1
|
Larson BM, Elkady D, Sharma S, Beaucock B, Lou RB, Khandelwal A. Comparative results of autologous skin cell suspension combined with a contact layer dressing versus autologous skin cell suspension and a poly-lactic acid dressing in larger total body surface burns. Burns 2024; 50:1832-1839. [PMID: 38704317 DOI: 10.1016/j.burns.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 03/22/2024] [Accepted: 04/18/2024] [Indexed: 05/06/2024]
Abstract
INTRODUCTION Contact layer dressing (CLD) is standard after autologous skin cell suspension (ASCS); however, the authors wondered whether a poly-lactic acid dressing (PLAD) results in superior outcomes and cost savings. MATERIAL AND METHODS Retrospective cohort study including greater than 10% total body surface area (TBSA) burns treated with ASCS and either PLAD or CLD. Primary outcomes were infection and length of stay (LOS). RESULTS 71 patients (76% male, 24% pediatric, mean age 37 years) were included. Twenty-eight patients (39%) received CLD and 43 (61%) received PLAD. Wound infections were decreased in PLAD (7 vs 32%, p = 0.009). When controlling for area grafted (cm2) and TBSA, logistic regression revealed odds of post-operative infection was 8.1 times higher in CLD (p = 0.015). PLAD required antibiotics for fewer days (mean 0.47 vs 4.39, p = 0.0074) and shorter LOS (mean 17 vs 29 days, p < 0.001). Mean adjusted charges per %TBSA was $18,459 in PLAD vs. $25,397 in CLD (p = 0.0621). CONCLUSION In the first analysis of its kind, this study showed polylactic acid dressing combined with autologous skin cell suspension led to a decrease in postoperative infections, length of hospital stay, and total patient charges.
Collapse
Affiliation(s)
| | - Djoni Elkady
- Loyola University Medical Center, Chicago, IL, United States
| | - Steffi Sharma
- Adult and Pediatric Burn Institute, Akron Children's Hospital, Akron, OH, United States
| | - Beverly Beaucock
- Adult and Pediatric Burn Institute, Akron Children's Hospital, Akron, OH, United States
| | - Richard B Lou
- Adult and Pediatric Burn Institute, Akron Children's Hospital, Akron, OH, United States
| | - Anjay Khandelwal
- Adult and Pediatric Burn Institute, Akron Children's Hospital, Akron, OH, United States.
| |
Collapse
|
2
|
Suzuki DRR, Santana LA, Ávila JEHG, Amorim FF, Modesto GP, Gottems LBD, Maldaner V. Quality indicators for hospital burn care: a scoping review. BMC Health Serv Res 2024; 24:486. [PMID: 38641612 PMCID: PMC11031897 DOI: 10.1186/s12913-024-10980-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 04/10/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND Burn treatments are complex, and for this reason, a specialised multidisciplinary approach is recommended. Evaluating the quality of care provided to acute burn patients through quality indicators makes it possible to develop and implement measures aiming at better results. There is a lack of information on which indicators to evaluate care in burn patients. The purpose of this scoping review was to identify a list of quality indicators used to evaluate the quality of hospital care provided to acute burn patients and indicate possible aspects of care that do not have specific indicators in the literature. METHOD A comprehensive scoping review (PRISMA-ScR) was conducted in four databases (PubMed, Cochrane Library, Embase, and Lilacs/VHL) between July 25 and 30, 2022 and redone on October 6, 2022. Potentially relevant articles were evaluated for eligibility. General data and the identified quality indicators were collected for each included article. Each indicator was classified as a structure, process, or outcome indicator. RESULTS A total of 1548 studies were identified, 82 were included, and their reference lists were searched, adding 19 more publications. Thus, data were collected from 101 studies. This review identified eight structure quality indicators, 72 process indicators, and 19 outcome indicators listed and subdivided according to their objectives. CONCLUSION This study obtained a list of quality indicators already used to monitor and evaluate the hospital care of acute burn patients. These indicators may be useful for further research or implementation in quality improvement programs. TRIAL REGISTRATION Protocol was registered on the Open Science Framework platform on June 27, 2022 ( https://doi.org/10.17605/OSF.IO/NAW85 ).
Collapse
Affiliation(s)
- Denise R Rabelo Suzuki
- Programa de Pós-Graduação em Ciências para a Saúde, Escola Superior de Ciências da Saúde (ESCS/FEPECS), SMNH Quadra 3 Conjunto A Bloco 01 Edifício Fepecs, Asa Norte, Brasília, Distrito Federal, Brazil.
- Secretaria de Saúde do Distrito Federal (SES-DF), Setor de Rádio e TV Norte (SRTVN) 701, Via W5 Norte, lote D, Brasília, Distrito Federal, Brazil.
- Unidade de Queimados, Hospital Regional da Asa Norte (HRAN), 3° andar. Setor Médico Hospitalar Norte Q 2, Brasília, Distrito Federal, 70710-100, Brazil.
| | - Levy Aniceto Santana
- Programa de Pós-Graduação em Ciências para a Saúde, Escola Superior de Ciências da Saúde (ESCS/FEPECS), SMNH Quadra 3 Conjunto A Bloco 01 Edifício Fepecs, Asa Norte, Brasília, Distrito Federal, Brazil
- Secretaria de Saúde do Distrito Federal (SES-DF), Setor de Rádio e TV Norte (SRTVN) 701, Via W5 Norte, lote D, Brasília, Distrito Federal, Brazil
| | - Juliana Elvira H Guerra Ávila
- Secretaria de Saúde do Distrito Federal (SES-DF), Setor de Rádio e TV Norte (SRTVN) 701, Via W5 Norte, lote D, Brasília, Distrito Federal, Brazil
- Programa de Pós-Graduação em Ciências da Saúde, Universidade de Brasília (UnB), Campus Universitário Darcy Ribeiro, Asa Norte, Brasília, Distrito Federal, Brazil
- Unidade de Queimados, Hospital Regional da Asa Norte (HRAN), 3° andar. Setor Médico Hospitalar Norte Q 2, Brasília, Distrito Federal, 70710-100, Brazil
| | - Fábio Ferreira Amorim
- Programa de Pós-Graduação em Ciências da Saúde, Universidade de Brasília (UnB), Campus Universitário Darcy Ribeiro, Asa Norte, Brasília, Distrito Federal, Brazil
| | - Guilherme Pacheco Modesto
- Programa de Pós Graduação em Ciências do Movimento Humano e Reabilitação, Universidade Evangélica de Goiás, Cidade Universitária, Avenida Universitária, Anápolis, Goiás, Brazil
| | - Leila Bernarda Donato Gottems
- Programa de Pós-Graduação em Ciências para a Saúde, Escola Superior de Ciências da Saúde (ESCS/FEPECS), SMNH Quadra 3 Conjunto A Bloco 01 Edifício Fepecs, Asa Norte, Brasília, Distrito Federal, Brazil
- Secretaria de Saúde do Distrito Federal (SES-DF), Setor de Rádio e TV Norte (SRTVN) 701, Via W5 Norte, lote D, Brasília, Distrito Federal, Brazil
| | - Vinicius Maldaner
- Programa de Pós Graduação em Ciências do Movimento Humano e Reabilitação, Universidade Evangélica de Goiás, Cidade Universitária, Avenida Universitária, Anápolis, Goiás, Brazil
- Universidade de Brasília (UnB), Ceilândia Sul Campus Universitário, Centro Metropolitano, Ceilândia, Distrito Federal, Brazil
| |
Collapse
|
3
|
Ribeiro AF, Martins Pereira S, Nunes R, Hernández-Marrero P. What are the triggers for palliative care referral in burn intensive care units? Results from a qualitative study based on healthcare professionals' views, clinical experiences and practices. Palliat Med 2024; 38:297-309. [PMID: 38372020 PMCID: PMC10955784 DOI: 10.1177/02692163241229962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
BACKGROUND Burns are a global public health problem, accounting for around 300,000 deaths annually. Burns have significant consequences for patients, families, healthcare teams and systems. Evidence suggests that the integration of palliative care in burn intensive care units improves patients' comfort, decision-making processes and family care. Research is needed on how to optimise palliative care referrals. AIM To identify triggers for palliative care referral in critically burned patients based on professionals' views, experiences and practices. DESIGN Qualitative study using in-depth interviews. SETTING/PARTICIPANTS All five Burn Intensive Care Units reference centres across Portugal were invited; three participated. Inclusion criteria: Professionals with experience/working in these settings. A total of 15 professionals (12 nurses and 3 physicians) participated. Reflexive thematic analysis was performed. RESULTS Three main triggers for palliative care referral were identified: (i) Burn severity and extension, (ii) Co-morbidities and (iii) Multiorgan failure. Other triggers were also generated: (i) Rehabilitative palliative care related to patients' suffering and changes in body image, (ii) Family suffering and/or dysfunctional and complex family processes, (iii) Long stay in the burn intensive care unit and (iv) Uncontrolled pain. CONCLUSIONS This study identifies triggers for palliative care in burn intensive care units based on professionals' views, clinical experiences and practices. The systematisation and use of triggers could help streamline referral pathways and strengthen the integration of palliative care in burn intensive care units. Research is needed on the use of these triggers in clinical practice to enhance decision-making processes, early and high-quality integrated palliative care and proportionate patient and family centred care.
Collapse
Affiliation(s)
- André Filipe Ribeiro
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- Centro Hospitalar de Entre o Douro e Vouga, Santa Maria da Feira, Portugal
| | - Sandra Martins Pereira
- Universidade Católica Portuguesa, CEGE: Research Center in Management and Economics – Ethics and Sustainability Research Area, Católica Porto Business School, Porto, Portugal
| | - Rui Nunes
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- International Network UNESCO Chair in Bioethics, Porto, Portugal
| | - Pablo Hernández-Marrero
- Universidade Católica Portuguesa, CEGE: Research Center in Management and Economics – Ethics and Sustainability Research Area, Católica Porto Business School, Porto, Portugal
- Portuguese Nurses Association for Long-Term and Palliative Care (AECCP), Lisbon, Portugal
| |
Collapse
|
4
|
Muro I, Qualman AC, Kovacs EJ, Idrovo JP. Burn-Induced Apoptosis in the Livers of Aged Mice Is Associated With Caspase Cleavage of Bcl-xL. J Surg Res 2023; 290:147-155. [PMID: 37267704 PMCID: PMC10330893 DOI: 10.1016/j.jss.2023.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 04/05/2023] [Accepted: 04/29/2023] [Indexed: 06/04/2023]
Abstract
INTRODUCTION Older adult burn victims have poorer outcomes than younger burn victims. The liver is critical for the recovery of patients with burns. Postburn hepatic apoptosis in young individuals compromises liver integrity; however, this pathway has not yet been studied in older individuals. Because aged animals with burns suffer significant liver damage, we hypothesized that apoptosis is altered in these animals and may affect liver function. Understanding postburn hepatic apoptosis and its effects on liver function in aged animals may help improve outcomes in older patients. METHODS We compared the protein and gene expression levels in young and aged mice after a 15% total-body-surface-area burn. Liver and serum samples were collected at different time points after injury. RESULTS Caspase-9 expression in liver tissue was downregulated by 47% in young animals and upregulated by 62% in aged animals 9 h postburn (P < 0.05). The livers of aged mice showed a Bcl-extra-large (Bcl-xL) transcription increase only after 6 h; however, the livers of young mice exhibited 4.3-fold, 14.4-fold, and 7.8-fold Bcl-xL transcription increases at 3, 6, and 9 h postburn, respectively (P < 0.05). The livers of young mice showed no changes in Caspase-9, Caspase-3, or Bcl-xL protein levels during the early postburn period. In contrast, the livers of aged mice contained cleaved caspase-9, reduced full-length caspase-3, and an accumulation of ΔN-Bcl-x at 6 and 9 h postburn (P < 0.05). p21 expression decreased in aged mice; however, it was significantly increased in the liver tissue of young mice postburn (P < 0.05). Serum amyloid A1 and serum amyloid A2 serum protein levels were 5.2- and 3.1-fold higher in young mice than in aged mice, respectively, at 6 and 9 h postburn (P < 0.05). CONCLUSIONS Livers of aged mice exhibited different apoptotic processes compared to those of young mice early after burn injury. Collectively, burn-induced liver apoptosis in aged mice compromises hepatic serum protein production.
Collapse
Affiliation(s)
- Israel Muro
- Division of G.I., Trauma, and Endocrine Surgery, Department of Surgery, University of Colorado, Aurora, Colorado
| | - Andrea C Qualman
- Division of G.I., Trauma, and Endocrine Surgery, Department of Surgery, University of Colorado, Aurora, Colorado
| | - Elizabeth J Kovacs
- Division of G.I., Trauma, and Endocrine Surgery, Department of Surgery, University of Colorado, Aurora, Colorado; Division of Burn Research, Division of Alcohol Research, Department of Immunology and Microbiology, University of Colorado, Aurora, Colorado
| | - Juan-Pablo Idrovo
- Division of G.I., Trauma, and Endocrine Surgery, Department of Surgery, University of Colorado, Aurora, Colorado.
| |
Collapse
|
5
|
Alhusayni MA, Alotaibi NM, Alshaer AA, Alnefaie A, Alotaibi MM, Albogami ARR, Juohari TB, Alnofaiey Y. Assessment of Awareness and Practices Related to Burn Injury First Aid Among the General Public: Cross-Sectional Study in Taif, Saudi Arabia. Cureus 2023; 15:e45912. [PMID: 37885549 PMCID: PMC10599189 DOI: 10.7759/cureus.45912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2023] [Indexed: 10/28/2023] Open
Abstract
Background Burn injuries can be highly traumatic and harmful, leading to significant mortality rates, extended hospital stays, deformity, and incapacity. In the long term, they may also result in rejection, social stigma, and psychiatric issues. This study aimed to estimate the awareness and practices related to burn injury first aid among the general public in Taif, Saudi Arabia. Methods This is an online cross-sectional survey in Taif, Saudi Arabia. An online self-administered questionnaire was distributed to the adult population, comprising individuals aged 18 years and older, of both genders, from June 2023 to August 2023. The questionnaire consisted of 24 questions divided into demographics and first aid for burns. The Scientific Research Ethics Committee at Taif University, Taif, Saudi Arabia, obtained the ethical approval for the study. Results A total of 531 individuals were included in the study. About half were male (58.4%) and in the age group of 22-29 years (52%). Out of that number, 24.1% were medical field students. About one-third of the respondents had participated in a burn training course (33.7%), and 73.8% reported experiencing a burn injury before, either to themselves or their family. Most respondents chose to treat the burn area using honey, and only 15.6% knew that they should administer water to a burn injury for 10 to 15 or >15 minutes. Most of the participants reported an excellent knowledge level (62.9%). Only 8.7% had an excellent practice level. The total knowledge and practice score was significantly associated with participation in the burn training course (P-value < 0.001 and 0.015, respectively). The work nature and prior experience with a burn injury were significantly associated with the knowledge scores (P-value=0.003, for both). Monthly income and the work nature also correlated with the practice total score (P-value=0.023 and <0.001, respectively). Conclusion Most participants had an excellent knowledge level, however, most of them reported poor or acceptable practice scores. It highlights the need for training sessions, awareness campaigns, and dissemination of evidence-based information to bridge the gap between knowledge and practice.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Yasser Alnofaiey
- Department of Internal Medicine, College of Medicine, Taif University, Taif, SAU
| |
Collapse
|
6
|
Gasteratos K, McCarthy M, Chatziathanasiou D, Vradeli G, Vlachopoulos N, Voitsidis P, Goverman J. A Systematic Review of Pediatric Nonaccidental Burns: Protecting the Children Through Knowledge, Vigilance, and Prevention. Ann Plast Surg 2023; 90:551-558. [PMID: 37157138 DOI: 10.1097/sap.0000000000003559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND Inflicted burns on children are a particularly difficult medical and psychosocial issue. Pediatric nonaccidental burns (PNABs) are unfortunately relatively common. In our study, we aim to present the key findings on PNABs with the intention of raising awareness, improving early, and recognizing accurately by identifying red flags, developing triage tools, and establishing prevention strategies for this sensitive issue. METHODS A computerized literature search was conducted on PubMed, Google Scholar, and Cochrane for articles published until November 2020. The online screening process was performed by 3 independent reviewers with the Covidence tool against set inclusion/exclusion criteria. The protocol was reported using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) protocol. The study was registered with the International Prospective Register of Systematic Reviews (PROSPERO). RESULTS A total of 12 studies were included for analysis. Scald burns via forced immersion accounted for the majority of reported PNABs affecting both feet and hands. Complications included wound infection, sepsis, requiring systemic antibiotics, or intensive care. Abused children's parents had a history of mental illness, unemployment, substance abuse, incarceration, and/or low annual income. CONCLUSIONS Scalds via forced immersion remain the most common mechanism of PNABs. All health care professionals must remain vigilant, be able to recognize subtle signs of abuse, triage patients appropriately, report to police and/or social services, and ensure no further harm is made to the child or children. Repeated abuse with burns can lead to death. Prevention and education are the cornerstones for addressing this social phenomenon.
Collapse
Affiliation(s)
| | | | | | - Georgia Vradeli
- Department of Dermatology, Städtisches Klinikum Dessau, Germany
| | | | - Pantelis Voitsidis
- 1st Psychiatric Clinic, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Jeremy Goverman
- Sumner M. Redstone Burn Center, Department of Surgery, Massachusetts General Hospital, Boston, MA
| |
Collapse
|
7
|
Tracy LM, Darton A, Gabbe BJ, Heath K, Kurmis R, Lisec C, Lo C, Singer Y, Wood FM, Cleland HJ. Examining the patient profile and variance of management and in-hospital outcomes for Australian adult burns patients. ANZ J Surg 2022; 92:2641-2647. [PMID: 36054463 PMCID: PMC9804322 DOI: 10.1111/ans.17985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 08/04/2022] [Accepted: 08/05/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Burn injuries are a common subtype of trauma. Variation in models of care impacts clinical measures of interest, but a nation-wide examination of these measures has not been undertaken. Using data from the Burns Registry of Australia and New Zealand (BRANZ), we explored variation between Australian adult burn services with respect to treatment and clinical measures of interest. METHODS Data for admissions July 2016 to June 2020 were extracted. Clinical measures of interest included intensive care admission, skin grafting, in-hospital death, unplanned readmissions, and length of stay (LOS). Estimated probabilities, means, and corresponding 95% confidence intervals (CI) were calculated for each service. RESULTS The BRANZ recorded 8365 admissions during the study period. Variation between specialist burn services in admissions, demographics, management, and clinical measures of interest were observed. This variation remained after accounting for covariates. Specifically, the adjusted proportion (95% CI) of in-hospital mortality ranged from 0.15% (0.10-0.21%) to 1.22% (0.9-1.5%). The adjusted mean LOS ranged from 3.8 (3.3-4.3) to 8.2 (6.7-9.7) days. CONCLUSIONS A decade after its launch, BRANZ data displays variation between Australian specialist burn services. We suspect differences in models of care between services contributes to this variation. Ongoing research has begun to explore reasons underlying how this variation influences clinical measures of interest. Further engagement with services about models of care will enhance understanding of this variation and develop evidence-based guidelines for burn care in Australia.
Collapse
Affiliation(s)
- Lincoln M. Tracy
- School of Public Health and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
| | - Anne Darton
- Statewide Burn Injury ServiceNew South Wales Agency for Clinical InnovationSydneyNew South WalesAustralia
| | - Belinda J. Gabbe
- School of Public Health and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia,Health Data Research UK, Swansea University Medical SchoolSwansea UniversitySwanseaUK
| | - Kathryn Heath
- Adult Burns ServiceRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Rochelle Kurmis
- Adult Burns ServiceRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Carl Lisec
- Faculty of MedicineThe University of QueenslandBrisbaneQueenslandAustralia,Professor Stuart Pegg Adult Burns CentreThe Royal Brisbane And Women's HospitalBrisbaneQueenslandAustralia
| | - Cheng Lo
- Victorian Adult Burns ServiceThe AlfredMelbourneVictoriaAustralia,Department of Surgery, Central Clinical SchoolMonash UniversityMelbourneVictoriaAustralia
| | - Yvonne Singer
- Victorian Adult Burns ServiceThe AlfredMelbourneVictoriaAustralia
| | - Fiona M. Wood
- State Adult Burn UnitFiona Stanley HospitalMurdochWestern AustraliaAustralia,Burn Injury Research UnitUniversity of Western AustraliaPerthWestern AustraliaAustralia
| | | |
Collapse
|
8
|
Is Antibiotic Prophylaxis Necessary in Small (≤20% TBSA) Burn Excisions? A Retrospective Study. Plast Reconstr Surg Glob Open 2022; 10:e4388. [PMID: 35919889 PMCID: PMC9278909 DOI: 10.1097/gox.0000000000004388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 05/04/2022] [Indexed: 12/03/2022]
Abstract
Background: This study investigates the effect of prophylactic perioperative antibiotic use on patients with small burns [≤20% total body surface area (TBSA)] on rates of infection, graft loss, or readmission. Methods: A retrospective chart review was conducted on patients admitted to our institution’s burn center between January 2020 and July 2021. Patients were included if they had a 20% or less TBSA burn with 1 or more operating room visit for burn excision and were excluded if a preoperative infection was present. Data were gathered regarding patient demographics, burn mechanism, burn characteristics, and outcome measures including infection, graft loss, and readmission. Statistical analysis was conducted by Mann–Whitney U and Fisher exact tests, and P values reported at two-sided significance of less than 0.05. Results: There were no significant differences in age, body mass index, TBSA, percent third-degree burn, or comorbidities between patients who received (n = 29) or did not receive (n = 47) prophylactic perioperative antibiotics. There was a nonsignificant trend toward higher length of stay in the prophylactic antibiotic group, possibly driven by a nonsignificant trend toward higher rates of flame injuries in this group. There was no difference in infection (P = 0.544), graft loss (P = 0.494), or 30-day readmission (P = 0.584) between the two groups. Conclusion: This study finds no significant difference in postoperative infection, graft loss, or 30-day readmission in two similar patient cohorts who received or did not receive prophylactic perioperative antibiotics for acute excision of small (≤20% TBSA) burns.
Collapse
|
9
|
Zhang JX, Ahmed SN, Pangli H, Papp A. Predicting and Estimating Burn Outcomes: An Institutional Analysis of 4622 cases. J Burn Care Res 2022; 43:1426-1433. [PMID: 35481479 DOI: 10.1093/jbcr/irac051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Advances in burn care have improved patient outcomes, and independently validated indices and predictors of burn outcomes warrant re-evaluation. The purpose of this study is to consolidate predictors of burn outcomes and determine the factors that significantly contribute to length-of-stay (LOS) and mortality. A retrospective review was conducted of all burn patients (n=5778) admitted to a quaternary provincial burn unit from 1973 to 2017. Our inclusion criteria yielded 4622 independent cases. Multivariate linear and logistic regression models were generated, and area-under-receiver-operator-curve (AUROC) analysis was performed. Burn predictors included %TBSA, Baux (classic and revised) index, Abbreviated Burn Severity Index (ABSI), and Ryan score. Primary outcomes were mortality and LOS. Multivariate logistic regression for mortality showed the Baux index to be the best predictor for mortality (OR=1.11, p<0.001). The AUROC for Baux index was 0.95. With regards to LOS, ABSI was the best predictor for LOS (p<0.001). ICU stay, ventilator use, alcoholism, age, significantly associated with increased LOS. Interestingly, hypertension had a protective effect for LOS (p<0.01) and trended towards a protective effect in mortality. Lethal score 50% (LS50) improved over the study period. The regressions show that burn mortality and LOS are best predicted with the Baux index and ABSI, respectively. Hypertension may have a protective effect on burn outcomes and may be attributed to increased perfusion to the periphery. These predictive scores are useful in determining institutional outcomes in burn surgery. Objective benchmarking of improvement in burn care outcomes can be established using LS50 trends.
Collapse
Affiliation(s)
- Jacques X Zhang
- Division of Plastic Surgery, Department of Surgery, University of British Columbia
| | - S Nafeel Ahmed
- Faculty of Medicine, Department of Surgery, University of British Columbia
| | - Harpreet Pangli
- Division of Plastic Surgery, Department of Surgery, University of British Columbia
| | - Anthony Papp
- Division of Plastic Surgery, Department of Surgery, University of British Columbia
| |
Collapse
|
10
|
O'Neil AM, Rush C, Griffard L, Roggy D, Boyd A, Hartman B. 5 -Year Retrospective Analysis of a Vented Mobility Algorithm in the Burn ICU. J Burn Care Res 2022; 43:1129-1134. [PMID: 34978322 DOI: 10.1093/jbcr/irab248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Early mobilization with mechanically ventilated patients has received significant attention within recent literature, however limited research has focused specifically on the burn population. The purpose of this single center, retrospective analysis was to review the use of a burn critical care mobility algorithm, to determine safety and feasibility of a burn vented mobility program, share limitations preventing mobility progression at our facility, and discuss unique challenges to vented mobility with intubated burn patients. A retrospective review was completed for all intubated burn center admissions between January 2015 to December 2019. Burn Therapy notes were then reviewed for data collection, during the intubation period, using stages of the mobility algorithm. In 5 years following initial implementation, the vented mobility algorithm was utilized on 127 patients with an average total body surface area of 22.8%. No adverse events occurred. Stage 1 (Range of motion) was completed with 100% of patients (n=127). Chair mode of bed, stage 2a, was utilized in 39.4%(n=50) of patients, while 15.8% (n=20) of patients were dependently transferred to the cardiac chair in stage 2b. Stage 3 (sitting on the edge-of-bed) was completed with 25% (n=32) of patients, with 11% (n=14) progressing to stage 5 (standing), and 3.9% (n=5) actively transferring to a chair. In 5 years, only 4.7% (n=6) reached stage 6 (ambulation). The most common treatment limitations were medical complications (33%) and line placement (21%). Early mobilization during mechanical ventilation is safe and feasible within the burn population, despite challenges including airway stability, sedation, and line limitations.
Collapse
Affiliation(s)
| | | | | | - David Roggy
- Richard M Fairbanks Burn Center, Indianapolis, IN
| | - Allison Boyd
- Richard M Fairbanks Burn Center, Indianapolis, IN
| | - Brett Hartman
- Indiana University School of Medicine, Indianapolis, IN
| |
Collapse
|
11
|
Carter JE, Amani H, Carter D, Foster KN, Griswold JA, Hickerson WL, Holmes JH, Jones S, Khandelwal A, Kopari N, Litt JS, Savetamal A, Schupp JW, Sood R, Ferrufino CP, Vadagam P, Kowal S, Walsh T, Sparks J. Evaluating real-world national and regional trends in definitive closure in US burn care: A survey of US Burn Centers. J Burn Care Res 2021; 43:141-148. [PMID: 34329478 PMCID: PMC8737084 DOI: 10.1093/jbcr/irab151] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
To better understand trends in burn treatment patterns related to definitive closure, this study sought to benchmark real-world survey data with national data contained within the National Burn Repository version 8.0 (NBR v8.0) across key burn center practice patterns, resource utilization, and clinical outcomes. A survey, administered to a representative sample of U.S. burn surgeons, collected information across several domains: burn center characteristics, patient characteristics including number of patients and burn size and depth, aggregate number of procedures, resource use such as autograft procedure time and dressing changes, and costs. Survey findings were aggregated by key outcomes (number of procedures, costs) nationally and regionally. Aggregated burn center data were also compared to the NBR to identify trends relative to current treatment patterns. Benchmarking survey results against the NBR v8.0 demonstrated shifts in burn center patient mix, with more severe cases being seen in the inpatient setting and less severe burns moving to the outpatient setting. An overall reduction in the number of autograft procedures was observed compared to NBR v8.0, and time efficiencies improved as the intervention time per TBSA decreases as TBSA increases. Both nationally and regionally, an increase in costs was observed. The results suggest resource use estimates from NBR v8.0 may be higher than current practices, thus highlighting the importance of improved and timely NBR reporting and further research on burn center standard of care practices. This study demonstrates significant variations in burn center characteristics, practice patterns, and resource utilization, thus increasing our understanding of burn center operations and behavior.
Collapse
Affiliation(s)
| | - H Amani
- Lehigh Valley Health Network Regional Burn Center, Allentown PA
| | | | - Kevin N Foster
- Arizona Burn Center at Valleywise Health Medical Center, Phoenix AZ
| | | | - William L Hickerson
- University of Tennessee Health Science Center: Firefighters Regional Burn Center, Memphis TN
| | | | | | | | - Nicole Kopari
- . University of California San Francisco Fresno, Fresno CA
| | | | - Alisa Savetamal
- Connecticut Burn Center at Bridgeport Hospital, Bridgeport CT
| | | | - Rajiv Sood
- Richard M. Fairbanks Burn Center at Eskenazi Health, Indianapolis IN
| | | | | | | | | | | |
Collapse
|
12
|
Min D, Wu B, Chen L, Chen R, Wang J, Zhang H, Chen J, Kim S, Zhang L, Xia Z, Lin J. Level of Decoy Receptor 3 for Monitoring Clinical Progression of Severe Burn Patients. J Burn Care Res 2021; 42:925-933. [PMID: 34213565 DOI: 10.1093/jbcr/irz170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The clinical value of Decoy receptor 3 (DcR3) in severe burn is investigated. Ten patients with severe burns were monitored for DcR3, PCT, CRP, IL6, SOFA score, white blood cell (WBC), and platelet. The correlations were analyzed. DcR3 increased on day 1. The nonsurvivors had a steady high level of DcR3 while the survivors had a relatively low level of DcR3. The peak magnitude of DcR3 was high in five nonsurvivors and low in five survivors without overlap. Three patients had a continuously increasing DcR3 level and then died. In the other two nonsurvivors, DcR3 reached the peak and then decreased before death. DcR3 correlated well with PCT (ρ = 0.4469, P < .0001), less with CRP, platelet, IL6, SOFA score and WBC (ρ = 0.4369, 0.4078, 0.3995, 0.2631, 0.1504, respectively, all P < .001). To explore the mechanisms, the HaCaT or THP-1 cells were stimulated by the plasma of burn patients, 45°C, LPS or stimulators of TLRs or NOD2 (PGN, CL264, MDP, iE-DAP, Gardiquimod), and their DcR3 was increased, which could be reduced by GDC-0941 or BEZ235 (inhibitors of PI3K and mTOR). The levels of DcR3 appeared to be a useful biomarker for monitoring the clinical severity and a predictor of mortality of severe burns.
Collapse
Affiliation(s)
- Dong Min
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, China
| | - Bing Wu
- First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Long Chen
- Division of Neurocritical Care, Huashan Hospital, Fudan University, Shanghai, China
| | - Ruiqin Chen
- First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Jiling Wang
- Department of Oncology, Putian First Hospital, China
| | - Hailong Zhang
- Hailong Zhang Fujian Center for Disease Control and Prevention, Fuzhou, China
| | - Jinrong Chen
- First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | | | - Lurong Zhang
- Department of Radiation Biology, Fujian Cancer Hospital, Fuzhou, China
| | - Zhaofan Xia
- Brun Center, Shanghai Changhai Hospital, China
| | - Jianhua Lin
- First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| |
Collapse
|
13
|
Wen JJ, Williams TP, Cummins CB, Colvill KM, Radhakrishnan GL, Radhakrishnan RS. Effect of Mitochondrial Antioxidant (Mito-TEMPO) on Burn-Induced Cardiac Dysfunction. J Am Coll Surg 2021; 232:642-655. [PMID: 33421567 PMCID: PMC8753741 DOI: 10.1016/j.jamcollsurg.2020.11.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 11/30/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Imbalance of oxidants/antioxidants results in heart failure, contributing to mortality after burn injury. Cardiac mitochondria are a prime source of reactive oxygen species (ROS), and a mitochondrial-specific antioxidant may improve burn-induced cardiomyopathy. We hypothesize that the mitochondrial-specific antioxidant, Triphenylphosphonium chloride (Mito-TEMPO), could protect cardiac function after burn. STUDY DESIGN Male rats had a 60% total body surface area (TBSA) scald burn injury and were treated with/without Mito-TEMPO (7 mg/kg-1, intraperitoneal) and harvested at 24 hours post-burn. Echocardiography (ECHO) was used for measurement of heart function. Masson Trichrome and hematoxylin and eosin (H & E) staining were used for cardiac fibrosis and immune response. Qualitative polymerase chain reaction (qPCR) was used for mitochondrial DNA replication and gene expression. RESULTS Burn-induced cardiac dysfunction, fibrosis, and mitochondrial damage were assessed by measurement of mitochondrial function, DNA replication, and DNA-encoded electron transport chain-related gene expression. Mito-TEMPO partially improved the abnormal parameters. Burn-induced cardiac dysfunction was associated with crosstalk between the NFE2L2-ARE pathway, PDE5A-PKG pathway, PARP1-POLG-mtDNA replication pathway, and mitochondrial SIRT signaling. CONCLUSIONS Mito-TEMPO reversed burn-induced cardiac dysfunction by rescuing cardiac mitochondrial dysfunction. Mitochondria-targeted antioxidants may be an effective therapy for burn-induced cardiac dysfunction.
Collapse
Affiliation(s)
- Jake J Wen
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Taylor P Williams
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Claire B Cummins
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Kayla M Colvill
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | | | - Ravi S Radhakrishnan
- Department of Surgery, University of Texas Medical Branch, Galveston, TX; Department of Pediatrics, University of Texas Medical Branch, Galveston, TX.
| |
Collapse
|
14
|
Dolan KJ, Flint JL, Benton TC, Miller M, Miller JO. Implementation and Maintenance of a Pediatric Severe Burn Guidelines Quality Improvement Project. Pediatr Qual Saf 2021; 6:e388. [PMID: 38571517 PMCID: PMC10990325 DOI: 10.1097/pq9.0000000000000388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 09/26/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction Critically injured pediatric burn patients require specialized management, yet few verified pediatric burn centers exist in the United States. Many pediatric hospitals have resources to care for severely burned patients but lack standardized care guidelines, which improve outcomes. To improve the morbidity and mortality of severely burned pediatric patients admitted to the pediatric intensive care unit, we created a specialized burn team. We implemented Pediatric Severe Burn Guidelines, focusing on improving fluid resuscitation accuracy and providing timely nutritional support. Methods This investigation is of a 9-year (2010-2019) retrospective preintervention and postintervention study of the effect of the formation of a multidisciplinary burn leadership committee and development and implementation of Pediatric Severe Burn Guidelines. The primary outcome measures are increasing the accuracy of fluid resuscitation and improving the timely administration of nutritional support. The process measure is the percentage of time the electronic health record power plan was used for burn admissions with burn leadership review of the cases. Balancing measures are pediatric intensive care unit and hospital length of stay. Results Preprotocol patients received acceptable fluid resuscitation 25% (5/20) of the time compared to 61.5% (8/13) of the time in postprotocol patients (P = 0.04). In postprotocol patients, there is an improvement in the timely placement of postpyloric feeding tube and initiation of feeds 48 hours after admission. Conclusions Extensive guidelines for standardized care require careful implementation and monitoring of adherence gaps. Creating a specialized burn team and implementing clinical guidelines standardize care leading to improvement in critical patient outcomes.
Collapse
Affiliation(s)
- Kristin J. Dolan
- From the Section of Critical Care Medicine, Texas Children’s Hospital, Baylor College of Medicine, Houston, Tex
| | - Jennifer L. Flint
- Department of Critical Care, Children’s Mercy Hospital, Kansas City, Mo
| | - Tara C. Benton
- Department of Critical Care, Children’s Mercy Hospital, Kansas City, Mo
| | - Mikaela Miller
- From the Section of Critical Care Medicine, Texas Children’s Hospital, Baylor College of Medicine, Houston, Tex
- Department of Critical Care, Children’s Mercy Hospital, Kansas City, Mo
- Constituent Understandings and Insights, Children International, Kansas City, Mo
| | - Jenna O. Miller
- Department of Critical Care, Children’s Mercy Hospital, Kansas City, Mo
| |
Collapse
|
15
|
Belval LN, Cramer MN, Moralez G, Huang MU, Cimino FA, Watso JC, Crandall CG. Interaction of Exercise Intensity and Simulated Burn Injury Size on Thermoregulation. Med Sci Sports Exerc 2021; 53:367-374. [PMID: 32826639 PMCID: PMC7995740 DOI: 10.1249/mss.0000000000002480] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE This study aimed to test the hypothesis that the elevation in internal body temperature during exercise in a hot environment is influenced by the combination of exercise intensity and BSA burned. METHODS Ten healthy participants (8 males, 2 females; 32 ± 9 yr; 75.3 ± 11.7 kg) completed eight exercise trials on a cycle ergometer, each with different combinations of metabolic heat productions (low, 4 W·kg-1; moderate, 6 W·kg-1) and simulated BSA burn in a hot environmental chamber (39.9°C ± 0.3°C, 20.1% ± 1.5% RH). Burns were simulated by covering 0%, 20%, 40%, or 60% of participants' BSA with a highly absorbent, vapor-impermeable material. Gastrointestinal temperature (TGI) was recorded, with the primary analysis being the increase in TGI after 60 min of exercise. RESULTS We identified an interaction effect for the increase in TGI (P < 0.01), suggesting TGI was influenced by both intensity and simulated burn BSA. Regardless of the percentage BSA burn simulated, the increase in TGI was similar across low-intensity trials (0.70°C ± 0.26°C, P > 0.11 for all). However, during moderate-intensity exercise, the increase in TGI was greater for the 60% (1.78°C ± 0.38°C, P < 0.01) and 40% BSA coverage trials (1.33°C ± 0.44°C, P = 0.04), relative to 0% (0.82°C ± 0.36°C). There were no differences in TGI responses between 0% and 20% trials. CONCLUSION These data suggest that exercise intensity influences the relationship between burn injury size and thermoregulatory responses in a hot environment.
Collapse
Affiliation(s)
- Luke N Belval
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center, Dallas, TX
| | - Matthew N Cramer
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center, Dallas, TX
| | | | | | - Frank A Cimino
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center, Dallas, TX
| | - Joseph C Watso
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center, Dallas, TX
| | - Craig G Crandall
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center, Dallas, TX
| |
Collapse
|
16
|
Escandón-Vargas K, Tangua AR, Medina P, Zorrilla-Vaca A, Briceño E, Clavijo-Martínez T, Tróchez JP. Healthcare-associated infections in burn patients: Timeline and risk factors. Burns 2020; 46:1775-1786. [DOI: 10.1016/j.burns.2020.04.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 03/13/2020] [Accepted: 04/24/2020] [Indexed: 02/06/2023]
|
17
|
Yoshimura Y, Saitoh D, Yamada K, Nakamura T, Terayama T, Ikeuchi H, Sasaki J, Nemoto M. Comparison of prognostic models for burn patients: A retrospective nationwide registry study. Burns 2020; 46:1746-1755. [PMID: 33148486 DOI: 10.1016/j.burns.2020.10.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 09/03/2020] [Accepted: 10/08/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Prognostic burn index (PBI) is a unique model utilized to predict mortality of burn patients in Japan. In contrast, other prediction models are rarely used in Japan, and their accuracy and predictive value are unknown. The present study aimed to compare commonly used burn prediction models and determine the appropriate model for mortality prediction in Japanese burn patients. METHODS Japanese burn patients registered in the nationwide burn registry of Japanese Society for Burn Injury between April 1, 2011 and March 31, 2019 were reviewed retrospectively. The prognostic performance of PBI was compared with Baux score, revised Baux score, abbreviated burn severity index (ABSI), Ryan score and Belgian outcome in burn injury score (BOBI). The primary outcome was in-hospital mortality. RESULTS The study included 7911 acute burn patients. The overall mortality rate was 10.7%, the median age was 52 (interquartile range, 26-72) years, and the median % total body surface area was 7% (interquartile range, 3%-17%). The areas under the receiver operating characteristic curve for PBI, Baux score, ABSI, revised Baux score, Ryan score, and BOBI were 0.940 (95% confidence interval [CI]: 0.931-0.948), 0.943 (95% CI: 0.934-0.951; p=0.002), 0.945 (95% CI: 0.937-0.953; p=0.058), 0.946 (95% CI: 0.937-0.953; p=0.002), 0.859 (95% CI: 0.846-0.870; p<0.001), and 0.896 (95% CI: 0.885-0.905; p<0.001), respectively. CONCLUSION Although the performance of PBI was good, it was not superior to the Baux score, revised Baux score, and ABSI. These three scores have a high prognostic accuracy. Hence, they are considered as alternative burn prognostic scores in Japan. The Baux score was an optimal prognostic model for patients with burns in Japan.
Collapse
Affiliation(s)
- Yuya Yoshimura
- Department of Traumatology and Critical Care Medicine, National Defense Medical College, Saitama, Japan; Department of Emergency and Acute Medicine, Saitama Medical University International Medical Center, Saitama, Japan.
| | - Daizoh Saitoh
- Department of Traumatology and Critical Care Medicine, National Defense Medical College, Saitama, Japan; Division of Traumatology, Research Institute, National Defense Medical College, Saitama, Japan
| | - Kohei Yamada
- Department of Traumatology and Critical Care Medicine, National Defense Medical College, Saitama, Japan
| | - Takahiro Nakamura
- Department of Mathematics, National Defense Medical College, Saitama, Japan
| | - Takero Terayama
- Department of Traumatology and Critical Care Medicine, National Defense Medical College, Saitama, Japan
| | - Hisashi Ikeuchi
- Department of Traumatology and Critical Care Medicine, National Defense Medical College, Saitama, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Manabu Nemoto
- Department of Emergency and Acute Medicine, Saitama Medical University International Medical Center, Saitama, Japan
| |
Collapse
|
18
|
Malkoc A, Wong DT. Lessons Learned From Two Survivors of Greater Than 90% TBSA Full-Thickness Burn Injuries Using NovoSorb Biodegradable Temporizing Matrix™ and Autologous Skin Cell Suspension, RECELL™: A Case Series. J Burn Care Res 2020; 42:577-585. [PMID: 33022032 DOI: 10.1093/jbcr/iraa176] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Since autologous split-thickness skin grafts are scarce and lab skin growth requires a significant amount of time, there are limited available treatment approaches for patients with full-thickness burns greater than 90% TBSA. Additionally, to achieve the primary goal of skin coverage and resuscitation, there must exist a balance between fluid loss and metabolic derangement. Allografts and xenografts have traditionally been used early in the process to achieve these goals. Currently, novel approaches to treatment consider the additional use of synthetic dermal substitutes and autologous skin cell suspension to improve outcomes. This case series describes the treatment course of patients with greater than 90% TBSA full-thickness burn injuries using a staged, multifaceted approach of using NovoSorb Biodegradable Temporizing Matrix™ as the primary dermal substitute in conjunction with a RECELL™ Autologous Cell Suspensions Device applied with autograft and allograft to achieve improved resuscitation, limiting fluid loss, and finally skin coverage. Allograft and NovoSorb Biodegradable Temporizing Matrix™ were used early to cover excised burns, resulting in improved metabolic control by limiting the systemic inflammatory response syndrome and fluid loss. Both patients survived using this approach.
Collapse
Affiliation(s)
- Aldin Malkoc
- St. George's University School of Medicine, True Blue, Grenada.,Arrowhead Regional Medical Center, Colton, California
| | - David T Wong
- Arrowhead Regional Medical Center, Colton, California
| |
Collapse
|
19
|
Yin HN, Hao JW, Chen Q, Li F, Yin S, Zhou M, Zhang QH, Yao YM, Chai JK. Plasma glucagon-like peptide 1 was associated with hospital-acquired infections and long-term mortality in burn patients. Surgery 2020; 167:1016-1022. [PMID: 32295709 DOI: 10.1016/j.surg.2020.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 12/19/2019] [Accepted: 01/07/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Although glucagon-like peptide 1 levels have been closely associated with inflammation and mortality in septic patients, the clinical importance of glucagon-like peptide 1 on hospital-acquired infections and long-term mortality after burn injury remains unexplored. METHODS Plasma samples from 144 burn patients were collected on admission to determine total glucagon-like peptide 1, interleukin 6, and monocyte chemotactic protein-1 levels. Hospital-acquired infections were determined by positive microbial culture. One-year mortality was assessed by telephone interview. Factors associated with glucagon-like peptide 1 were determined by multivariable linear logistic regression. Predicting the clinical importance of glucagon-like peptide 1 on the development of hospital-acquired infections and mortality were determined by Cox proportional hazards models and further by receiver operating characteristic curve analysis. Kaplan-Meier analyses were performed to examine whether the mean glucagon-like peptide 1 level of the cohort could discriminate the hospital-acquired infections-free survival. RESULTS Median burn size was 41% (19%-70%) of total body surface area. Hospital-acquired infections developed in 36 (25%) patients after a mean of 10 ± 1 days after injury. Interleukin 6, monocyte chemotactic protein-1, and blood urea nitrogen levels and thrombin time were independently associated with increased glucagon-like peptide 1 levels. Levels of glucagon-like peptide 1 (median, interquartile range) were greater in patients who developed hospital-acquired infections than in those who did not (237 pmol/L, 76-524 vs 80 pmol/L, 51-158; P < .001) and in patients who died (536 pmol/L, interquartile range: 336-891 pmol vs 98 pmol/L, 47-189; P < .001). Although the glucagon-like peptide 1 level could not predict hospital-acquired infections-free survival in individual patients, it could predict 1-year mortality independently (P = .021). Moreover, a glucagon-like peptide 1 level of 200 pmol/L could discriminate hospital-acquired infections-free survival (P < .001). CONCLUSION Admission glucagon-like peptide 1 level can discriminate hospital-acquired infections-free survival and predict long-term mortality in a group of patients with burn injury. Our data suggests that glucagon-like peptide 1 may be a predictive biomarker for hospital-acquired infections and mortality in burn patients.
Collapse
Affiliation(s)
- Hui-Nan Yin
- Department of Burn and Plastic Surgery, Fourth Medical Center of Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Ji-Wei Hao
- Trauma Repairment and Tissue Regeneration Center, Department of Medical Innovation Study, Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Qi Chen
- Department of Burn and Plastic Surgery, Fourth Medical Center of Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Feng Li
- Department of Burn and Plastic Surgery, Fourth Medical Center of Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Song Yin
- Department of Outpatient Service, Fourth Medical Center of Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Min Zhou
- Neurocritical Care Unit, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, Hefei, Anhui, People's Republic of China
| | - Qing-Hong Zhang
- Trauma Repairment and Tissue Regeneration Center, Department of Medical Innovation Study, Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China.
| | - Yong-Ming Yao
- Trauma Repairment and Tissue Regeneration Center, Department of Medical Innovation Study, Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Jia-Ke Chai
- Department of Burn and Plastic Surgery, Fourth Medical Center of Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China
| |
Collapse
|
20
|
Guest JF, Fuller GW, Edwards J. Cohort study evaluating management of burns in the community in clinical practice in the UK: costs and outcomes. BMJ Open 2020; 10:e035345. [PMID: 32273318 PMCID: PMC7245389 DOI: 10.1136/bmjopen-2019-035345] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To evaluate health outcomes, resource use and corresponding costs attributable to managing burns in clinical practice, from initial presentation, among a cohort of adults in the UK. DESIGN Retrospective cohort analysis of the records of a randomly selected cohort of 260 patients from The Health Improvement Network (THIN) database who had 294 evaluable burns. SETTING Primary and secondary care sectors in the UK. PRIMARY AND SECONDARY OUTCOME MEASURES Patients' characteristics, wound-related health outcomes, healthcare resource use and total National Health Service (NHS) cost of patient management. RESULTS Diagnosis was incomplete in 63% of patients' records as the location, depth and size of the burns were missing. Overall, 70% of all the burns healed within 24 months and the time to healing was a mean of 7.8 months per burn. Sixty-six per cent of burns were initially managed in the community and the other 34% were managed at accident and emergency departments. Patients' wounds were subsequently managed predominantly by practice nurses and hospital outpatient clinics. Forty-five per cent of burns had no documented dressings in the patients' records. The mean NHS cost of wound care in clinical practice over 24 months from initial presentation was an estimated £16 924 per burn, ranging from £12 002 to £40 577 for a healed and unhealed wound, respectively. CONCLUSIONS Due to incomplete documentation in the patients' records, it is difficult to say whether the time to healing was excessive or what other confounding factors may have contributed to the delayed healing. This study indicates the need for education of general practice clinicians on the management and care of burn wounds. Furthermore, it is beholden on the burns community to determine how the poor healing rates can be improved. Strategies are required to improve documentation in patients' records, integration of care between different providers, wound healing rates and reducing infection.
Collapse
Affiliation(s)
- Julian F Guest
- Catalyst Consultants, Rickmansworth, UK
- King's College London, London, UK
| | | | - Jacky Edwards
- Burns Nurse Consultant, Burn Centre, Manchester University NHS Foundation Trust, Manchester, UK
| |
Collapse
|
21
|
Kruger E, Kowal S, Bilir SP, Han E, Foster K. Relationship Between Patient Characteristics and Number of Procedures as well as Length of Stay for Patients Surviving Severe Burn Injuries: Analysis of the American Burn Association National Burn Repository. J Burn Care Res 2020; 41:1037-1044. [PMID: 32221517 PMCID: PMC7510847 DOI: 10.1093/jbcr/iraa040] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
This study establishes important, national benchmarks for burn centers to assess length of stay (LOS) and number of procedures across patient profiles. We examined the relationship between patient characteristics such as age and total body surface area (TBSA) burned and number of procedures and LOS in the United States, using the American Burn Association National Burn Repository (NBR) database version 8.0 (2002–2011). Among 21,175 surviving burn patients (TBSA > 10–60%), mean age was 33 years, and mean injury size was 19.9% TBSA. Outcomes included the number of debridement, excision, autograft procedures, and LOS. Independent variables considered were: age (linear, squared, and cubed to account for nonlinearity), TBSA, TBSAs of partial-thickness and mixed/full-thickness burns, sex, hospital-acquired infection, other infection, inhalation injury, and diabetes status. Regression methods included a mixed-effects model for LOS and ordinary least squares for number of procedures. A backward stepwise procedure (P <0.2) was used to select variables. Number of excision and autografting procedures increased with TBSA; however, this relationship did not hold for debridement. After adjusting for sex, age, and comorbidities, predicted LOS for adults (18+) was 12.1, 21.7, 32.2, 43.7, and 56.1 days for 10, 20, 30, 40, and 50% TBSA, respectively. Similarly, predicted LOS for pediatrics (age < 18) was 8.1, 18.8, 33.2, 47.6, and 56.1 days for the same TBSA groups, respectively. While average estimates for adults (1.12 days) and pediatrics (1.01) are close to the one day/TBSA rule-of-thumb, consideration of other important patient and burn features in the NBR can better refine predictions for LOS.
Collapse
|
22
|
Abstract
OBJECTIVE The aim of this study is to report patterns of burn injury within the United States from 1990 to 2016 with regard to age, sex, geography, and year. SUMMARY BACKGROUND DATA Advances in the management of burn injuries as well as successful public health efforts have contributed to reductions in the annual incidence and mortality of burns. However, several studies suggest that these reductions are not equally distributed throughout the US population. MAIN OUTCOMES AND MEASURES The Global Burden of Disease Study 2016 was utilized to collect incidence, mortality, disability-adjusted life years (DALYs), and years lived with disability (YLD) from 1990 to 2016. All measures were computed with 95% uncertainty intervals (UI). RESULTS The overall incidence of burn injury in the United States has decreased from 215 (95% UI, 183-246) to 140 (95% UI, 117-161) per 100,000. However, the relative mortality of burn injury has been fixed over the 26-year study period. Alaska had the highest rates of burn incidence in 1990 and 2016, closely followed by southeastern states. When adjusted for incidence, relative mortality in 1990 was highest in Alabama and Mississippi and the mortality-incidence ratio increased for these states in 2016. In addition, 35 states also demonstrated an increase in the relative mortality of burn injury during the study period. CONCLUSIONS Regional trends of burn incidence and mortality are highly variable and are likely due to a multitude of factors. Addressing these disparities will require close examination of the contributing factors of burn injury and severity.
Collapse
|
23
|
Clayton RP, Herndon DN, Abate N, Porter C. The Effect of Burn Trauma on Lipid and Glucose Metabolism: Implications for Insulin Sensitivity. J Burn Care Res 2020; 39:713-723. [PMID: 29931151 DOI: 10.1093/jbcr/irx047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Severe burns represent a unique form of trauma in terms of the magnitude and persistence of the stress response they incur. Given advances in acute burn care in the last quarter of a century and the resultant reduction in mortality rates, even for those with massive burns, greater emphasis is now placed on understanding the metabolic stress response to severe burn trauma in order to devise strategies that promote recovery and reduce morbidity. Derangements in metabolism including protein and lipid redistribution and altered glucose handling are hallmarks of the pathophysiological response to burn trauma. In this review article, we aim to distill and discuss the c urrent literature concerning the effect of burn trauma on lipid and glucose metabolism. Furthermore, we will discuss the implications of altered lipid metabolism with regards to insulin sensitivity and glucose control, while discussing the utility of agents and strategies aimed at restoring normal lipid and glucose metabolism in burned patients.
Collapse
Affiliation(s)
- Robert P Clayton
- Shriners Hospitals for Children®-Galveston.,The Institute for Translational Sciences, University of Texas Medical Branch, Galveston
| | - David N Herndon
- Shriners Hospitals for Children®-Galveston.,The Institute for Translational Sciences, University of Texas Medical Branch, Galveston.,Department of Surgery, University of Texas Medical Branch, Galveston
| | - Nicola Abate
- Shriners Hospitals for Children®-Galveston.,The Institute for Translational Sciences, University of Texas Medical Branch, Galveston.,Department of Internal Medicine, University of Texas Medical Branch, Galveston
| | - Craig Porter
- Shriners Hospitals for Children®-Galveston.,The Institute for Translational Sciences, University of Texas Medical Branch, Galveston
| |
Collapse
|
24
|
Abstract
Burn injuries are under-appreciated injuries that are associated with substantial morbidity and mortality. Burn injuries, particularly severe burns, are accompanied by an immune and inflammatory response, metabolic changes and distributive shock that can be challenging to manage and can lead to multiple organ failure. Of great importance is that the injury affects not only the physical health, but also the mental health and quality of life of the patient. Accordingly, patients with burn injury cannot be considered recovered when the wounds have healed; instead, burn injury leads to long-term profound alterations that must be addressed to optimize quality of life. Burn care providers are, therefore, faced with a plethora of challenges including acute and critical care management, long-term care and rehabilitation. The aim of this Primer is not only to give an overview and update about burn care, but also to raise awareness of the ongoing challenges and stigmata associated with burn injuries.
Collapse
Affiliation(s)
- Marc G Jeschke
- Ross Tilley Burn Center, Department of Surgery, Sunnybrook Health Science Center, Toronto, Ontario, Canada.
- Departments of Surgery and Immunology, University of Toronto, Toronto, Ontario, Canada.
| | - Margriet E van Baar
- Association of Dutch Burn Centres, Maasstad Hospital, Rotterdam, Netherlands
- Erasmus MC, University Medical Center Rotterdam, Department of Public Health, Rotterdam, Netherlands
| | - Mashkoor A Choudhry
- Burn and Shock Trauma Research Institute, Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL, USA
| | - Kevin K Chung
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Nicole S Gibran
- Department of Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Sarvesh Logsetty
- Departments of Surgery and Psychiatry, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| |
Collapse
|
25
|
Evaluation of measurement properties of health-related quality of life instruments for burns: A systematic review. J Trauma Acute Care Surg 2020; 88:555-571. [DOI: 10.1097/ta.0000000000002584] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
26
|
Abstract
OBJECTIVES Survival of elderly burn patients remains unacceptably poor. The acute phase, defined as the first 96 hours after burn, includes the resuscitation period and influences subsequent outcomes and survival. The aim of this study was to determine if the acute phase response post burn injury is significantly different in elderly patients compared with adult patients and to identify elements contributing to adverse outcomes. DESIGN Cohort study. SETTING Tertiary burn center. PATIENTS Adult (< 65 yr old) and elderly (≥ 65 yr old) patients with an acute burn injury. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We included all patients with an acute burn injury greater than or equal to 20% total body surface area to our burn center from 2011 to 2016. Clinical and laboratory measures during the acute phase were compared between adult and elderly patients. Outcomes included clinical hemodynamic measurements, organ biomarkers, volume of fluid resuscitation, cardiac agents, and the inflammatory cytokine response in plasma. Data were analyzed using the Student t test, Mann-Whitney U test, and Fisher exact test. A total of 149 patients were included, with 126 adults and 23 elderly. Injury severity was not significantly different among adult and elderly patients. Elderly had significantly lower heart rates (p < 0.05), cardiac index (p < 0.05), mean arterial pressure (p < 0.05), PaO2/FIO2 (p < 0.05), and pH (p < 0.05), along with higher lactate (p < 0.05). Organ biomarkers, particularly creatinine and blood urea nitrogen, showed distinct differences between adults and elderly (p < 0.05). Elderly had significantly lower levels of interleukin-6, monocyte chemotactic protein-1, monocyte chemotactic protein-3, and granulocyte-colony stimulating factor during the acute phase (p < 0.05). Overall mortality was significantly higher in elderly patients (5% vs 52%; p < 0.0001). CONCLUSIONS Response to the burn injury during the acute phase response after burn is substantially different between elderly and adult burn patients and is characterized by cardiac depression and hypoinflammation.
Collapse
|
27
|
Skeletal Muscle Mitochondrial Function is Determined by Burn Severity, Sex, and Sepsis, and is Associated With Glucose Metabolism and Functional Capacity in Burned Children. Shock 2019; 50:141-148. [PMID: 29206761 DOI: 10.1097/shk.0000000000001074] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Restoring normal mitochondrial function represents a new target for strategies aimed at mitigating the stress response to severe burn trauma and hastening recovery. Our objective was to investigate the determinants of skeletal muscle mitochondrial respiratory capacity and function and its association with glucose metabolism and functional capacity in burned children. METHODS Data from burned children enrolled in the placebo arm of an ongoing prospective clinical trial were analyzed. Mitochondrial respiratory capacity was determined in permeabilized myofibers by high-resolution respirometry on at least one occasion per participant. In subsets of patients, glucose kinetics and cardiorespiratory fitness (VO2peak) were also determined. Mixed multiple regression models were used to identify the determinants of mitochondrial respiratory function and to assess the relationship between mitochondrial respiration and both glucose control and functional capacity (VO2peak). MAIN RESULTS Increasing full-thickness burn size was associated with greater adjusted coupled (ATP-producing) respiration, adjusted for age, sex, sepsis, and time of testing (P < 0.01; n = 55, obs = 97). Girls had on average 23.3% lower coupled respiration (adjusted mean and 95% confidence of interval [CI], -7.1; -12.6 to -1.7 pmol/s/mg; P < 0.025) and 29.8% lower respiratory control than boys (adjusted mean and 95% CI, -0.66; -1.07 to -0.25; P < 0.01; n = 55, obs = 97). The presence of sepsis was associated with lower respiration coupled to ATP production by an average of 25.5% compared with nonsepsis (adjusted mean and 95% CI, -6.9; -13.0 to -0.7 pmol/s/mg; P < 0.05; n = 55, obs = 97), after adjustment for age, sex, full-thickness burn size, and time of testing. During a hyperinsulinemic euglycemic clamp, hepatic glucose release was associated with greater coupled respiration and respiratory control (P < 0.05; n = 42, obs = 73), independent of age, sepsis, full-thickness burn size, and time postinjury testing. Coupled respiration was positively associated with VO2peak after adjustment for age, full-thickness burn size, and time of exercise testing (P < 0.025; n = 18, obs = 25). CONCLUSIONS Burn severity, sex, and sepsis influence skeletal muscle mitochondrial function in burned children. Glucose control and functional capacity are associated with altered mitochondrial respiratory function in muscle of burn survivors, highlighting the relationship of altered muscle bioenergetics with the clinical sequelae accompanying severe burn trauma.
Collapse
|
28
|
Brook K, Otero TMN, Yeh DD, Canales C, Belcher D, Quraishi SA. Admission 25-Hydroxyvitamin D Levels Are Associated With Functional Status at Time of Discharge from Intensive Care Unit in Critically Ill Surgical Patients. Nutr Clin Pract 2019; 34:572-580. [PMID: 30294930 DOI: 10.1002/ncp.10196] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Vitamin D status is associated with length of stay (LOS) and discharge destination in critically ill patients. To further understand this relationship, we investigated whether admission 25-hydroxyvitaminD (25OHD) levels are associated with discharge functional status in the intensive care unit (ICU). METHODS In this retrospective study, data from 2 surgical ICUs at a large teaching hospital were analyzed. 25OHD levels were measured within 24 hours of ICU admission and Functional Status Score for the ICU (FSS-ICU) was calculated within 24 hours of ICU discharge for all patients. To investigate the association of vitamin D status with FSS-ICU, we constructed linear and logistic regression models, controlling for body mass index, Nutrition Risk in the Critically Ill score, ICU LOS, and cumulative protein or caloric deficit during ICU admission. RESULTS Mean 25OHD level and FSS-ICU was 19 (SD 8) ng/mL and 17 (SD 4), respectively, in the analytic cohort (n = 300). Each unit increase in 25OHD level was associated with a 0.2 increment in FSS-ICU (β = .20; 95% CI 0.14-0.25). Patients with 25OHD levels <20 ng/mL had >3-fold risk of low FSS-ICU (<17) compared with patients with 25OHD >20 ng/mL (OR 3.45; 95% CI 1.96-6.08). CONCLUSIONS Our results suggest that vitamin D status at admission is associated with discharge FSS-ICU in critically ill surgical patients. Future studies are needed to validate our results, to build upon our findings, and to determine whether optimizing 25OHD levels can improve functional status and other important clinical outcomes in ICU patients.
Collapse
Affiliation(s)
- Karolina Brook
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Tiffany M N Otero
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Carney Hospital, Boston, Massachusetts.,Tufts University School of Medicine, Boston, Massachusetts
| | - D Dante Yeh
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.,Division of Trauma and Surgical Critical Care, the DeWitt Daughtry Family Department of Surgery Ryder Trauma Center/Jackson Memorial Hospital Miller School of Medicine, University of Miami, Miami, Florida
| | - Cecilia Canales
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts.,University of California, Irvine School of Medicine, Irvine, California
| | - Donna Belcher
- Department of Nutrition and Food Services, Massachusetts General Hospital, Boston, Massachusetts
| | - Sadeq A Quraishi
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusett
| |
Collapse
|
29
|
Kowal S, Kruger E, Bilir P, Holmes JH, Hickerson W, Foster K, Nystrom S, Sparks J, Iyer N, Bush K, Quick A. Cost-Effectiveness of the Use of Autologous Cell Harvesting Device Compared to Standard of Care for Treatment of Severe Burns in the United States. Adv Ther 2019; 36:1715-1729. [PMID: 31065995 PMCID: PMC6647544 DOI: 10.1007/s12325-019-00961-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Indexed: 11/24/2022]
Abstract
Introduction When introducing a new intervention into burn care, it is important to consider both clinical and economic impacts, as the financial burden of burns in the USA is significant. This study utilizes a health economic modeling approach to estimate cost-effectiveness and burn center budget-impact for the use of the RECELL® Autologous Cell Harvesting Device to prepare autologous skin cell suspension (ASCS) compared to standard of care (SOC) split-thickness skin graft (STSG) for the treatment of severe burn injuries requiring surgical intervention for definitive closure. Methods A hospital-perspective model using sequential decision trees depicts the acute burn care pathway (wound assessment, debridement/excision, temporary coverage, definitive closure) and predicts the relative differences between use of ASCS compared to SOC. Clinical inputs and ASCS impact on length of stay (LOS) were derived from clinical trials and real-world use data, American Burn Association National Burn Repository database analyses, and burn surgeon interviews. Hospital resource use and unit costs were derived from three US burn centers. A budget impact calculation leverages Monte Carlo simulation to estimate the overall impact to a burn center. Results ASCS treatment is cost-saving or cost-neutral (< 2% difference) and results in lower LOS compared to SOC across expected patient profiles and scenarios. In aggregate, ASCS treatment saves a burn center 14–17.3% annually. Results are sensitive to, but remain robust across, changing assumptions for relative impact of ASCS use on LOS, procedure time, and number of procedures. Conclusions Use of ASCS compared to SOC reduces hospital costs and LOS of severe burns in the USA. Funding AVITA Medical. Electronic supplementary material The online version of this article (10.1007/s12325-019-00961-2) contains supplementary material, which is available to authorized users.
Collapse
|
30
|
Initiales klinisches Management des Brandverletzten. Notf Rett Med 2019. [DOI: 10.1007/s10049-018-0494-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
31
|
Smith RR, Hill DM, Hickerson WL, Velamuri SR. Analysis of factors impacting length of stay in thermal and inhalation injury. Burns 2019; 45:1593-1599. [PMID: 31130323 DOI: 10.1016/j.burns.2019.04.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 04/16/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Several studies have analyzed single or combinations of variables for impact on length of stay (LOS) in thermally-injured patients. The objective of this study was to evaluate a multitude of established variables and potentially identify novel variables associated with LOS in a single study. METHODS This two-year, retrospective study included all patients admitted to the burn center between January 2015 and December 2016. Exclusions included death during admission, lack of thermal or inhalation injury, age less than 18 years, readmission(s), and if pregnant or incarcerated. Baseline demographics and pertinent data were collected using electronic medical records. Regression analysis was used to determine the most predictive variables. RESULTS Six hundred twenty-nine patients were admitted during the inclusion period and 354 patients remained for analysis after exclusion. Univariable analysis revealed 32 variables significantly associated with LOS. Using multivariable regression, the best-fit baseline demographic model included: percent total body surface area (TBSA) injured, lower/middle socioeconomic status, clotting disorders, anemia, admission serum creatinine, and percent third degree injured (r2 = 0.557). The best-fit combined model (incorporating baseline demographics and early in-hospital variables) included: acute kidney injury, infection and received vasopressor(s), percent TBSA injured, admission serum ethanol level, maximum C-reactive protein, and maximum total bilirubin (r2 = 0.828). CONCLUSIONS There are multiple factors associated with the increased LOS seen in patients with thermal and inhalation injury. This study confirmed and identified novel factors not previously discussed in the literature that were significantly associated with LOS. Expansion of the data submitted to the National Burn Repository and the Burn Quality Improvement Program may be warranted. This study confirms claims from previous studies on inadequacy of current data submitted for benchmarking and under-reimbursement for the care of such a complex population.
Collapse
Affiliation(s)
- Rebecca R Smith
- Department of Clinical Pharmacy, Regional One Health, 877 Jefferson Avenue, Memphis, TN 38103, USA.
| | - David M Hill
- Department of Clinical Pharmacy, Regional One Health, 877 Jefferson Avenue, Memphis, TN 38103, USA; Department of Burn Research, Firefighters Regional Burn Center, Regional One Health, 877 Jefferson Avenue, Memphis, TN 38103, USA; Department of Clinical Pharmacy, College of Pharmacy, University of Tennessee Health Science Center, 881 Madison Avenue, Memphis, TN 38103, USA.
| | - William L Hickerson
- Department of Plastic Surgery, Firefighters Regional Burn Center, Regional One Health, 877 Jefferson Avenue, Memphis, TN 38103, USA; Department of Plastic Surgery, College of Medicine, University of Tennessee Health Science Center, 910 Madison Avenue, Memphis, TN 38103, USA.
| | - Sai R Velamuri
- Department of Plastic Surgery, Firefighters Regional Burn Center, Regional One Health, 877 Jefferson Avenue, Memphis, TN 38103, USA; Department of Plastic Surgery, College of Medicine, University of Tennessee Health Science Center, 910 Madison Avenue, Memphis, TN 38103, USA.
| |
Collapse
|
32
|
Moiemen N, Mathers J, Jones L, Bishop J, Kinghorn P, Monahan M, Calvert M, Slinn G, Gardiner F, Bamford A, Wright S, Litchfield I, Andrews N, Turner K, Grant M, Deeks J. Pressure garment to prevent abnormal scarring after burn injury in adults and children: the PEGASUS feasibility RCT and mixed-methods study. Health Technol Assess 2019; 22:1-162. [PMID: 29947328 DOI: 10.3310/hta22360] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Eleven million people suffer a fire-related injury worldwide every year, and 71% have significant scarring. Pressure garment therapy (PGT) is a standard part of burn scar management, but there is little evidence of its clinical effectiveness or cost-effectiveness. OBJECTIVE To identify the barriers to, and the facilitators of, conducting a randomised controlled trial (RCT) of burn scar management with and without PGT and test whether or not such a trial is feasible. DESIGN Web-based surveys, semistructured individual interviews, a pilot RCT including a health economic evaluation and embedded process evaluation. SETTING UK NHS burns services. Interviews and the pilot trial were run in seven burns services. PARTICIPANTS Thirty NHS burns services and 245 staff provided survey responses and 15 staff participated in individual interviews. Face-to-face interviews were held with 24 adult patients and 16 parents of paediatric patients who had undergone PGT. The pilot trial recruited 88 participants (57 adults and 31 children) who were at risk of hypertrophic scarring and were considered suitable for scar management therapy. Interviews were held with 34 participants soon after recruitment, with 23 participants at 12 months and with eight staff from six sites at the end of the trial. INTERVENTIONS The intervention was standard care with pressure garments. The control was standard care comprising scar management techniques involving demonstration and recommendations to undertake massage three or four times per day with moisturiser, silicone treatment, stretching and other exercises. MAIN OUTCOME MEASURES Feasibility was assessed by eligibility rates, consent rates, retention in allocated arms, adherence with treatment and follow-up and completion of outcome assessments. The outcomes from interview-based studies were core outcome domains and barriers to, and facilitators of, trial participation and delivery. RESULTS NHS burns services treat 2845 patients per annum (1476 paediatric and 1369 adult) and use pressure garments for 6-18 months, costing £2,171,184. The majority of staff perceived a need for a RCT of PGT, but often lacked equipoise around the research question and PGT as a treatment. Strong views about the use of PGT have the potential to influence the conduct of a full-scale RCT. A range of outcome domains was identified as important via the qualitative research: perceptions of appearance, specific scar characteristics, function, pain and itch, broader psychosocial outcomes and treatment burden. The outcome tools evaluated in the pilot trial did not cover all of these domains. The planned 88 participants were recruited: the eligibility rate was 88% [95% confidence interval (CI) 83% to 92%], the consent rate was 47% (95% CI 40% to 55%). Five (6%) participants withdrew, 14 (16%) were lost to follow-up and 8 (9%) crossed over. Adherence was as in clinical practice. Completion of outcomes was high for adult patients but poorer from parents of paediatric patients, particularly for quality of life. Sections on range of movement and willingness to pay were found to be challenging and poorly completed. LIMITATIONS The Brisbane Burn Scar Impact Profile appears more suitable in terms of conceptual coverage than the outcome scales that were used in the trial but was not available at the time of the study. CONCLUSIONS A definitive RCT of PGT in burn scar management appears feasible. However, staff attitudes to the use of pressure garments may lead to biases, and the provision of training and support to sites and an ongoing assessment of trial processes are required. FUTURE WORK We recommend that any future trial include an in-depth mixed-methods recruitment investigation and a process evaluation to account for this. TRIAL REGISTRATION Current Controlled Trials ISRCTN34483199. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 36. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Naiem Moiemen
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jonathan Mathers
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Laura Jones
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Jonathan Bishop
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Philip Kinghorn
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Mark Monahan
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Melanie Calvert
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Gemma Slinn
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Fay Gardiner
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Amy Bamford
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Susan Wright
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Ian Litchfield
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Nicole Andrews
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Karen Turner
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Margaret Grant
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Jonathan Deeks
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| |
Collapse
|
33
|
Does Increased Patient Load Improve Mortality in Burns?: Identifying Benchmark Parameters Defining Quality of Burn Care. Ann Plast Surg 2019; 82:386-392. [PMID: 30855365 DOI: 10.1097/sap.0000000000001844] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION In burn care, as in other medical fields, there is a tendency to increase the required number of patients for center certifications. Does the increase in patient load automatically improve the quality of burn care? What are the benchmark parameters that have been shown to improve burn care? METHODS To answer these questions, Medline, Cochrane Library, and Livivo were searched from inception through January 2018 for all studies evaluating the influence of treatment parameters on outcomes in different burn care settings. RESULTS Fifteen studies were included in this systematic review. In adults, not a single study showed a decreased mortality due to a higher patient load. However, in children, 2 studies demonstrated a further decrease of the already low mortality due to an increase in patient load. In contrast to patient load, benchmark parameters that had a significant influence on the outcome of burn care for adults and children were: single bed isolation, residency programs, American Burn Association certifications of burn centers, speed of wound closure, and standard operating procedures for burn care. CONCLUSIONS This systematic review demonstrates that a clear correlation between patient load and mortality reduction in adult burn treatment is not supported by the existing literature, requiring future studies. In contrast, all efforts aiming to improve the quality of burn care, such as isolation of burn patients, speed of wound closure, American Burn Association verification and especially standard operating procedures for burn care improve survival and quality of burn care.
Collapse
|
34
|
Bartley CN, Atwell K, Cairns B, Charles A. Racial and Ethnic Disparities in Discharge to Rehabilitation Following Burn Injury. J Burn Care Res 2019; 40:143-147. [PMID: 30698732 DOI: 10.1093/jbcr/irz001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Racial and ethnic disparities in access to inpatient rehabilitation have been previously described for various injury groups; however, no studies have evaluated whether such disparities exist among burn patients. Their aim was to determine if racial disparities in discharge destination (inpatient rehabilitation, skilled nursing facility, home with home health, or home) following burn injury existed in this single-institution study. A retrospective analysis of all adult burn patients admitted to UNC Jaycee Burn Center from 2002 to 2012 was conducted. Patient characteristics included age, gender, burn mechanism, insurance status, percentage total body surface area (%TBSA) burned, presence of inhalation injury, and hospital length of stay. Patients were categorized into one of three mutually exclusive racial or ethnic groups: White, Hispanic, or Black. Propensity score weighting followed by ordered logistic regression was performed in the analytical sample and in a subgroup analysis of patients with severe burns (TBSA > 20%). For analysis, 4198 patients were included: 2661 White, 340 Hispanic, and 1197 Black. Propensity weighting resulted in covariate balance among racial groups. Black patients (OR: 1.58, 95% CI: 1.23-2.03; P < .001) were more likely than Whites to be discharged to a higher level of rehabilitation, whereas Hispanics were less likely (OR: 0.78, 95% CI: 0.38-1.58; P = .448). In their subgroup analysis, Black (OR: 1.88, 95% CI: 1.07-3.28; P = .026) and Hispanic (OR: 1.53, 95% CI: 0.31-7.51; P = .603) patients were more likely to discharge to a higher level of rehabilitation than White patients. Racial and ethnic disparities in discharge destination to a higher level of rehabilitative services among burn-injured patients exist particularly for Hispanic patients but not for Black or White burn patient groups. Further studies are needed to elucidate the potential sources of these disparities specifically for Hispanic patients.
Collapse
Affiliation(s)
- Colleen N Bartley
- Department of Surgery, University of North Carolina at Chapel Hill, North Carolina Jaycee Burn Center, Chapel Hill, North Carolina
| | - Kenisha Atwell
- Department of Surgery, University of North Carolina at Chapel Hill, North Carolina Jaycee Burn Center, Chapel Hill, North Carolina
| | - Bruce Cairns
- Department of Surgery, University of North Carolina at Chapel Hill, North Carolina Jaycee Burn Center, Chapel Hill, North Carolina
| | - Anthony Charles
- Department of Surgery, University of North Carolina at Chapel Hill, North Carolina Jaycee Burn Center, Chapel Hill, North Carolina
| |
Collapse
|
35
|
Young AE, Davies A, Bland S, Brookes S, Blazeby JM. Systematic review of clinical outcome reporting in randomised controlled trials of burn care. BMJ Open 2019; 9:e025135. [PMID: 30772859 PMCID: PMC6398699 DOI: 10.1136/bmjopen-2018-025135] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Systematic reviews collate trial data to provide evidence to support clinical decision-making. For effective synthesis, there must be consistency in outcome reporting. There is no agreed set of outcomes for reporting the effect of burn care interventions. Issues with outcome reporting have been identified, although not systematically investigated. This study gathers empirical evidence on any variation in outcome reporting and assesses the need for a core outcome set for burn care research. METHODS Electronic searches of four search engines were undertaken from January 2012 to December 2016 for randomised controlled trials (RCTs), using medical subject headings and free text terms including 'burn', 'scald' 'thermal injury' and 'RCT'. Two authors independently screened papers, extracted outcomes verbatim and recorded the timing of outcome measurement. Duplicate outcomes (exact wording ± different spelling), similar outcomes (albumin in blood, serum albumin) and identical outcomes measured at different times were removed. Variation in outcome reporting was determined by assessing the number of unique outcomes reported across all included trials. Outcomes were classified into domains. Bias was reduced using five researchers and a patient working independently and together. RESULTS 147 trials were included, of which 127 (86.4%) were RCTs, 13 (8.8%) pilot studies and 7 (4.8%) RCT protocols. 1494 verbatim clinical outcomes were reported; 955 were unique. 76.8% of outcomes were measured within 6 months of injury. Commonly reported outcomes were defined differently. Numbers of unique outcomes per trial varied from one to 37 (median 9; IQR 5,13). No single outcome was reported across all studies demonstrating inconsistency of reporting. Outcomes were classified into 54 domains. Numbers of outcomes per domain ranged from 1 to 166 (median 11; IQR 3,24). CONCLUSIONS This review has demonstrated heterogeneity in outcome reporting in burn care research which will hinder amalgamation of study data. We recommend the development of a Core Outcome Set. PROSPERO REGISTRATION NUMBER CRD42017060908.
Collapse
Affiliation(s)
- Amber E Young
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Anna Davies
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Sara Brookes
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Jane M Blazeby
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| |
Collapse
|
36
|
Bailey ME, Sagiraju HKR, Mashreky SR, Alamgir H. Epidemiology and outcomes of burn injuries at a tertiary burn care center in Bangladesh. Burns 2019; 45:957-963. [PMID: 30612889 DOI: 10.1016/j.burns.2018.12.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 11/15/2018] [Accepted: 12/13/2018] [Indexed: 10/27/2022]
Abstract
Globally, burns are among some of the most devastating injuries and account for more than 265,000 deaths worldwide. In Bangladesh alone, nearly 3000 people die annually from burn-related injuries. This study was conducted at the National Institute of Burn and Plastic Surgery in Dhaka, Bangladesh in June of 2016. Data included conducting surveys of hospitalized burn patients (N=66) and a chart review of deceased burn patients (N=88). In addition to reporting on the demographic profile of patients, information was also obtained on clinical measures during hospitalization. For non-fatal burns, high risk groups included young adult males (early 30s) of lower socioeconomic status. Among children, the most vulnerable group was found to be children less than eight years old. The most common non-fatal types of burn injuries were flame (35%), electrical (31%) and scald (24%). Discharged patients had an average hospital stay of around 30days with half of all patients requiring surgical intervention, thus indicating the severity of those cases and the need for resource-intensive care. Among the discharged patient population, factors significantly associated with a longer duration of hospital stay included severity of injury, not having received prior treatment before admission and whether or not patients required surgery during hospitalization. Among the mortality cases, the high-risk groups also included young adult males and children of around eight years of age. The average total body surface area (TBSA) sustained in these cases was 46.4%, with 65% of deaths attributable to complications from flame burns. These findings highlight the frequency and severity of burn injuries, identify vulnerable population groups and list common causes of burns in this large developing country of 160 million people. Furthermore, these findings may be applicable to the epidemiology and outcome of burns in similar low and middle income countries.
Collapse
Affiliation(s)
- M E Bailey
- School of Medicine, University of Texas Health Science Center San Antonio, 7733 Louis Pasture San Antonio, TX 78229, USA; The University of Texas School of Public Health, 7411 John Smith Dr, #1100 San Antonio, TX 78229, USA.
| | - H K R Sagiraju
- The University of Texas School of Public Health, 7411 John Smith Dr, #1100 San Antonio, TX 78229, USA
| | - S R Mashreky
- Centre for Injury Prevention and Research, Bangladesh (CIPRB), House # B-162, Road # 23, New DOHS, Mohakhali, Dhaka, 1206, Bangladesh
| | - H Alamgir
- New York Medical College, 40 Sunshine Cottage Rd, Valhalla, NY 10595, USA
| |
Collapse
|
37
|
The impact of simulated multidisciplinary Trauma Team Training on team performance: A qualitative study. Australas Emerg Care 2018; 22:1-7. [PMID: 30998866 DOI: 10.1016/j.auec.2018.11.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 11/16/2018] [Accepted: 11/20/2018] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Effective teamwork is imperative in the emergency trauma setting as trauma teams work in the uncertain and complex context of resuscitating critically injured patients. Poorly performing teams have the potential to contribute to adverse events. Efforts to improve teamwork in trauma include simulation-based multidisciplinary team training with a non-technical skills (NTS) focus. However, there is a lack of evidence linking teamwork training programs with the uptake of NTS in real life trauma resuscitations. The aim of this study was to understand trauma team members' perspectives and experiences of teamwork in real world trauma resuscitations at a Level 1 Trauma Hospital, following completion of a simulated multidisciplinary Trauma Team Training (TTT) program. METHOD Semi-structured interviews were used to explore trauma team members' experiences and perspectives of the impact of TTT on the team's performance. Trauma team members who had completed TTT were invited to participate in the study. Fifteen participants from various disciplines (nursing, medical, allied health) and specialities (emergency, intensive care, trauma, anaesthetics, allied health) were interviewed. Qualitative data were thematically analysed. RESULTS The overarching finding was that teamwork was the essential component to facilitate a group of skilled experts to collectively perform at an optimum level in emergency trauma care. Four main themes were developed: Leader-follower synergy promotes trauma teamwork; Instability and inconsistency threaten trauma teamwork; Clear communication enhances trauma team decision-making and Team training improves trauma team performance. CONCLUSION A quickly constructed specialty team with unstable membership, will not transform naturally into an expert trauma team. The creation and maintenance of effective trauma teams requires training strategies such as multidisciplinary simulation that target team training and team interaction. Specifically, training should focus on developing non-technical skills for resuscitation trauma teams that have to form quickly and function effectively, often having never met before. As participants were overwhelmingly female, the data generated by this study are not necessarily generalisable to male members of trauma teams.
Collapse
|
38
|
Liu SH, Huang YC, Chen LY, Yu SC, Yu HY, Chuang SS. The skin microbiome of wound scars and unaffected skin in patients with moderate to severe burns in the subacute phase. Wound Repair Regen 2018; 26:182-191. [DOI: 10.1111/wrr.12632] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 04/09/2018] [Indexed: 12/26/2022]
Affiliation(s)
- Su-Hsun Liu
- College of Medicine; Chang Gung University; Taoyuan Taiwan
- Department of Family Medicine; Chang Gung Memorial Hospital; Taoyuan Taiwan
| | - Yhu-Chering Huang
- College of Medicine; Chang Gung University; Taoyuan Taiwan
- Department of Pediatrics; Chang Gung Memorial Hospital; Taoyuan Taiwan
| | - Leslie Y Chen
- Department of Research and Development; Chang Gung Memorial Hospital; Taoyuan Taiwan
| | - Shu-Chuan Yu
- Department of Family Medicine; Chang Gung Memorial Hospital; Taoyuan Taiwan
| | - Hsiao-Yun Yu
- College of Medicine; Chang Gung University; Taoyuan Taiwan
| | - Shiow-Shuh Chuang
- College of Medicine; Chang Gung University; Taoyuan Taiwan
- Department of Plastic and Reconstructive Surgery; The Burn Center, Chang Gung Memorial Hospital; Taoyuan Taiwan
| |
Collapse
|
39
|
Garside TL, Lee RP, Delaney A, Milliss D. Clinical Practice Variation in Acute Severe Burn Injury. Anaesth Intensive Care 2018; 46:321-325. [DOI: 10.1177/0310057x1804600310] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The New South Wales (NSW) Statewide Burn Injury Service Database was reviewed to identify variations in clinical practice with respect to care of severely burn-injured patients in intensive care. We compared differences in practice relating to duration of endotracheal intubation and surgical grafting. In this retrospective observational study, we reviewed all intensive care unit (ICU) admissions to the two NSW adult burns centres, ICU A and ICU B, between January 2008 and December 2015. Data were analysed for association between duration of intubation and outcome. There were 855 admissions to adult ICU, with a significant difference in the percentage total body surface area (% TBSA) of burn and inhalation injury between patients in the two units. There was a significant difference in duration of intubation and ICU length of stay (LOS) between the units, which persisted when adjusted for age, % TBSA and inhalational injury. When analysing patients with more severe burns (>20% TBSA or intubated), the difference in duration of intubation remained significant (median of three days [interquartile range, IQR, 1–11 days] in A and 2 days [IQR 1–6 days] in B, P=0.003) as did ICU LOS (median 3 days [IQR 2–11 days] for A and 2 days [IQR 1–6 days] for B, P <0.0005). There was no significant difference in mortality between the two units for the severe or the more severe subgroup of burns when adjusted for age, % TBSA and inhalational injury (adjusted odds ratio, OR, for mortality 1.17 [95% confidence intervals 0.6 to 2.3, P=0.65]). There were significant differences in clinical practice, including duration of intubation, between the two ICUs. Longer intubation was associated with a longer ICU LOS, but was not associated with a difference in mortality. Large collaborative, prospective multicentre studies in severe burns are needed to identify best practice and variations in practice to determine if they are associated with increased mortality and/or cost.
Collapse
Affiliation(s)
- T. L. Garside
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, New South Wales
| | - R. P. Lee
- Intensivist, Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, New South Wales
| | - A. Delaney
- Intensivist, Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, New South Wales
| | - D. Milliss
- Intensivist and Former Director, Intensive Care Services, Concord Hospital, Sydney, New South Wales
| |
Collapse
|
40
|
Capek KD, Sousse LE, Hundeshagen G, Voigt CD, Suman OE, Finnerty CC, Jennings K, Herndon DN. Contemporary Burn Survival. J Am Coll Surg 2018; 226:453-463. [PMID: 29530306 PMCID: PMC6027619 DOI: 10.1016/j.jamcollsurg.2017.12.045] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 12/19/2017] [Indexed: 10/17/2022]
Abstract
BACKGROUND The standard of burn treatment today reflects major advances. We sought to quantitate the impact of these advances on burn survival via age-stratified mortality ratios compared with other reported mortality analyses in burns. STUDY DESIGN Age, percent of the total body surface area (TBSA) burned, presence of inhalation injury, length of stay, and survival status were recorded at admission and at discharge for all new burn admissions between 1989 and 2017. The expected mortality probability was calculated using historical multiple regression techniques and compared with observed data. We developed a prediction model for our observed data. RESULTS Between 1989 and 2017, there were 10,384 consecutive new burn admissions, with 355 mortalities (median age, 13 years; median percent TBSA burn, 11%). We saw a significant decrease in our observed mortality data compared to historical predictions (p < 0.0001), and a 2% reduction per year in mortality during the 3 decades. The prediction model of mortality for the data is as follows: Pr(dying) = ex/(1 + ex) where x = -6.44 - 0.12 age + 0.0042 age2 - 0.0000283 age3 + 0.0499 TBSA + 1.21 Inhalation Injury + 0.015 third degree TBSA. CONCLUSIONS The reduction in mortality over time may be attributed to successful changes in standard of care protocols in the burn center that improved the outlook for burned individuals, including protocols for management of inhalation injury, nutrition, resuscitation, and early excision and grafting.
Collapse
Affiliation(s)
- Karel D Capek
- Department of Surgery, University of Texas Medical Branch, Galveston, TX; Shriners Hospitals for Children-Galveston, Galveston, TX
| | - Linda E Sousse
- Department of Surgery, University of Texas Medical Branch, Galveston, TX; Shriners Hospitals for Children-Galveston, Galveston, TX
| | - Gabriel Hundeshagen
- Department of Surgery, University of Texas Medical Branch, Galveston, TX; Shriners Hospitals for Children-Galveston, Galveston, TX
| | - Charles D Voigt
- Department of Surgery, University of Texas Medical Branch, Galveston, TX; Shriners Hospitals for Children-Galveston, Galveston, TX
| | - Oscar E Suman
- Department of Surgery, University of Texas Medical Branch, Galveston, TX; Shriners Hospitals for Children-Galveston, Galveston, TX
| | - Celeste C Finnerty
- Department of Surgery, University of Texas Medical Branch, Galveston, TX; Shriners Hospitals for Children-Galveston, Galveston, TX; Institute for Translational Sciences, University of Texas Medical Branch, Galveston, TX; Sealy Center for Molecular Medicine, University of Texas Medical Branch, Galveston, TX
| | - Kristofer Jennings
- Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX
| | - David N Herndon
- Department of Surgery, University of Texas Medical Branch, Galveston, TX; Shriners Hospitals for Children-Galveston, Galveston, TX; Institute for Translational Sciences, University of Texas Medical Branch, Galveston, TX.
| |
Collapse
|
41
|
Cobb AN, Daungjaiboon W, Brownlee SA, Baldea AJ, Sanford AP, Mosier MM, Kuo PC. Seeing the forest beyond the trees: Predicting survival in burn patients with machine learning. Am J Surg 2018; 215:411-416. [PMID: 29126594 PMCID: PMC5837911 DOI: 10.1016/j.amjsurg.2017.10.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 10/04/2017] [Accepted: 10/05/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND This study aims to identify predictors of survival for burn patients at the patient and hospital level using machine learning techniques. METHODS The HCUP SID for California, Florida and New York were used to identify patients admitted with a burn diagnosis and merged with hospital data from the AHA Annual Survey. Random forest and stochastic gradient boosting (SGB) were used to identify predictors of survival at the patient and hospital level from the top performing model. RESULTS We analyzed 31,350 patients from 670 hospitals. SGB (AUC 0.93) and random forest (AUC 0.82) best identified patient factors such as age and absence of renal failure (p < 0.001) and hospital factors such as full time residents (p < 0.001) and nurses (p = 0.004) to be associated with increased survival. CONCLUSIONS Patient and hospital factors are predictive of survival in burn patients. It is difficult to control patient factors, but hospital factors can inform decisions about where burn patients should be treated.
Collapse
Affiliation(s)
- Adrienne N Cobb
- Loyola University Medical Center, Department of Surgery, 2160 S. 1st Avenue, Maywood, IL 60153, USA; One:MAP Section of Surgical Analytics, Department of Surgery, Loyola University Chicago, 2160 S. 1st Avenue, Maywood, IL 60153, USA.
| | - Witawat Daungjaiboon
- DePaul University, College of Computing and Digital Media, Department of Predictive Analytics, 243 South Wabash Avenue, Chicago, IL 60604, USA.
| | - Sarah A Brownlee
- One:MAP Section of Surgical Analytics, Department of Surgery, Loyola University Chicago, 2160 S. 1st Avenue, Maywood, IL 60153, USA.
| | - Anthony J Baldea
- Loyola University Medical Center, Department of Surgery, 2160 S. 1st Avenue, Maywood, IL 60153, USA.
| | - Arthur P Sanford
- Loyola University Medical Center, Department of Surgery, 2160 S. 1st Avenue, Maywood, IL 60153, USA.
| | - Michael M Mosier
- Loyola University Medical Center, Department of Surgery, 2160 S. 1st Avenue, Maywood, IL 60153, USA.
| | - Paul C Kuo
- Loyola University Medical Center, Department of Surgery, 2160 S. 1st Avenue, Maywood, IL 60153, USA; One:MAP Section of Surgical Analytics, Department of Surgery, Loyola University Chicago, 2160 S. 1st Avenue, Maywood, IL 60153, USA.
| |
Collapse
|
42
|
Abstract
The objective of this study was to determine whether urine ubiquitin levels are elevated after burns and to assess whether urine ubiquitin could be useful as a noninvasive biomarker for burn patients. Forty burn patients (%TBSA: 20 ± 22; modified Baux scores: 73 ± 26) were included (control: 11 volunteers). Urine was collected in 2-hour intervals for 72 hours, followed by 12-hour intervals until discharge from the intensive care unit. Ubiquitin concentrations were analyzed by enzyme linked immunosorbent assay and Western blot. Total protein was determined with a Bradford assay. Patient characteristics and clinical parameters were documented. Urine ubiquitin concentrations, renal ubiquitin excretion, and excretion rates were correlated with patient characteristics and outcomes. Initial urine ubiquitin concentrations were 362 ± 575 ng/ml in patients and 14 ± 18 ng/ml in volunteers (P < .01). Renal ubiquitin excretion on day 1 was 292.6 ± 510.8 μg/24 hr and 21 ± 27 μg/24 hr in volunteers (P < .01). Initial ubiquitin concentrations correlated with modified Baux scores (r = .46; P = .02). Ubiquitin levels peaked at day 6 postburn, whereas total protein concentrations and serum creatinine levels remained within the normal range. Total renal ubiquitin excretion and excretion rates were higher in patients with %TBSA ≥20 than with %TBSA <20, in patients who developed sepsis/multiple organ failure than in patients without these complications and in nonsurvivors vs survivors. These data suggest that ubiquitin urine levels are significantly increased after burns. Renal ubiquitin excretion and/or excretion rates are associated with %TBSA, sepsis/multiple organ failure, and mortality. Although these findings may explain previous correlations between systemic ubiquitin levels and outcomes after burns, the large variability of ubiquitin urine levels suggests that urine ubiquitin will not be useful as a noninvasive disease biomarker.
Collapse
|
43
|
Frankel JH, Boe DM, Albright JM, O'Halloran EB, Carter SR, Davis CS, Ramirez L, Burnham EL, Gamelli RL, Afshar M, Kovacs EJ. Age-related immune responses after burn and inhalation injury are associated with altered clinical outcomes. Exp Gerontol 2017; 105:78-86. [PMID: 29080833 DOI: 10.1016/j.exger.2017.10.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 10/20/2017] [Accepted: 10/23/2017] [Indexed: 12/20/2022]
Abstract
This prospective study aimed to address changes in inflammatory response between different aged populations of patients who sustained burn and inhalation injury. Plasma and bronchoalveolar lavage (BAL) samples were collected from 104 patients within 15h of their estimated time of burn injury. Clinical variables, laboratory parameters, and immune mediator profiles were examined in association with clinical outcomes. Older patients were at higher odds for death after burn injury (odds ratio (OR)=7.37 per 10years, p=0.004). In plasma collected within 15h after burn injury, significant increases in the concentrations of interleukin 1 receptor antagonist (IL-1RA), interleukin 2 (IL-2), interleukin 4 (IL-4), interleukin 6 (IL-6), granulocyte colony-stimulating factor (G-CSF), interferon-gamma-induced protein 10 (IP-10) and monocyte chemoattractant protein 1 (MCP-1) (p<0.05 for all) were observed in the ≥65 group. In the BAL fluid, MCP-1 was increased three-fold in the ≥65 group. This study suggests that changes in certain immune mediators were present in the older cohort, in association with in-hospital mortality.
Collapse
Affiliation(s)
- John H Frankel
- Burn Research Program, Department of Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Devin M Boe
- Burn Research Program, Department of Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA; Immunology Graduate Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, Loyola University Chicago, Maywood, IL, USA; Alcohol Research Program, Burn and Shock Trauma Research Institute, Department of Surgery, Loyola University Chicago Health Sciences Campus, Maywood, IL, USA
| | - Joslyn M Albright
- Department of Surgery, Loyola University Chicago, Maywood, IL, USA; Alcohol Research Program, Burn and Shock Trauma Research Institute, Department of Surgery, Loyola University Chicago Health Sciences Campus, Maywood, IL, USA
| | - Eileen B O'Halloran
- Department of Surgery, Loyola University Chicago, Maywood, IL, USA; Alcohol Research Program, Burn and Shock Trauma Research Institute, Department of Surgery, Loyola University Chicago Health Sciences Campus, Maywood, IL, USA
| | - Stewart R Carter
- Department of Surgery, Loyola University Chicago, Maywood, IL, USA; Alcohol Research Program, Burn and Shock Trauma Research Institute, Department of Surgery, Loyola University Chicago Health Sciences Campus, Maywood, IL, USA
| | - Christopher S Davis
- Department of Surgery, Loyola University Chicago, Maywood, IL, USA; Alcohol Research Program, Burn and Shock Trauma Research Institute, Department of Surgery, Loyola University Chicago Health Sciences Campus, Maywood, IL, USA
| | - Luis Ramirez
- Department of Surgery, Loyola University Chicago, Maywood, IL, USA
| | - Ellen L Burnham
- Burn Research Program, Department of Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA; Colorado Alcohol Pulmonary Research Collaborative, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | | | - Majid Afshar
- Division of Pulmonary and Critical Care Medicine, Loyola University Chicago, Maywood, IL, USA; Alcohol Research Program, Burn and Shock Trauma Research Institute, Department of Surgery, Loyola University Chicago Health Sciences Campus, Maywood, IL, USA; Division of Public Health Sciences, Loyola University Chicago, Maywood, IL, USA
| | - Elizabeth J Kovacs
- Burn Research Program, Department of Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA; Immunology Graduate Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, Loyola University Chicago, Maywood, IL, USA; Colorado Alcohol Pulmonary Research Collaborative, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA; Alcohol Research Program, Burn and Shock Trauma Research Institute, Department of Surgery, Loyola University Chicago Health Sciences Campus, Maywood, IL, USA.
| |
Collapse
|
44
|
Nygaard RM, Endorf FW. Effects of demographic and socioeconomic factors on the use of skin substitutes in burn patients. BURNS OPEN 2017. [DOI: 10.1016/j.burnso.2017.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
|
45
|
Mobayen M, Farzan R, Dadashi A, Rimaz S, Aghebati R. Effect of early grafting on improvement of lethal area index (la50) in burn patients: a 7-year investigation in a burn referral centre in the North of Iran. ANNALS OF BURNS AND FIRE DISASTERS 2017; 30:189-192. [PMID: 29849521 PMCID: PMC5946751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 08/24/2017] [Indexed: 06/08/2023]
Abstract
Burning is a major health challenge in all societies. In this descriptive cross-sectional study, health information about hospitalized burn patients was extracted from the hospital information system from April 2009 to February 2015. Logistic regression method was used to identify risk factors and mortality predictors. Lethal area index (LA50) was investigated to evaluate the quality of annual hospital medical care. A total of 7725 patient medical files were examined. Mean age of the patients was 32.3±22.5 years old. The most common cause of burning accidents was hot liquids. Mean percentage of total body surface area was 15.8±17.9%. The most and the least common affected areas were upper parts and posterior thorax, respectively. Total calculated LA50 was 56.22 (CI95% = 50.09-62.20). This index was 43.89%, 46.43%, 52.29%, 52.29%, 57.00%, 62.08% and 67.53% annually from 2009 to 2015, respectively. There was a statistically significant difference with regards to mortality rate in the different age groups, higher-degree burns, burn location and burn causes. Analysis of mortality predictors in a model adjusted by age and sex showed that old age (p<0.0001), inhalational injuries (p<0.0001) and burn percentage (P<0.0001) were the three mortality predictors in the multiple logistic regression model. The relationship between early grafting and decreased mortality and increased LA50 was nearly significant in statistical analyses. Burn patient survival rate and annual LA50 had an increasing trend in this hospital. Early grafting surgery seemed to be effective on this trend and decreased mortality risk to a large extent.
Collapse
Affiliation(s)
| | - R. Farzan
- Guilan University of Medical Sciences, Rasht, Iran
| | | | | | | |
Collapse
|
46
|
The P50 Research Center in Perioperative Sciences: How the investment by the National Institute of General Medical Sciences in team science has reduced postburn mortality. J Trauma Acute Care Surg 2017; 83:532-542. [PMID: 28697015 DOI: 10.1097/ta.0000000000001644] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Since the inception of the P50 Research Center in Injury and Peri-operative Sciences (RCIPS) funding mechanism, the National Institute of General Medical Sciences has supported a team approach to science. Many advances in critical care, particularly burns, have been driven by RCIPS teams. In fact, burns that were fatal in the early 1970s, prior to the inception of the P50 RCIPS program, are now routinely survived as a result of the P50-funded research. The advances in clinical care that led to the reduction in postburn death were made by optimizing resuscitation, incorporating early excision and grafting, bolstering acute care including support for inhalation injury, modulating the hypermetabolic response, augmenting the immune response, incorporating aerobic exercise, and developing antiscarring strategies. The work of the Burn RCIPS programs advanced our understanding of the pathophysiologic response to burn injury. As a result, the effects of a large burn on all organ systems have been studied, leading to the discovery of persistent dysfunction, elucidation of the underlying molecular mechanisms, and identification of potential therapeutic targets. Survival and subsequent patient satisfaction with quality of life have increased. In this review article, we describe the contributions of the Galveston P50 RCIPS that have changed postburn care and have considerably reduced postburn mortality.
Collapse
|
47
|
C-C Chemokine Receptor Type 2 Expression on Monocytes Before Sepsis Onset Is Higher Than That of Postsepsis in Septic Burned Patients: A New Predictor for Sepsis in Burned Injury. Ann Surg 2017; 264:392-8. [PMID: 26727083 DOI: 10.1097/sla.0000000000001531] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The present study aims to investigate the alterations in monocytes (Mo) and dendritic cells (DCs) in septic burned patients with a special focus on C-C chemokine receptor type 2 (CCR2) expressions on classical Mo. BACKGROUND The phenotypes of Mo and DCs, particularly CCR2 expression on Mo, are not fully explored in severely burned patients with sepsis. METHODS The prospective cohort study was conducted in Ross Tilley Burn Centre and Sunnybrook Research Institute (Toronto, Canada). We enrolled 8 healthy patients and 89 burned patients with various burned sizes, of those burned patients, 12 were with sepsis. Blood was collected upon admission to the hospital and throughout their course in hospital. The expression of human leukocyte antigen-DR was determined on all DCs and Mo, along with CCR2 on CD14/CD16 Mo. RESULTS We found a profound decrease in human leukocyte antigen-DR on Mo and DCs in burned patients with sepsis compared with healthy controls and nonseptic burned patients. In addition, septic burned patients presented an increased CCR2 expression on classical Mo (CD14/CD16), which was paralleled by greater chemokine (C-C motif) ligand 2 concentrations in the plasma when compared with controls and nonseptic burned patients. Furthermore, burned patients with sepsis had a more profound expansion of CD14/CD16 Mo when compared with nonseptic burned patients. CONCLUSION Our results demonstrate that burned patients with sepsis have more profound impairment of monocytes and dendritic cells than burned patients without sepsis. With CCR2 level on Mo before sepsis onset being higher than postsepsis, CCR2 expression could be a new predictor of sepsis onset in severe burn injury.
Collapse
|
48
|
Herndon DN. Southern Surgical Association: A Tradition of Mentorship in Translational Research. J Am Coll Surg 2017; 224:381-395. [PMID: 28088599 DOI: 10.1016/j.jamcollsurg.2016.12.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 12/23/2016] [Indexed: 12/11/2022]
Affiliation(s)
- David N Herndon
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, Galveston, TX.
| |
Collapse
|
49
|
Epidemiology and Outcome of Patients With Burns Treated With Cerium Nitrate Silversulfadiazine. J Burn Care Res 2017; 38:e432-e442. [DOI: 10.1097/bcr.0000000000000448] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
50
|
Lipidomic analysis enables prediction of clinical outcomes in burn patients. Sci Rep 2016; 6:38707. [PMID: 27982130 PMCID: PMC5159901 DOI: 10.1038/srep38707] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 11/10/2016] [Indexed: 12/17/2022] Open
Abstract
Recent discoveries have highlighted the novel metabolic functions of adipose tissue in enhancing hypermetabolism after trauma. As the exact function and expression profiles of serum lipids and free fatty acids (FFA) are essentially unknown, we determined the lipidomic expression profile after burn in correlation to clinical outcomes to identify important lipid mediators affecting post-burn outcomes. We conducted a prospective cohort study with 46 adult burn patients and 5 healthy controls at the Ross Tilley Burn Center in Toronto, Canada. Patients were stratified based on major demographic and clinical variables, including age, burn severity, mortality, and sepsis. Serum FFAs and inflammatory markers were measured during acute hospital stay. We found that FFAs were acutely elevated post-burn and returned to baseline over time. Greater burn severity and age were associated with an impaired acute response in unsaturated FFAs and pro-inflammatory cytokines. Elevations in saturated and mono-unsaturated FFAs correlated significantly to increased mortality. In summary, persistent elevation of unsaturated lipids was associated with a functionally altered inflammatory-immunological milieu and worse clinical outcomes. The present lipidomic analysis indicates profound alterations in the lipid profile after burn by characterizing key lipids as potential diagnostic and outcome indicators in critically injured patients.
Collapse
|