Impact of Opioid-Minimizing Pain Protocols After Burn Injury.

In 2019, we implemented a pill-based, opioid-minimizing pain protocol and protocolized moderate sedation for dressing changes in order to decrease opioid exposure in burn patients. We hypothesized that these interventions would reduce inpatient opioid exposure without increasing acute pain scores. Two groups of consecutive patients admitted to the burn service were compared: Pre-group (from January 1, 2018 to July 31, 2019) and Post-group (from January 1, 2020 to June 30, 2020) from before and after the implementation of the protocols (from August 1, 2019 to December 31, 2019). We abstracted patient demographics and burn injury characteristics from the burn registry. We obtained opioid exposure and pain scale scores from the electronic medical record. The primary outcome was total morphine milligram equivalents (MMEs). Secondary outcomes included MMEs/day, pain domain-specific MMEs, and pain scores. Pain was estimated by creating a normalized pain score (range 0-1), which incorporated three different pain scales (Numeric Rating Scale, Behavioral Pain Scale, and Behavioral Pain Assessment Scale). Groups were compared using Wilcoxon rank-sum and chi-square tests. Treatment effects were estimated using Bayesian generalized linear models. There were no differences in demographics or burn characteristics between the Pre-group (n = 495) and Post-group (n = 174). The Post-group had significantly lower total MMEs (Post-group 110 MMEs [32, 325] vs Pre-group 230 [60, 840], P < .001), MMEs/day (Post-group 33 MMEs/day [15, 54] vs Pre-group 52 [27, 80], P < .001), and domain-specific total MMEs. No difference in average normalized pain scores was seen. Implementation of opioid-minimizing protocols for acute burn pain was associated with a significant reduction in inpatient opioid exposure without an increase in pain scores.

Endothelial glycocalyx shedding in patients with burns.

Shedding of syndecan-1 from the endothelial glycocalyx layer (EGL), referred to as endotheliopathy of trauma (EoT), is associated with poorer outcomes. This study aims to determine if EoT is also present in the burn population. We enrolled 458 burn and non-burn trauma patients at a Level 1 trauma center and defined EoT by a syndecan-1 level of ≥40 ng/mL. Sixty-eight of the enrolled patients had burns with a median TBSA of 19%, with 27.9% also suffering inhalational injury (II). Mortality was similar between the burn and non-burn group, also for patients with EoT. The incidence of II was significantly greater in the EoT+ burn group compared to the EoT- group (p = 0.038). Patients with II received significantly larger amounts of i.v. fluids (p = 0.001). The incidence of EoT was significantly different between the II-groups, as was mortality (pEoT = 0.038, pmortality < 0.001). EoT is attributed to the shock rather than the mechanism of trauma and may in burns be associated to II rather than TBSA. Patients with burns and II had worse outcomes and higher mortality compared to patients with burns alone. Burn injury induces EGL shedding similar to that in non-burn patients with EoT, and results in similar higher rate of mortality.

Let the right one in: High admission rate for low-acuity pediatric burns.

BACKGROUND: The purpose of this study was to characterize emergency pediatric burn care triage at a tertiary children's hospital to identify targets for quality improvement. METHODS: A retrospective review of patients <18 years with primary burn injuries who presented to a children's emergency department in 2016 was conducted. Demographic and injury characteristics were recorded. Low acuity was defined by size (<5% total body surface area burn), depth (not third degree), and no need for conscious sedation for debridement. Multiple logistic regression was used for analysis. RESULTS: A total of 309 pediatric burn patients were triaged in the emergency department. Patients were typically young (median 3.3 years), male (59%), Hispanic (47%), publically insured (77%), and transferred in (65%). Scalding was the most common mechanism (59%). Though most burns were small (median 2% total body surface area), not deep (

Levamisole-induced vasculitis.

Levamisole is a veterinary antihelminthic, chemotherapeutic agent, and immunomodulator that also is used as an adulterant and cutting agent in cocaine distribution. This drug may potentiate the sympathomimetic actions of cocaine and can cause neutropenia, agranulocytosis, purpuric retiform lesions, and skin necrosis. This article describes two cases of suspected levamisole-induced vasculitis. No standardized diagnostic or treatment algorithm exists for this challenging condition. Diagnosis and treatment require a multidisciplinary team approach.

Admission Rapid Thrombelastography (rTEG®) Values Predict Resuscitation Volumes and Patient Outcomes After Thermal Injury.

In trauma, admission rapid thrombelastography (rTEG) has been shown to predict in-hospital thromboembolic events, guide treatment of coagulopathy, and identify likely to require large volume resuscitations. We sought to evaluate the use of rTEG in describing the coagulation status of major burn patients at admission and assess whether rTEG values predicted resuscitation volumes and patient outcomes. This is a retrospective study of all patients admitted to our Burn intensive care unit between January 2010 and December 2012. We excluded those with < 15% TBSA burns, < 18 years of age, and with concomitant injuries requiring admission to the Trauma intensive care unit. Previously published and validated cut points for hypocoagulable (activated clotting time ≥ 128; k-time ≥ 2.5; angle ≤ 60; mA ≤ 55; LY30 ≥ 3%) and hypercoagulable (mA ≥ 65) rTEG values were used. Supra-normal burn resuscitation was defined as ≥ 5.0 mL/kg/TBSA. Statistical analyses were conducted using STATA 13.1. Sixty-five patients met inclusion with a median age of 45 years, 74% male and 49% white. Median TBSA was 38% with 14% having third-degree burns. Sixty percentage of patients were hypercoagulable on admission, while 24% were hypocoagulable. rTEG values predicted increased 24-hour resuscitation volumes, as well as plasma and platelet transfusions (P < 0.05). Controlling for age, TBSA, and base deficit, admission rTEG ≥ 128 predicted a 5-fold increased likelihood of supra-normal resuscitation. In addition, an angle < 60 predicted in-hospital mortality. While the majority of severely burned patients arrive hypercoagulable, one-quarter are hypocoagulable and have increased resuscitation and transfusion requirements. Moreover, those with admission activated clotting time ≥ 128 are at 5-fold increased risk of supra-normal resuscitation.

Comparing the Workload Perceptions of Identifying Patient Condition and Priorities of Care Among Burn Providers in Three Burn ICUs.

Multidisciplinary rounds (MDRs) in the burn intensive care unit serve as an efficient means for clinicians to assess patient status and establish patient care priorities. Both tasks require significant cognitive work, the magnitude of which is relevant because increased cognitive work of task completion has been associated with increased error rates. We sought to quantify this workload during MDR using the National Aeronautics and Space Administration Task Load Index (NASA-TLX). Research staff at three academic regional referral burn centers administered the NASA-TLX to clinicians during MDR. Clinicians assessed their workload associated with 1) "Identify(ing) if the patient is better, same, or worse than yesterday" and 2) "Identify(ing) the most important objectives of care for the patient today." Data were collected on clinician type, years of experience, and hours of direct patient care. Surveys were administered to 116 total clinicians, 41 physicians, 25 nurses, 13 medical students, and 37 clinicians in other roles. Clinicians with less experience reported more cognitive work when completing both tasks (P < .005). Clinicians in the "others" group (respiratory therapists, dieticians, pharmacists, etc.) reported less cognitive work than all other groups for both tasks (P < .05). The NASA-TLX was an effective tool for collecting perceptions of cognitive workload associated with MDR. Perceived cognitive work varied by clinician type and experience level when completing two key tasks. Less experience was associated with increased perceived work, potentially increasing mental error rates, and increasing risk to patients. Creating tools or work processes to reduce cognitive work may improve clinician performance.

Upon admission coagulation and platelet function in patients with thermal and electrical injuries.

RATIONAL: There has been increased focus on hemostatic potential and function in the initial assessment of the patient with traumatic injuries, that not been extensively studied in patients with burns. We proposed to determine the hemostatic potential of patients with burns upon admission to the emergency department and contrasted their condition with that of healthy controls and patients with other traumatic injuries. In addition we assessed differences due to thermal versus electrical injury and evaluated the effect of burn size. METHODS: This is a patient based prospective observational study conducted with delayed consented. Subjects at the highest level of trauma activation upon admission to the ED had a blood sample collected for research purposes and were subsequently consented. Hemostatic potential was measured by rapid thromelastography (r-TEG®), thrombin generation by calibrated automated thrombogram (CAT) and platelet function by Multiplate® using five activators. Burn subjects were compared to subjects with other traumatic injuries and controls. Within the burn subjects additional analysis compared mechanism (thermal vs. electrical) and burn size. Values are medians (IQR). RESULTS: Two hundred and eighty two trauma patients (with burns n=40, 14%) and 27 controls were enrolled. Upon admission, compared to controls, subjects with burns or trauma were hyper-coagulable based on r-TEG and CAT, with increased rates of clot formation and thrombin generation. There were no differences in burns compared to other traumatic injuries. The presence of hyper-coagulation did not appear to be related to the type of burn or the percentage of total body surface area involved. Employing previous defined cut points for R-TEG driven therapeutic interventions burn patients had similar rates of hyper- and hypo-coagulation noted in patients with traumatic injuries. CONCLUSION: Upon admission patients with burns are in a hyper-coagulable state similar to that of other trauma patients. Employing demonstrated cut points of hemostatic potential in trauma patients associated with increased risk of poor outcomes demonstrated the incidence in burn patients to be similar, suggesting that these values could be used in the early assessment of the patient with burns to guide treatment interventions.

Exposure to an iridium-192 source in an industrial safety worker.

Radiation burn injuries account for 0.2% of burn injury admissions. Treatment of radiation burns remains challenging because of unpredictable inflammatory changes and soft tissue necrosis. Conventional treatment consists of multistaged surgical procedures. Here, we present a case of an Iridium-192 exposure treated nonoperatively. A 23-year-old man presented with a 7-day-old, less than 1% TBSA radiation burn to his right hand. He initially sought treatment at an outside hospital and plastic surgeon's office postinjury days 2 and 3. He later presented to our facility because of worsening pain, edema, and discoloration. He was admitted and hospitalized for 15 days. Narcotics were initiated and wound care consisted of daily antibiotic ointment and petroleum gauze dressings. We continued dexamethasone and pentoxyfilline for 1 week. He underwent nineteen 90-minute treatments of hyperbaric oxygen therapy during an 8-week period. He had complete wound healing 1 month postdischarge. This case report provides background on radiation burn injuries and applicability of nonoperative management in treating radiation burn injuries. Furthermore, it encourages the development of individualized treatment plans, consideration of the use of hyperbaric oxygen therapy, referral to a burn center, and consulting radiation experts for guidance.

Silver-coated nylon dressing plus active DC microcurrent for healing of autogenous skin donor sites.

INTRODUCTION: Burn wounds are a significant cause of morbidity and mortality, and improved outcomes are demonstrated with early closure of both primary burn wounds and skin donor sites. Thus, technology that decreases the healing time of burns and donor sites would be potentially lifesaving. We present the results of a single-center, prospective, double-blinded, randomized controlled trial to evaluate the efficacy of silver-coated dressing with active microcurrent in comparison to silver-coated dressing with sham microcurrent on wound-closure time for autogenous skin donor sites. METHODS: Four hundred five patients were screened for treatment of their donor sites using a silver-coated nylon dressing with either sham or active microcurrent stimulation. Thirty patients were enrolled in the study and then randomized. Of these, 5 patients were removed from analysis due to protocol deviations. Differences in time-to-closure were analyzed using Kaplan-Meier analysis and the proportional hazard regression model. Subjective verbal pain rating scores (0-10; 0, no pain; 10, worst pain) were also recorded. All devices were blinded and programmed at an outside facility, so that every patient had either an active or sham device. The study was unblinded only after the final patient's donor site had healed. All patients achieved donor-site healing before postoperative day 20. The 14 patients in the active microcurrent group [mean, 10.8 (2.9) days; range, 7-15 days] experienced no difference in time to wound healing as compared to the remaining patients in the sham microcurrent group [mean, 11.1 (2.0) days; range, 8-14 days; P = 0.75]. There were no differences in pain from one group compared to the other. None of the donor sites exhibited clinical signs of infection. CONCLUSIONS: In a sample size of 25 burn patients, the addition of direct microcurrent to silver-nylon dressings did not decrease time to wound closure of skin donor sites, and it did not show a difference in reported pain levels.

Carbon monoxide and cyanide toxicity: etiology, pathophysiology and treatment in inhalation injury.

Inhalation injury is most commonly associated with damage to the mucosal surfaces of the small and large airways after exposure to smoke and other products of incomplete combustion. Yet, there are far deadlier things lurking within the smoke than just the heat and particulate matter: carbon monoxide and cyanide. These two toxic substances are found in varying concentrations within the fire room and are associated with early on-scene death and in-hospital morbidity and mortality. Patients suffering from carbon monoxide and/or cyanide poisoning present with vague symptoms requiring an astute physician to make the diagnosis. Fortunately, the toxic effects related to exposure to these agents can be reversed with readily available antidotes.

Association of rhabdomyolysis with renal outcomes and mortality in burn patients.

The contribution of rhabdomyolysis to acute kidney injury (AKI) in the context of burn injury is poorly studied. We sought to determine the impact of rhabdomyolysis on AKI (defined by the AKI Network classification), renal replacement therapy (RRT), and death. Patients admitted to the burn unit at our institution were examined. Information on sex, age, presence of inhalation injury, electrical burn, percentage TBSA burned, percentage of full-thickness burns, Injury Severity Score, and peak creatine kinase (CK) were recorded. These variables were examined via multivariate logistic regression analysis against AKI Network stage, RRT, and death. Of 1973 consecutive admissions meeting the inclusion criteria, 525 met our eligibility criteria. Log peak CK was found to be correlated with any stage of AKI (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.36-2.16; P < .0001), moderate to severe AKI (OR, 2.09; 95% CI, 1.40-3.11; P = .0003), need for RRT (OR, 1.67; 95% CI, 1.16-2.40; P = .0057), and mortality (OR, 1.49; 95% CI, 1.01-2.20; P = .0441), after adjustment. Each 10-fold increase in peak CK was associated with a 70% increase in the odds of AKI, more than a 100% increase in the odds of moderate to severe AKI, a nearly 70% increase in the odds of RRT, and an almost 50% increase in the odds of mortality in patients with burn injury.

Admission chest CT complements fiberoptic bronchoscopy in prediction of adverse outcomes in thermally injured patients.

In burned patients, inhalation injury can result in progressive pulmonary dysfunction, infection, and death. Although bronchoscopy is the standard for diagnosis, it only assesses the proximal airway and does not provide a comprehensive analysis of pulmonary insult. Chest radiographs have not been proven helpful in diagnosis of inhalation injury. Our hypothesis is that a CT scan alone or in conjunction with bronchoscopy can be used as a prognostic tool for critically ill burn patients, especially those with inhalation injury. The authors performed a retrospective study of all patients admitted to the U.S. Army Institute of Surgical Research Burn Center between 2002 and 2008 with chest CT within 24 hours of admission. They divided subjects into two groups, those with evidence of inhalation injury on bronchoscopy and those without. They used a radiologist's score to assess the degree of damage to the pulmonary parenchyma. The primary endpoint was a composite of pneumonia, acute lung injury/acute respiratory distress syndrome, and death. The inhalation injury group consisted of 25 patients and the noninhalation injury group of 19 patients. Groups were not different in age, TBSA burned, and percentage full-thickness burn. By multiple logistic regression, detection of inhalation injury on bronchoscopy was associated with an 8.3-fold increase in the composite endpoint. The combination of inhalation injury on bronchoscopy and a high radiologist's score was associated with a 12.7-fold increase in the incidence of the composite endpoint. Admission CT assists in predicting future lung dysfunction in burn patients.

Ventilator-associated pneumonia in burn patients: a cause or consequence of critical illness?

Infectious complications are a constant threat to thermally injured patients during hospitalizations and are a predominant cause of death. Most of the infections that develop in burn patients are nosocomial and of a pulmonary etiology. The bacteria that cause ventilator associated pneumonia (VAP) take advantage of the fact that uniquely among intensive care unit patients endotracheal intubation allows them a 'free' passage to the sterile lower airways; however, the combination of severe thermal injury (systemic immunosuppression) and inhalation injury (local immunosuppression and tissue injury) create an ideal environment for development of VAP. Thus, strategies directed at preventing and treating VAP in burn patients must address not only rapid extubation and VAP prevention bundles known to work in other intensive care unit populations, but therapies directed to more rapid wound healing and restoration of pulmonary patency.

Pneumatosis intestinalis in patients with severe thermal injury.

Severe thermal injury is associated with pronounced changes in intestinal physiology, which may cause ischemia, infarction, and pneumatosis intestinalis (PI). PI is a pathologic condition defined as infiltration of gas into the gastrointestinal tract wall. Historically, PI prompted urgent surgery, yet some surgeons "watch and wait" to avoid the risks of a negative laparotomy. The authors reviewed experience with PI at a single burn center. They retrospectively identified burn center intensive care unit patients with radiographic or pathologic evidence of PI. Data included demographics, injury severity score, TBSA burned, operative findings, length of stay, and mortality. From January 2003 through August 2009, 1129 patients were admitted to the authors' burn center intensive care unit. Fifteen had PI. Twelve had radiographic evidence of PI, and 10 had PI associated with intestinal infarction. Nonsurvivors had lower base deficits (P = .02), higher lactate levels (P = .05), and required vasopressor support (P = .02) within 24 hours of developing PI. Massive intestinal infarction (P = .004) and open abdomens (P = .004) were more common among nonsurvivors. PI can be identified by radiologic or pathologic findings. The authors' experience with PI among patients with burn injury revealed a high mortality rate. Because of the association of bowel ischemia with PI, exploratory laparotomy should be strongly considered in patients with burn injury with radiographic evidence of PI.

Outcomes with the use of recombinant human erythropoietin in critically ill burn patients.

Recent data demonstrate a possible mortality benefit in traumatically injured patients when given subcutaneous recombinant human erythropoietin (rhEPO). The purpose of this report is to examine the effect of rhEPO on mortality and transfusion in burn patients. We conducted a review of burn patients (greater than 30% total body surface area, intensive care unit [ICU] days greater than 15) treated with 40,000 u rhEPO over an 18-month period (January 2007 to July 2008). Matched historical controls were identified and a contemporaneous cohort of subjects not administered rhEPO was used for comparison (NrhEPO). Mortality, transfusions, ICU and hospital length of stay were assessed. A total of 105 patients were treated (25 rhEPO, 53 historical control group, 27 NrhEPO). Hospital transfusions (mean 13,704 +/- mL vs. 13,308 +/- mL; P = 0.42) and mortality (29.6 vs. 32.0%; P = 0.64) were similar. NrhEPO required more blood transfusions (13,308 +/- mL vs. 6827 +/- mL; P = 0.004). No difference in mortality for the rhEPO and NrhEPO (32.0 vs. 22.2%; P = 0.43) was found. Thromboembolic complications were similar in all three groups. No effect was seen for rhEPO treatment on mortality or blood transfusion requirements in the severely burned.

Blood transfusion and its effect on the clinical outcomes of patients undergoing major lower extremity amputation.

BACKGROUND: Patients in need of lower extremity amputation are often debilitated and have coronary artery disease and underlying anemia. The transfusion of blood is a common practice in the perioperative management of these patients. However, blood transfusion has been reported to have a negative effect on the incidence of perioperative complications in other patient populations. We undertook this study to determine the effect of blood transfusion on the incidence of adverse postoperative events in patients undergoing major amputations. METHODS: We conducted a retrospective review of 300 consecutive patients undergoing either above-knee or below-knee amputation over a 5-year period at our institution. The demographic variables, medical comorbidities, need for blood transfusion, and clinical outcomes were recorded. The impact of blood transfusion on clinical outcome was analyzed. RESULTS: Of the 300 patients undergoing major amputation, 191 (64%) had one or more blood transfusions. The demographic variables and incidence of medical comorbidities were comparable between the two groups. Patients undergoing blood transfusion were 2.5 more likely to suffer from a postoperative cardiac arrhythmia, 12.8 times more likely to develop acute renal failure, 5.7 times more likely to have pneumonia, and 2.2 times more likely to have a urinary tract infection. Each of these adverse postoperative events was statistically more likely in the transfused group. The postoperative mortality was 13% for the transfused group and 6% for those not transfused, which was a nonsignificant difference. The intensive care unit stay and overall hospital stay were significantly longer in patients who had blood transfusions (difference of 2.1 and 5.4 days, respectively). CONCLUSION: Blood transfusion in patients undergoing major lower extremity amputation is associated with an increased incidence of adverse postoperative events and prolonged intensive care unit and hospital stays. We therefore suggest a restricted approach to blood transfusion in patients requiring major amputation.