Wound healing and dermal regeneration in severe burn patients treated with NovoSorb® Biodegradable Temporising Matrix: A prospective clinical study.

INTRODUCTION: For extensive burns, autologous donor skin may be insufficient for early debridement and grafting in a single stage. A novel, synthetic polyurethane dermal template (NovoSorb® Biodegradable Temporising Matrix, BTM) was developed to address this need. The aim of this study was to evaluate use of BTM for primary dermal repair after deep burn injury. METHODS: A multicentre, prospective, clinical study was conducted from September 2015 to May 2018. The primary endpoint was % split skin graft take over applied BTM at 7-10 days after grafting. Secondary endpoints included % BTM take, incidence of infection and adverse events, and scar quality to 12 months after BTM application. RESULTS: Thirty patients were treated with BTM and delayed split skin grafting. The % graft take had a mean of 81.9% and % BTM take had a mean of 88.6%, demonstrating effective integration of BTM. When managed appropriately, it was possible for BTM to integrate successfully despite findings suggestive of infection. Scar quality improved over time. DISCUSSION: These results provide additional clinical evidence on the safety and performance of BTM as an effective dermal substitute in the treatment of patients with deep burn injuries.

Tracheal intubation difficulties in the setting of face and neck burns: myth or reality?

INTRODUCTION: Face and/or neck burn (FNB) exposes patients to the double respiratory risk of obstruction and hypoxia, and these risks may require a tracheal intubation. This study aims to describe the incidence and the characteristics of difficult intubation in FNB patients. METHODS: We conducted a 5-year retrospective, single-center study including all patients meeting the following criteria: 18 years of age or older, an FNB at least 1% of burned surface area with a severity equal to or greater than the superficial second degree, and intubation and a burn center admission within the first 24 hours after the burn. Patients were compared according to the difficulty of their intubation. RESULTS: Between January 2007 and December 2011, we included 134 patients. The incidence of difficult intubation was 11.2% but was greater in the burn center than in the pre-burn center: 16.9% vs 3.5% (P = .02). The most important difference between patients with or without difficult intubation was the time between the burn injury and the intubation: 210 (105-290) vs 120 (60-180) minutes (P = .047). After multivariate analysis, an intubation performed at a burn center was independently associated with difficult intubation: odds ratio = 3.2; 95% confidence interval, 1.1-528. CONCLUSIONS: This study underlines the high incidence of difficult intubation in FNB patients, greater than 11.2%, and demonstrates that intubation is more difficult when realized at a burn center, probably because it is performed later, allowing for development of cervical and laryngeal edema.

Comparison of the Berlin definition with the American European consensus definition for acute respiratory distress syndrome in burn patients.

OBJECTIVE: Acute respiratory distress syndrome (ARDS) is a leading cause of mortality in burn patients. Smoke inhalation, pneumonia and inflammation process are the major causes of ARDS in burn patients. The American European Consensus Conference (AECC) definition proposed in 1994 has recently been revised by the Berlin definition. Our objective was to describe the epidemiology of ARDS comparing the Berlin definition with the AECC definition in a retrospective cohort of burn patients. METHODS: We reviewed admitted burn adult patients for a two year period, and investigated patient who received mechanical ventilation for more than 48 h and in whom pneumonia was diagnosed. RESULTS: 40 patients were analyzed. According to the AECC definition, 11 patients met criteria for ALI (27.5%), and 29 patients for ARDS (72.5%). According to the Berlin definition, all patients met criteria for ARDS: 4 (10%) for a severe ARDS, 25 (62.5%) for a moderate ARDS, 11 (27.5%) for a mild ARDS. Inhalation injury was diagnosed in 10 patients (25%). Categorizing patients with the Berlin definition showed statistically significative difference of mortality within the three groups, but not with the AECC definition. CONCLUSION: The Berlin definition seems to be more accurate than the AECC definition to assess the severity of ARDS in term of outcome in burn patients. This definition may facilitate prompt recognition of ARDS in burn patients, and promote protective ventilation strategy to a larger number of patients.

Early onset pneumonia in patients with severely burned face and neck: a 5-year retrospective study.

Patients with face and neck burns (FNBs) often undergo prehospital intubation, or sustain inhalation injury which are risk factors for pneumonia in specific populations. Early onset pneumonia (EOP) might be caused by initial management. The primary goal of this study was to find risk factors for EOP in FNB patients. This is a retrospective, single-center trial. We screened all FNB patients for EOP with the Clinical Pulmonary Infection Score. Pneumonia diagnosis was with culture from a mini broncho-alveolar lavage. Potential risk factors for EOP were recorded. We included 152 patients, EOP was diagnosed in 58 (38.2%). EOP patients had a greater burned surface area median (20±17% vs. 10±17%; p<0.001), were more frequently intubated during prehospital care (65.5% vs. 21.3%; p<0.001), had more abnormal fiberoptic bronchoscopy at admission (58.6% vs. 19.1%; p=0.002) and a lower initial PaO2/FiO2 ratio (median 314±118.6 vs. 365±105.7; p=0.01). Multivariate analysis showed that only prehospital intubation was independently associated with EOP (odds ratio 3.6; 95% confidence interval, 1.34-10). Prehospital intubation appears to be an independent risk factor for EOP in severe burn patients. Assessments of the risk-benefit ratios of intubating and of not intubating those patients are indicated.

Maintenance of normothermia during burn surgery with an intravascular temperature control system: a non-randomised controlled trial.

BACKGROUND: Hypothermia remains one of the major factors limiting surgery in extensively burned patients. We evaluated the effectiveness of an intravascular rewarming technique using CoolGard 3000™ system and Icy™ catheter to maintain normothermia during surgeries of severe burned patients and compared these findings to a historical control group. METHODS: This was a controlled non-randomised trial conducted between March 2008 and August 2009. Patients with burns greater than or equal to 40% of the total body surface area were included. Before the first burn excision, the Icy™ catheter was placed in the inferior vena cava via the femoral vein. Warming was then initiated and maintained until the bladder temperature reached over 37.5°C. The bladder temperature was recorded every 30min during surgery and for the first hour post-operatively and compared to a historical control group. RESULTS: We enrolled 4 patients and 11 surgeries in the CoolGard™ group and compared them to 3 patients and 10 surgeries in the historical cohort. All intraoperative bladder temperatures from T=30 were statistically different in the two groups. In the CoolGard™ group, no patient became hypothermic and no surgery was aborted because the patient's temperature had rapidly fallen below the threshold temperature (35.5°C). No device-related complication was reported. CONCLUSION: The use of an intravenous warming catheter is a novel approach to maintain normothermia during surgery in burn victims and may be more effective than traditional methods.

Use of dermal regeneration template in contracture release procedures: a multicenter evaluation.

Integra dermal regeneration template (Integra Life Sciences, Plainsboro, N.J.) is an effective treatment for full-thickness burns. It can also be useful in contracture release procedures; however, the clinical utility of a dermal regeneration template in contracture release procedures has not been adequately characterized. In this multicenter investigation, the outcomes of release procedures incorporating a dermal regeneration template for 89 consecutive patients, who underwent a total of 127 contracture releases, were retrospectively evaluated. The procedures involved the application of Integra, which includes a temporary silicone epidermal substitute and an artificial dermal layer. After formation of a neodermis, the silicone layer is removed and replaced with an epidermal autograft. Data on patient and contracture site history, treatment methods, physician assessments of range of motion or function, patient satisfaction, recurrence, and adverse events were collected with a standardized questionnaire. Release procedures for the study patients involved the neck, axilla, trunk, elbow, knee, hand, and other anatomical sites. The mean postoperative follow-up period was 11.4 months. At 76 percent of the release sites, range of motion or function was rated as good (significant improvement in range of motion or function) or excellent (maximal range of motion or function possible) by physicians. Responding patients expressed satisfaction with the overall results of treatment at 82 percent of the sites. No recurrence of contracture at 75 percent of the sites was observed during follow-up monitoring. Patient age and prior surgical treatment at the site did not significantly affect the results of treatment. However, outcomes were superior at mature sites, i.e., those for which more than 12 months had elapsed since the original injury. Postoperative complications rarely necessitated regrafting. These results indicate that a dermal regeneration template provides a useful alternative technique for contracture release procedures. The study data indicate that this approach leads to favorable functional outcomes and a high rate of patient satisfaction. This modality also seems to be versatile, because a range of anatomical sites are amenable to treatment with a dermal regeneration template, regardless of prior surgical treatment, and both pediatric and adult patients respond well to this form of therapy. Furthermore, Integra confers functional and cosmetic benefits similar to those of full-thickness grafts but without comparable potential for donor-site morbidity.