Safety, feasibility, and acceptability of patient-controlled anxiolysis with dexmedetomidine for burn-care dressing changes: an open-label, single-arm, pilot study.

Anxiety is common among patients with burn injury, occurring frequently surrounding wound care. Few pharmacologic interventions targeting anxiety in burn injury have been evaluated. This study aimed to evaluate patient-controlled anxiolysis using dexmedetomidine (PCA-DEX) in patients undergoing burn dressing changes. This was a prospective, open-label, single-arm pilot study to determine the feasibility, safety, and acceptability of PCA-DEX. PCA-DEX included a loading dose, continuous infusion, and patient-administered boluses during dressing changes for up to 5 days. Vital signs were monitored throughout PCA-DEX. Procedural pain and anxiety were evaluated before and after each dressing change. Nursing and patient satisfaction were evaluated after each dressing change. Twenty patients were included; 9 (45%) males and 11 females (55%) with a mean age of 45.1 ± 16.9 years and median total body surface area burn injury of 7 [IQR 4-9.5]%. Median heart rate and systolic blood pressure prior to PCA-DEX on day 1 were 82 [75-97] bpm and 147 [128-170] mmHg. Overall PCA-DEX was tolerated well with a median heart rate of 72 [66-82] bpm and systolic blood pressure 115 [99-141] mmHg after PCA-DEX. One patient was withdrawn due to severe bradycardia (heart rate < 45 bpm) not attributed to PCA-DEX; 4 patients experienced mild hypotension (systolic blood pressure 85-89/diastolic blood pressure 45-49 mmHg), all of which resolved without intervention. The majority of both nurses and patients were either satisfied or highly satisfied with PCA-DEX overall (78.1% for nursing, 86.5% for patients). PCA-DEX is a novel, safe and feasible method of anxiolysis during burn dressing changes with high patient and nurse satisfaction rates. A randomized, controlled trial is warranted to confirm the efficacy of PCA-DEX.

The impact of serum zinc normalization on clinical outcomes in severe burn patients.

INTRODUCTION: Patients with thermal burns become zinc deficient due to exudative losses, increased urinary excretion, and reduction of carrier proteins which results in impaired immunity, wound healing and glucose control. Previous trials have demonstrated improved wound healing utilizing fixed zinc supplementation, but none have assessed the potential benefits associated with normalizing serum zinc concentrations. The objective of this study was to compare the impact of zinc normalization on clinical outcomes in patients with severe thermal burns. METHODS: This retrospective, single-center study of patients with at least 10% total body surface area (TBSA) burn and three serum zinc concentrations compared the ratio of hospital length of stay (LOS) over TBSA burned (LOS/TBSA index) between those with normal (≥60 mcg/mL) and non-normal (<60 mcg/mL) serum zinc concentrations; delineated by the third measurement. Secondary outcomes were time to 90% epithelialization, infection incidence, and percentage of blood glucose values greater than 180 mg/dL. Data are reported as median [25-75% interquartile range] for continuous variables and frequency (percent) for categorical variables. RESULTS: A total of 56 patients were included for evaluation (11 normal and 45 non-normal). Burn size was 20.5% TBSA [11-29] for those with normal zinc and 27.3% [22-36] for non-normal; number of grafts for each group was 1 [0-1] vs 2 [1-3] respectively. LOS/TBSA index did not differ significantly between groups (1.10 normal vs. 1.21 non-normal, unadjusted p = 0.69; p = 0.75 adjusting for number of grafts). Time to 90% epithelialization was reduced in the normal group (27.5 vs. 57 days, p = 0.02), but this did not remain statistically significant after adjustment for %TBSA and number of grafts (p = 0.18). The groups did not differ significantly in incidence of infection or hyperglycemia in either unadjusted or adjusted analyses. CONCLUSIONS: This was the first study, to our knowledge, to assess the clinical impact of normalizing serum zinc levels in patients with severe burns. Our results suggest the normalization of serum zinc levels through individualized zinc supplementation is not associated with improvement in clinical outcomes during hospitalization and therefore fixed-dose zinc supplementation without acquisition of serum zinc measurements should be considered.

Pregabalin in the reduction of pain and opioid consumption after burn injuries: A preliminary, randomized, double-blind, placebo-controlled study.

BACKGROUND: The primary objective of the study was to evaluate the efficacy of 300 milligrams (mg) and 600 mg of pregabalin compared to placebo in the reduction of pain in patients with noncritical partial and full thickness burn injuries. METHODS: A prospective, randomized, double-blinded, single center, placebo-controlled trial was conducted. Simple randomization method was used in this trial. After subjects met all the inclusion and none of the exclusion criteria, they were randomized and assigned to 1 of the 3 18-day treatments groups: Pregabalin 300 group, Pregabalin 600 group, or Placebo group. Demographics and clinical characteristics were recorded. The severity of pain was assessed by using the visual analog scale for pain intensity at baseline on day 3, day 9 ±â€Š3, day 25 ±â€Š7, day 90 ±â€Š6, and day 180 ±â€Š12. RESULTS: A total of 54 subjects were randomly assigned, and 51 were included in the data analysis. Demographics and clinical characteristics did not differ significantly between the 3 groups. There was a statistically significant difference in pain between the Pregabalin 300 and Pregabalin 600 groups (P-value = .0260). The Pregabalin 300 group had 17.93 units (95% confidence interval: 1.83-34.04) higher pain scores on average than the Pregabalin 600 group, regardless of time. The adjusted P-value comparing 0 to 300 was .1618, while the adjusted P-value for 0 versus 600 was .5304. There was an overall difference in pain across time regardless of study group (P-value = <.0001). An overall difference in opioid consumption (P-value = .0003) and BSHS (P-value = .0013) across time regardless of study group was noted. CONCLUSIONS: Pregabalin could be part of a promising multimodal analgesic regimen in noncritical burn population. Future placebo-controlled studies assessing the use of pregabalin in burn victim patients may further endorse our findings.

Survey of national and local practice of compression therapy timing for burn patients in the United States.

OBJECTIVE: Compression therapy (CT) has been an important, but debated, treatment for burn scars. To better understand one source of variation in observed outcomes after CT, an evaluation of CT timing of application is needed. MATERIALS AND METHODS: Following IRB approval, 126 burn centers were contacted to complete a 17-question survey regarding the center's practice pattern for compression garment therapy. Locally, study subjects were identified between March 1, 2014 and December 31, 2015 and medical records examined for timing of garment ordering, delivery and fitting. RESULTS: The majority believed that compression therapy is beneficial. Most centers reported using custom-fit and pre-fabricated garments, and a goal time of application between 2-4 weeks (42%) and 4-6 weeks (36%). After the garments are ordered, 61% of centers estimate that it takes 2-4 weeks for them to arrive. No significant differences in practices were found among centers treating pediatric patients only, adults only or both. Locally, the mean number of weeks between the date of original injury and garment order placement was 9.1 weeks with an additional 8.7 weeks between the date of order and date of delivery. CONCLUSIONS: The current study identified that although the national reporting of time to garment application is estimated to be between 2-6 weeks at the majority of burn centers including our own, we found our center to be well in excess of 17 weeks. The findings offer an opportunity for local improvement, and raise the possibility of similar incongruity between goals and practice at other centers.

Incidence of oxandrolone induced hepatic transaminitis in patients with burn injury.

The benefits of oxandrolone in burn patients has led to its accepted use in the burn care community, however details regarding the most common adverse effect, transaminitis, remains unclear. The purpose of this study was to determine the incidence of transaminitis in patients with burn injury and identify risk factors associated with the development of transaminitis. This single-center, retrospective risk factor analysis compared burn patients on oxandrolone with and without the development of transaminitis, defined as any aspartate aminotransferase or alanine aminotransferase value >100mg/dL. Patient demographics, past medical history, lab values, and burn characteristics were recorded. Overall 28 out of 66 (42%) patients developed transaminitis. The transaminitis group had a significantly higher proportion of other concomitant medications with a transaminitis risk (p=0.045). No significant difference in liver dysfunction or length of stay was observed between the two groups. Oxandrolone induced transaminitis is occurring in patients significantly more frequently than previously reported warranting further research to guide monitoring requirements, use of concomitant medications, and to determine if rechallenging after resolution should be considered.

Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis: A Multicenter Retrospective Study of 377 Adult Patients from the United States.

Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a rare, severe mucocutaneous reaction with few large cohorts reported. This multicenter retrospective study included patients with SJS/TEN seen by inpatient consultative dermatologists at 18 academic medical centers in the United States. A total of 377 adult patients with SJS/TEN between January 1, 2000 and June 1, 2015 were entered, including 260 of 377 (69%) from 2010 onward. The most frequent cause of SJS/TEN was medication reaction in 338 of 377 (89.7%), most often to trimethoprim/sulfamethoxazole (89/338; 26.3%). Most patients were managed in an intensive care (100/368; 27.2%) or burn unit (151/368; 41.0%). Most received pharmacologic therapy (266/376; 70.7%) versus supportive care alone (110/376; 29.3%)-typically corticosteroids (113/266; 42.5%), intravenous immunoglobulin (94/266; 35.3%), or both therapies (54/266; 20.3%). Based on day 1 SCORTEN predicted mortality, approximately 78 in-hospital deaths were expected (77.7/368; 21%), but the observed mortality of 54 patients (54/368; 14.7%) was significantly lower (standardized mortality ratio = 0.70; 95% confidence interval = 0.58-0.79). Stratified by therapy received, the standardized mortality ratio was lowest among those receiving both steroids and intravenous immunoglobulin (standardized mortality ratio = 0.52; 95% confidence interval 0.21-0.79). This large cohort provides contemporary information regarding US patients with SJS/TEN. Mortality, although substantial, was significantly lower than predicted. Although the precise role of pharmacotherapy remains unclear, co-administration of corticosteroids and intravenous immunoglobulin, among other therapies, may warrant further study.

Incidence of Unplanned 30-Day Readmissions in Adult Burn Patients in the United States.

This study characterizes adult burn readmissions in the United States using a nationally representative hospital inpatient sample. Readmission rates, diagnoses, and risk factors are discussed. We analyzed the 2013 and 2014 Nationwide Readmission Database for adult burn patients. The data were weighted to estimate national 30-day readmission rates. Principal readmission diagnoses were sorted into burn-specific or other readmission categories. We used multivariable logistic regression to assess the effects of patient and hospital stay risk factors on readmissions. An estimated 42,957 U.S. adult burn patients were discharged between January and November of 2013 and 2014. Of these patients, an estimated 3203 had unscheduled readmissions within 30 days (all-cause readmission rate: 7.5%, 95% CI: 6.7-8.2). An estimated 55.4 per cent of unplanned readmissions were for burn-specific principal readmission diagnoses. Burn-specific readmission was associated with burn severity and increased with both patient age and the number of comorbidities. Patients whose length of stay was less than 1 day per % total body surface area (%TBSA) burned had higher readmission risk (Adjusted odds ratio = 2.10, 95% CI = 1.48-2.99). The results of logistic regression models were similar for burn-specific readmissions and all-cause readmissions. In a nationally representative sample of adult burn patients, 4.1 per cent had unplanned 30-day readmissions for burn-specific reasons; 7.5 per cent were readmitted for any reason. Patient comorbidities and discharge before 1 day per %TBSA from the hospital impact readmission risk. Healthcare providers can use this information to identify at-risk patients, modify their treatment plans, and prevent readmissions.

The use of intravenous tPA for the treatment of severe frostbite.

OBJECTIVE: tPA and anticoagulation for treatment of severe frostbite have been reported suggesting differences in imaging techniques, route of tPA administration and management of patients after tPA infusion. This is a report of our results following a protocol of Tc-99m scanning, intravenous tPA administration, followed by either systemic anticoagulation or antiplatelet therapy. METHODS: Patients admitted to our burn center between February 13, 2015 and February 13, 2016 for frostbite who met inclusion criteria were treated with Tc-99m scan and intravenous tPA followed by systemic anticoagulation or antiplatelet therapy. Inclusion criteria included rewarming had not started more than 24h prior to the scan and no contraindications to the use of tPA. RESULTS: Fifteen patients met inclusion criteria and 12 were treated according to the protocol. Nine received scans with 2 showing normal perfusion. Seven displayed perfusion defects and received intravenous tPA. Five recovered fully after tPA. Two who showed improved but abnormal scans after tPA experienced bleeding complications necessitating stopping heparin/Coumadin. Those two went on to partial amputation of digits. CONCLUSION: The use of intra-arterial or intravenous tPA along with angiography or Tc-99m scanning followed by systemic anticoagulation or antiplatelet therapy may be beneficial to patients suffering frostbite.

TRALI following fresh frozen plasma resuscitation from burn shock.

INTRODUCTION: Resuscitation from burn shock using fresh frozen plasma (FFP) has been described. Critics of FFP resuscitation cite the development of transfusion related acute lung injury (TRALI) as a deterrent to its use. This study examines the occurrence of TRALI with FFP resuscitation of critically ill burned patients. METHODS: A retrospective chart review was conducted of severely burned patients who received FFP resuscitation. Data points included age, TBSA, TBSA full thickness, presence of alternate etiologies of acute lung injury, total FFP administered, and signs and symptoms of TRALI as defined per the Canadian Blood Services Consensus Conference. RESULTS: Eighty-three patients met the definition of severe burn and received FFP resuscitation. Of those, 65 met exclusion criteria. Eighteen patients were left for analysis with only one found to have signs and symptoms of TRALI. That patient suffered a 53.5% TBSA burn, received a total of 6228ml FFP, had no competing etiologies of ALI, and was diagnosed with TRALI within 6h of completing the FFP transfusion. CONCLUSION: The possible occurrence of TRALI in burn patients receiving FFP resuscitation should be weighed against the reported benefits of such a resuscitation strategy.

Burn Center Barrier Protocols During Dressing Change: A National Survey.

Infection control is a critical component of post-burn care with prevention of infection serving as a major cause of decreasing morbidity and mortality. One potential deterrent for infection is barrier protection during dressing changes; however, no evidence-based standard has been established among burn centers. The purpose of this study is to describe the current barrier techniques of American burn centers. A 24-question survey was sent to 121 burn center nurse managers within the United States. The survey was comprised of yes or no questions with comment sections available for further detail. Questions were constructed to gain insight into the variation and commonality that may exist between burn center barrier protocols. Forty-one out of 121 centers (34%) responded. Centers reported the use of head covers, masks, gowns, and gloves during admission of a new burn (71%, 82%, 95%, and 100% respectively); daily dressing changes (64%, 80%, 97%, and 100% respectively); postoperative dressing changes (64%, masks 80%, 97%, and 100% respectively); and dressing changes of a nonburn (66%, 82%, 97%, and 100% respectively). Burn centers reported their use of sterile gloves and gowns during typical burn dressing changes as occurring 20% and 10% of the time, respectively. Estimates for costs of these garments annually ranged from $0 to $250,000. A calculation performed for this study demonstrated that barrier garments used for dressing changes nationwide is approximately $2.43 million. We demonstrated the immense cost, to an institution and nationwide, of barrier garments used solely for dressing changes.

Comorbidity-polypharmacy score predicts in-hospital complications and the need for discharge to extended care facility in older burn patients.

Advancing age is associated with increased mortality despite smaller burn size. Chronic conditions are common in the elderly with resulting polypharmacy. The Comorbidity-Polypharmacy Score (CPS) facilitates quantitative assessment of the severity of comorbid conditions, or physiologic age. Burn injury in older patients is associated with increasing morbidity and mortality and the CPS may be predictive of outcomes such as mortality, ICU and hospital LOS, complications, and final hospital disposition. Our goal was to evaluate the predictive value of CPS for outcomes in the elderly burn population. A retrospective study was undertaken of 920 burn patients with age ≥45 admitted with acute burn injuries (January 1, 2006 to December 31, 2012). CPS was calculated by adding preinjury comorbidities and medications. Subjects were stratified into three groups according to CPS severity. Data collected included demographics, total body surface area burned (TBSA), presence of inhalation injury, ICU/hospital length of stay, complications, discharge disposition, and mortality. Univariate and multivariate analyses were performed. The mean age was 55.7; 72.9% were males; the mean initial TBSA was 6.93%; and mean CPS was 8.01. The risk of in-hospital complications is independently associated with CPS (OR 1.35). CPS (OR 1.81) was an independent predictor of discharge to a facility CPS but not of mortality. While increasing CPS was associated with lower TBSA, mortality remained unchanged. CPS is an independent predictor of in-hospital complications and need for transfer to extended care facilities in older burn patients, which can be determined at the stage of admission to help direct patient management.

Evaluation of TCOM/HBOT practice guideline for the treatment of foot burns occurring in diabetic patients.

OBJECTIVES: A multidisciplinary team developed an evidence-based guideline for the management of foot burns occurring in diabetic patients that included transcutaneous oxygen measurements (TCOM) and application of hyperbaric oxygen therapy (HBOT) to selected patients. This report represents an evaluation of preliminary TCOM/HBOT data. METHODS: This is a retrospective review of patients with diabetes mellitus (DM) who were admitted to a single American Burn Association (ABA) verified burn center for the treatment of foot burns. Patients were treated via the guideline if they were over the age of 16, admitted for the initial care of burns involving the feet between 4/01/2012 and 7/22/2013, and had a known or new diagnosis of DM. RESULTS: Eighteen patients were treated according to the guideline, 14 men and 4 women. Average age was 54 years+14.78. Average BMI was 30.63+6.34. Median burn size was 0.88% TBSA (median partial thickness of 1% and median full thickness of 0.5%). The average HbA1c was 9.08+2.42. Seven patients received pre-operative HBOT, two received post-operative HBOT and three patients healed their wounds with HBOT alone. Average hospital length of stay was 13.39 days+9.94 and was significantly longer for the group receiving HBOT. Admission HbA1c was not a predictor of the need for HBOT. CONCLUSIONS: While TCOM/HBOT therapy has not been widely applied to the management of diabetic foot burns, the use of an evidence-based guideline incorporating TCOM/HBOT can provide a systematic way to evaluate the patients' microcirculation and ability to heal burns of the foot. The incorporation of TCOM determination and application of HBOT in selected patients with DM and burns of the feet warrant continued study.

A clinician's guide to the treatment of foot burns occurring in diabetic patients.

INTRODUCTION: Diabetes mellitus affects 25.8 million Americans and is predicted to almost double by 2050. The presence of diabetes complicates hospital courses because of the microvascular complications associated with disease progression. Patients with diabetes represent 18.3% of annual burn admissions to our unit and 27% have burns to the feet. The purpose of this project was to develop an evidence-based guideline for care of the patient with diabetes and foot burns METHODS: A multidisciplinary group was charged with developing an evidence-based guideline for the treatment of foot burns in patients with diabetes. Evidence was evaluated in the areas of diabetes, burn care, hyperbaric medicine, care of diabetic foot wounds and physical therapy. After guideline development and approval, key aspects were incorporated into order sets. RESULTS: Key aspects of this guideline are the ability to identify patients with undiagnosed diabetes, assess diabetic control, optimize glycemic and metabolic control, optimize burn wound management, treat microvascular disease, and provide education and a discharge plan. Evaluated outcomes are glycemic control, length of stay, complication rates, amputation rates, infection rates and the use of hyperbaric oxygen. CONCLUSIONS: Best outcomes for this high risk population will be attainable with an evidence based guideline.