+/-8.86 g; AL=12.39+/-5.87 g). The albumin fraction in WF showed increasing values (24 h: 69%; 32 h: 86%) although the serum albumin fraction remained nearly unchanged (55%). Peak values were initially found for all immunoglobulins both in serum and WF. IgA, E and M reached a steady state 32 h post-trauma, whereas IgG continuously decreased until 40 h. IgG values in serum were significantly below physiological levels at all time points.

CONCLUSIONS

This study qualifies and quantifies a significant protein loss in second degree burn wounds. Protein concentrations in wound fluid correlate highly with serum concentrations until 48 h post-burn. A patient's entire amount of serum proteins accumulates in wound fluid in a 20% TBSA burn within approximately 24h. In contrast to capillary leak theory proteins and immunoglobulins extravasate to wound fluid even after 48 h post-trauma.

Peripheral axon caliber and conduction velocity are decreased after burn injury in mice

Peripheral neuropathies are reported to arise as a result of the systemic inflammatory response produced by a full-thickness cutaneous burn injury. This study was designed to characterize the magnitude and time course of functional and morphological changes in peripheral axons that arise after a full-thickness dermal burn injury in an animal model. A 20% body surface area (20% BSA) full-thickness dermal burn was applied to the back of C57BL6 female mice. Longitudinal H- and M-wave recordings were used to determine the conduction velocities (CV) of large myelinated motor and sensory axons in the tibial nerve of sham control and burn-injured mice. Motor CVs were significantly reduced from 6 h to 28 days after the burn, and sensory CVs were significantly reduced from 7 to 14 days after the burn. Morphological evaluation also showed that the mean caliber of large axons in tibial nerves and L5 ventral and dorsal roots in burned mice was significantly decreased. The results demonstrate that both functional and morphological deficits may be produced in peripheral nerve axons at sites well removed from a full-thickness dermal burn injury. The neural deficits may contribute to changes in neuromuscular transmission and the development of limb and respiratory muscle weakness that also accompany burn injury.

A prospective double blind randomized study comparing the need for blood transfusion with terlipressin or a placebo during early excision and grafting of burns

INTRODUCTION

Early excision and skin grafting has become the standard of good burn management, but it is associated with major blood loss.

AIM

To determine the haemostatic effect of terlipressin compared with placebo.

MATERIAL AND METHODS

Fifty-one patients with burns of 10-20% total body surface area had early excision and split skin grafting of deep burns. The surface area of the burn wound and of the healed graft were measured by planimetry. The patients were randomly allocated to medication, either terlipressin or placebo. Blood loss and number of transfused units of blood were recorded.

RESULTS

Twenty-one patients received terlipressin, 13 received terlipressin late (cross-over) and 17 received placebo. Six out of 21 patients exposed to terlipressin were transfused with eleven units of packed red blood cells. Seven out of 13 patients crossed over from placebo to terlipressin (late terlipressin) were transfused with 17 units of blood. Eight out of 17 patients exposed to the placebo were transfused with 22 units of blood (P < 0.05). Graft healing was 1055 +/- 609 cm2 out of 1452 +/- 11 cm2 in terlipressin and 914 +/- 633 cm2 out of 1288 +/- 720 cm2 in the placebo group (n.s.).

CONCLUSION

Terlipressin reduced the need for blood transfusion by a factor of 2.5 compared to a placebo without impairment of graft healing.

Pseudomonas infections in the thermally injured patient

Pseudomonas aeruginosa, remains a serious cause of infection and septic mortality in burn patients, particularly when nosocomially acquired. A prototypic burn patient who developed serious nosocomially acquired Pseudomonas infection is described as an index case which initiated investigations and measures taken to identify the source of the infection. The effect of changes in wound care to avoid further nosocomial infections was measured to provide data on outcome and cost of care. The bacteriology of Pseudomonas is reviewed to increase the burn care providers understanding of the behaviour of this very common and serious pathogen in the burn care setting, before reviewing the approach to detection of the organism and treatment both medically and surgically. After controlling the nosocomial spread of Pseudomonas in our burn unit, we investigated the morbidity and mortality associated with nosocomial infection with an aminoglycoside resistant Pseudomonas and the associated costs compared to a group of case-matched control patients with similar severity of burn injury, that did not acquire resistant Pseudomonas during hospitalization at our institution. We found a significant increase in the mortality rate in the Pseudomonas group compared to controls. The morbidity in terms of length of stay, ventilator days, number of surgical procedures, and the amount of blood products used were all significantly higher in the Pseudomonas group compared to controls. Costs associated with antibiotic requirements were also significantly higher in the Pseudomonas group. Despite this increased resource consumption necessary to treat Pseudomonas infections, these efforts did not prevent significantly higher mortality rates when compared to control patients who avoided infection with the resistant organism. Thus, in addition to the specific measures required to identify and treat nosocomial Pseudomonas infections in burn patients, prevention of infection through modification of treatment protocols together with continuous infection control measures to afford early identification and eradication of nosocomial Pseudomonas infection are critical for cost-effective, successful burn care.

Influence of demographics and inhalation injury on burn mortality in children

BACKGROUND

Pulmonary failure has emerged as one of the leading causes of mortality in burned children due, in part, to the success in reducing the incidence of sepsis, early surgery and fluid resuscitation, and new advances in nutritional support. To evaluate the effect of pulmonary injury, age, gender, race, and burn size on mortality, the records of 3179 burned children admitted to our burn center from 1985 to 2001 were reviewed. In this population, 1246 were admitted within 14 days of injury with burns greater than 20% of their total body surface area (TBSA).

METHODS

Lethal burn areas (LAs) for a thermal injury only or burn plus inhalation injury were estimated from best fit probit curve within 95% confidence limits. Data analysis was by chi(2)-test, t-test, or Fisher's exact test where appropriate.

RESULTS

The lethal burn area for a 10% mortality rate with and without concomitant inhalation injury was a 50 and 73% TBSA burn, respectively. Children up to the age of 3 with >/=20% TBSA burns had a higher rate of mortality (9.9%) compared to those 3-12 years of age (4.9%) and 13-18 years of age (4.2%). Children with 21-80% TBSA burns showed a significant difference in mortality (P<0.05) between those with burn plus inhalation injury (13.9%) and burn only (2.9%), while those with 81-100% TBSA burns showed no significant difference between burn only and burn plus inhalation injury.

CONCLUSION

Inhalation injury remains one of the primary contributors to burn mortality. Children under the age of 3 years, however, are at a higher risk both with and without inhalation injury.

Burn patients in Portugal: analysis of 14,797 cases during 1993-1999

The incidence and cause of burns in Portugal are unknown. The present study seeks to collect these data as a basis for future studies in prevention and development of treatment regimes. The data used in this work was obtained from the registries existing in The Direcção Geral de Saúde (General Health Administration) and relates to burn patients admitted to 91 Portuguese hospitals--that serve all the territory--during the period of 1993-1999. All patients selected had at least one diagnosis of burn (ICD-9: 94.###) among all the diagnoses motivating an admission. A total of 14,797 burn patients were obtained. Among all the patients admitted to hospitals, 8731 (59.0%) were male and 6066 (41.0%) were female, with a male/female ratio of 1.44:1. The mean length of in-hospital stay was 15.5+/-21.0 days. Throughout this period, 553 (3.7%) patients died in Portuguese hospitals as a result of burn injury. There were no significant differences in the number of deaths in each year, P=0.45, in contrast to the decrease of burn mortality rates reported in other studies. It is likely that the reason for this situation is the lack of investment in the last years in this area and the delay in opening new Burn Centres.