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.

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.

Refining the referral criteria of persons who have been burned to palliative care: A modified Delphi approach.

A paucity of evidence is available to guide integration of specialist palliative care into burn care. This study's purpose was to develop consensus on referral criteria using a modified Delphi process. Content experts were defined as burn or palliative care providers in locations where the teams have collaborative history; published at least one manuscript or presented nationally on burn and palliative care collaboration; or nomination as having equivalent expertise. N = 202 eligible persons were identified; n = 43 participated in Iteration 1 and Iteration 3 retained 79%. Iteration 1 invited participants to rank published referral criteria on a 9-point Likert-style scale. Consensus was defined as an interquartile range ≤ 2. Consensus items with median scores ≤ 3 were dropped from further consideration. Consensus items with median scores ≥ 7 were considered to be important and excluded in Iteration 2. Iteration 2 which presented non-consensus items with their associated median (interquartile range) and the participant's own ranking from Iteration 1. Iteration 3 presented three models; participants ranked in order of preference and suggested revisions. Consensus was achieved on a final set of criteria for specialist palliative care for persons who sustain burn injuries. Future research should prospectively evaluate the criteria against meaningful outcomes.

Management and Outcomes of Acute Kidney Injury due to Burns: A Literature Review.

Acute kidney injury (AKI), a common and severe complication following burn injuries, presents a significant challenge due to its broad clinical manifestations and diverse etiologies. AKI, previously known as acute renal failure, can present abruptly following burns or thermal injuries, causing detrimental health outcomes such as progressive kidney dysfunction, increased hospital length of stay, and requirement of renal replacement therapy (RRT). AKI affects the maintenance of homeostasis of fluid and electrolytes, elimination of metabolic wastes and byproducts, and acid-base balance. Aggressive nutritional support is particularly necessitated in burn patients to prevent protein-energy wasting and a negative nitrogen balance. Understanding the pathogenesis of AKI in burns and improving its prevention and early diagnosis are active areas of research in this field. Despite the potential benefits, the optimal timing and threshold for RRT initiation in burn patients with AKI remain unclear, warranting further studies. Ongoing investigations focus on refining RRT techniques, evaluating biomarkers for early detection of AKI, and exploring adjunctive therapies to enhance renal recovery. The aim of this study is to review the etiology, diagnostic tools, and interventions that improve outcomes associated with AKI in burn-related settings.

Acute kidney injury occurs in nearly one-quarter of people with severe burns and leads to increased mortality rates. Burn injuries can be associated with numerous complications, such as hypermetabolic response, hypovolemia, hypotension, and sepsis, and involves early burn- and late burn-related complications. Validated metrics for classifying the extent of burn injuries, such as the Abbreviated Burn Severity Index on admission, Sequential Organ Failure Assessment Score on admission, Modified Marshall Score, baseline blood urea nitrogen, and serum creatinine all serve to discriminate the risk of acute kidney injury. With no current consensus on predictive energy equations or ideal nutritional goals, optimal nutritional support in burn patients with acute kidney injury largely relies on the burn severity, individual presentation of malnourishment, and timely resuscitation. Although novel biomarkers such as plasma and urinary NGAL levels, KIM-1, and IL-18 are still being investigated as diagnostic tools for acute kidney injury in both the early and late burn periods, and artificial intelligence/machine learning may soon be incorporated as an efficacious assessment tool in the future. Renal replacement therapy is often indicated in the setting of acute kidney injury due to severe burns, especially if the metabolic and fluid disturbances due to acute kidney injury are not adequately managed with fluid resuscitation, diuretics, electrolyte repletion, and other supportive measures. However, with over a third of all burn-related acute kidney injury patients requiring some form of renal replacement therapy, elevated mortality rates remain a cause for concern.

Integrating Palliative Care into Burn Care: A Retrospective Application of Criteria for Appropriate Referral.

Burn injuries often require complex interdisciplinary care. Despite potential benefits, consultation with specialist palliative care typically occurs in 2% of burn admissions, due largely to lack of availability and misconceptions concerning palliative care. Criteria to guide consultation with specialist palliative care have been developed at this institution. The purpose of this study was to quantify the sensitivity and specificity of these criteria, and then optimize them. Retrospective examination of 388 admissions over 15 months at this adult and pediatric Burn Center were conducted. Chi-square or Fisher's exact test for categorical variables and Wilcoxon Rank Sum test for continuous variables were used to test for between-group differences in demographic and clinical characteristics. Logistic regression model was built to determine modified Baux cut-off score using Youden index (J) value. Criteria were sensitive (0.96) and specific (0.90), though with a low positive predictive value (0.43). Persons with lengths of stay greater than one week, advanced directives, Allow Natural Death orders, and/or deterioration events were significantly more likely to have had palliative care consulted. There were significant between-group differences (with/without palliative care consultation) based on burn surface area, modified Baux score, and mortality risk. Potential criteria revisions are proposed. Prospective adherence to revised criteria could provide useful guidance to providers and benefit to patients and families.

High-Volume Hemodiafiltration with Step-Down Approach versus Standard-of-Care Continuous Renal Replacement Therapy Approach in Critically Ill Burn Patients.

INTRODUCTION: Acute kidney injury (AKI) is a common complication of severe burn injuries and contributes to morbidity and mortality. It is exacerbated in burn patients by elevated serum creatinine and pro-inflammatory cytokines, leading to immune dysregulation. Chronic renal replacement therapy is standard of care and removes cytokines to return the body to homeostasis. Continuous veno-venous hemodiafiltration (CVVHDF) is a high-filtration method to enhance cytokine clearance; we analyze a step-down approach for improved outcomes in burn patients. METHODS: This study reviewed 15 burn patients at Akron Children's Hospital stratified into 2 groups: high-flow CVVHDF with step-down approach versus standard CVVHDF. A normocarbia bicarbonate-based dialysate solution and citrate anticoagulation was applied, and blood flow rate was maintained greater than 200 mL/min. RESULTS: Fifteen burn patients at Akron Children's Hospital were separated into groups managed with high-flow CVVHDF (n = 9) and standard-flow CVVHDF (n = 6). All 15 developed AKI symptoms and diuretic-resistant fluid overload, with 4/15 displaying fluid overload greater than 40%. The most common indication for hemofiltration was acute tubular necrosis (11/15). Average time on CVVHDF was 20.2 days and length of admission was 58.6 days. Vasodepressor dependency index was significantly reduced in the high-flow group at 48 h, but no significant difference in mortality was identified. No significant difference was identified in adverse reactions, notably electrolyte imbalances. CONCLUSION: The literature on the efficacy of high-flow CVVHDF is limited. This study suggests improved mortality rates and length of stay with high flow compared to the literature. Further studies with multicenter involvement are necessary.

Burn Resuscitation Practices in North America: Results of the Acute Burn ResUscitation Multicenter Prospective Trial (ABRUPT).

OBJECTIVES: ABRUPT was a prospective, noninterventional, observational study of resuscitation practices at 21 burn centers. The primary goal was to examine burn resuscitation with albumin or crystalloids alone, to design a future prospective randomized trial. SUMMARY BACKGROUND DATA: No modern prospective study has determined whether to use colloids or crystalloids for acute burn resuscitation. METHODS: Patients ≥18 years with burns ≥ 20% total body surface area (TBSA) had hourly documentation of resuscitation parameters for 48 hours. Patients received either crystalloids alone or had albumin supplemented to crystalloid based on center protocols. RESULTS: Of 379 enrollees, two-thirds (253) were resuscitated with albumin and one-third (126) were resuscitated with crystalloid alone. Albumin patients received more total fluid than Crystalloid patients (5.2 ± 2.3 vs 3.7 ± 1.7 mL/kg/% TBSA burn/24 hours), but patients in the Albumin Group were older, had larger burns, higher admission Sequential Organ Failure Assessment (SOFA) scores, and more inhalation injury. Albumin lowered the in-to-out (I/O) ratio and was started ≤12 hours in patients with the highest initial fluid requirements, given >12 hours with intermediate requirements, and avoided in patients who responded to crystalloid alone. CONCLUSIONS: Albumin use is associated with older age, larger and deeper burns, and more severe organ dysfunction at presentation. Albumin supplementation is started when initial crystalloid rates are above expected targets and improves the I/O ratio. The fluid received in the first 24 hours was at or above the Parkland Formula estimate.

Palliative Care and Burn Care: Empirically Derived Referral Criteria.

Burns frequently require complex interdisciplinary care. Specialist palliative care (PC) minimizes suffering, aids in decision making, and provides family support in addition to end-of-life care. Specialist PC is a limited resource, best conserved by identifying persons most likely to benefit from a PC referral. Little guidance is available for clinicians on whether and when to refer to PC. This study's purpose was to identify referral criteria using a mixed-methods approach. Data were examined for between-group differences using Fisher's exact, chi-square, or Wilcoxon Rank Sum tests. Qualitative thematic analysis was used to analyze PC provider notes to describe interventions provided. These data formed initial referral criteria, which were reviewed by an expert panel. Significant between-group differences included dying in the burn center; whether multiple patients were transported to the burn center from one event; and ventilator days. Four themes emerged from qualitative analysis. These included managing physical aspects of care; clarifying goals of care; managing end-of-life care; and managing patient/family psychosocial distress. Expert panel input clarified referral criteria language and supplemented the proposed criteria. We present empirically derived referral criteria to guide burn providers in referring persons for specialist PC. Subsequent testing is required to determine their efficacy in improving patient/family outcomes.

Enhanced disinfection with hybrid hydrogen peroxide fogging in a critical care setting.

BACKGROUND: Environmental contamination contributes to hospital associated infections, particularly those caused by multi-drug resistant organisms (MDRO). This study investigated bioburden presence on surfaces in a critical care center's patient rooms following typical environmental services (EVS) practices and following intervention with hybrid hydrogen peroxide™ (HHP™) fogging. METHODS: Upon patient discharge, following standard cleaning or cleaning with ultraviolet (UV) light use, patient rooms were sampled by swabbing for adenosine triphosphate (ATP) and aerobic colony counts (ACC) from five preset locations. Rooms were then fogged via HHP technology using chemical indicators and Geobacillus stearothermophilus biological indicators for sporicidal validation monitoring. Following fogging, rooms were sampled again, and results were compared. RESULTS: A 98% reduction in ACC was observed after fogging as compared to post EVS practices both with and without UV light use. No statistical difference was seen when comparing cleaning to cleaning with UV light use. Methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa were identified following EVS practices and not detected following HHP fogging. ATP samples were reduced 88% by fogging application. Chemical and biological indicators confirmed correct application of HHP fogging, as seen through its achievement of a 6-log reduction of bacterial spores. CONCLUSION: HHP fogging is a thorough and efficacious technology which, when applied to critical care patient rooms, significantly reduces bioburden on surfaces, indicating potential benefits for implementation as part of infection prevention measures.

Evaluating Real-World National and Regional Trends in Definitive Closure in U.S. Burn Care: A Survey of U.S. Burn Centers.

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.

Risk Factors for Wound Infection in Outpatients With Lower Extremity Burns.

BACKGROUND: We sought to evaluate risk factors for wound infection in patients with lower extremity (LE) burn. METHODS: Adults presenting with LE burn from January 2014 to July 2015 were included. Data regarding demographics, injury characteristics, and outcomes were obtained. The primary outcome was wound infection. Multivariate logistic regression analysis was performed to identify independent risk factors for wound infection. RESULTS: 317 patients were included with a mean age of 43 years and median total body surface area of .8%; 22 (7%) patients had a component of full-thickness (FT) burn; and 212 (67%) patients had below-the-knee (BTK) burn. The incidence of wound infection was 15%. The median time to infection was 5 days, and majority (61%) of the patients developed wound infection by day 5. Patients who developed wound infection were more likely to have an FT burn (22% vs. 5%, P < .001) and BTK burn (87% vs. 64%, P = .002), without a difference in other variables. Multivariate logistic regression analysis showed age (Odds ratio (OR) 1.02 and CI 1.00-1.04), presence of FT burn (OR 5.33 and CI 2.09-13.62), and BTK burn (OR 3.42 and CI 1.37-8.52) as independent risk factors for wound infection (area under the curve = .72). CONCLUSION: Age, presence of FT burn, and BTK burn are independent risk factors for wound infection in outpatients with LE burns.

When Is It Appropriate to Put a Live Donor at Risk to Help Another Patient?

This article considers the nature and scope of ethical decision making in monozygotic sibling (MZS) skin grafting. Although rare, identical twin-to-twin skin grafting has been reported with excellent survival rates in burn patients. Of 16 cases published to date, only a few address the ethical decision making process that is involved with monozygotic sibling skin grafting; this article discusses clinical indications and ethical challenges.

Reconstruction of a Circumferential Upper Extremity Soft Tissue Defect With a Dermal Regeneration Template and Skin Grafting.

Extensive degloving injuries of the upper extremity are rare and pose unique reconstructive challenges. Circumferential loss of soft tissue coverage over the elbow treated by skin grafting is often complicated by elbow contracture and decreased range of motion, requiring secondary contracture release and free-flap reconstruction to restore function. As an alternative approach, we report a good outcome after the use of a dermal regenerative template and subsequent split-thickness skin grafting. A 38-year-old right hand dominant man presented with circumferential degloving injury of the entire right upper extremity to the level of the chest wall after an industrial accident. An immediate right transradial amputation was performed and serial debridement was required to remove all devitalized tissue. A dermal regenerative template with subsequent split-thickness skin grafting was used to cover the circumferential elbow soft tissue defect. Occupational therapy and splinting were used preoperatively and postoperatively to prevent contracture. However, axillary scar contracture release was required 4 months after injury. Six months after skin grafting, the patient had stable soft tissue coverage of the upper extremity. Shoulder motion measured 120-degree abduction and 140-degree forward flexion and elbow range of motion was 15 to 150 degrees. In this case, an excellent clinical outcome was obtained with a dermal regenerative template, aggressive wound care, and a multidisciplinary team approach.

Utility of Sequential Organ Failure Assessment score in predicting bacteremia in critically ill burn patients.

BACKGROUND: We evaluated whether qSOFA ≥2 and an increase in SOFA (ΔSOFA) ≥2 can help predict bacteremia in a critically ill burn population. METHODS: Patients age ≥15 and TBSA ≥15% admitted between 2009 and 2015 were included. All blood cultures were recorded, and positive and negative blood culture days were defined based on the culture results. SOFA and qSOFA scores were compared between positive and negative blood culture days. RESULTS: There were 50 patients in our study with a mean age of 47yrs and mean TBSA burn of 37%. Bacteremic patients had larger TBSA and full thickness burns, higher revised Baux score, and longer hospital LOS, without a difference in mortality, compared to non-bacteremic patients. There was no difference in qSOFA and SOFA scores between positive and negative blood culture days. A ΔSOFA ≥5 was highly specific for positive blood culture days. CONCLUSIONS: SOFA and qSOFA have limited ability to predict bacteremia in critically ill burn patients.

Ablative fractional photothermolysis for the treatment of hypertrophic burn scars in adult and pediatric patients: a single surgeon's experience.

Many patients develop hypertrophic scarring after a burn injury. Numerous treatment modalities have been described and are currently in practice. Photothermolysis or laser therapy has been recently described as an adjunct for management of hypertrophic burn scars. This study is a retrospective chart review of adult and pediatric patients undergoing fractional photothermolysis at a verified burn center examining treatment parameters as well as pre- and post-Vancouver Scar Scale scores. Forty-four patients underwent fractional photothermolysis during the study period of 8 months. Mean pretreatment score was 7.6, and mean posttreatment score was 5.4. The mean decrease in score was 2.2, which was found to be statistically significant. There were no complications. Fractional photothermolysis is a safe and efficacious adjunct therapy for hypertrophic burn scars. Prospective trials would be beneficial to determine optimal therapeutic strategies.

The use of Integra® Dermal Regeneration Template in the reconstruction of traumatic degloving injuries.

Traumatic soft tissue, or "degloving" injuries from trauma are common. These injuries are a result of shearing and disrupt tissue planes, such as the junction between muscle and bone. Traditional repair involves debridement followed by skin grafting or flap reconstruction. Many degloving injuries, however, extend to bone or tendon and the decreased vascularity of the wound bed can compromise the success of traditional repairs. Additionally, medical comorbidities make some patients poor candidates for flap reconstruction. The purpose of this study was to evaluate the success of a dermal regeneration template in the treatment of complex traumatic degloving injuries at an American College of Surgeons verified Level 1 Trauma Center. A retrospective review was conducted on all patients sustaining traumatic degloving injuries from January 2009 to July 2010, who were treated with Integra Dermal Regeneration Template followed by split-thickness autografting. Medical records were reviewed and patient demographics, injury characteristics, comorbidities, hospital course, and outcomes were summarized. Ten patients were studied. All had traumatic degloving injuries of an extremity ranging from 50 to 1000 cm. Nine had injuries extending to bone and/or tendon. After debridement, patients underwent placement of Integra followed by a split-thickness skin graft. Of the 10 patients nine had complete take of their grafts with excellent cosmetic and functional results. Degloving injuries are common in trauma. These injuries often extend to tendon and bone, which poses challenges to repair because of decreased vascularity. Placement of a dermal regeneration template followed by a split-thickness autograft is a viable alternative to traditional methods of repair.

The challenges of resident training in complex hepatic, pancreatic, and biliary procedures.

Operations on the liver and pancreas have fallen within the domain of the general surgeon and have been part of general surgery training. The more complex procedures involving these organs are limited in number in most general surgery residencies and do not afford an opportunity for vast experience. Moreover, fellowship programs in hepato-bilio-pancreatic (HPB) surgery and the development of laparoscopic techniques may have further limited the familiarity of general surgery residents with these operations. To determine the experience accrued by finishing general surgery residents, we accessed, through the Residency Review Committee of the Accreditation Council for Graduate Medical Education, the Resident Case Log System used by general surgery residents throughout their training to document operative cases. The number of operations on the gallbladder, bile ducts, pancreas, and liver was examined over the past 16 years (there were missing data for 3 years). Reference years 1995 and 2005 were compared to detect trends. Experience with laparoscopic cholecystectomy has steadily increased and averaged more than 100 cases in 2006. Experience in liver resection, distal pancreatectomy, and partial (Whipple) pancreatectomy has statistically improved from 1995 to 2005, but the numbers of cases are low, generally less than five per finishing resident. Experience in open common bile duct and choledocho-enteric anastomoses has statistically declined from 1995 to 2005, averaging less than four cases per finishing resident. The mode (most frequently performed number) for liver and pancreas resections was either 0 or 1. It is doubtful this experience in HPB surgery engenders confidence in many finishing residents. Attention should be focused on augmenting training in HPB surgery for general surgery residents perhaps through a combination of programmatic initiatives, ex vivo experiences, and minifellowships. Institutional initiatives might consist of defined HPB services with appropriate expertise, infrastructure, process, and outcome measures in which a resident-oriented, competency-based curriculum could be developed.

Common bile duct MALT lymphoma: case report and review of the literature.

We report a rare case of common bile duct mucosa-associated lymphoid tissue (MALT) lymphoma treated with pancreatico-duodenectomy with a partial gastrectomy. MALT lymphoma involving the biliary tree is extremely rare. Diagnosis is difficult and treatment options are controversial. Even though Helicobacter pylori treatment is effective in the early stages of the disease, surgery is still helpful especially when obstruction, perforation, or bleeding is present.

Therapeutic options for occult breast cancer: a survey of the American Society of Breast Surgeons and review of the literature.

BACKGROUND: Axillary presentation of occult breast cancer (OBC) is uncommon, and continues to be a diagnostic and therapeutic challenge to physicians. After our recent experience with a similar patient, a survey of the American Society of Breast Surgeons (ASBS) was conducted to assess the Society's member's opinions on treatment. METHODS: A survey was sent by mail to 1837 members of the ASBS. The survey consisted of a brief case presentation after which the surgeon's preference for management of the breast was sought. The choices included "mastectomy," "whole breast radiation" or "other." RESULTS: A total of 776 (42%) responses were received. The majority of respondents, 338 or 43%, preferred "mastectomy," while 285 or 37% opted for "whole breast radiation." Twenty percent of respondents (153 responses) chose "other," of which 46 physicians (6% of total) indicated they would observe the patient. CONCLUSIONS: Although recent literature supports the use of whole breast radiation, these results demonstrate that a small majority of physicians still prefer mastectomy. The appropriate treatment of the breast after an axillary presentation of OBC continues to be a controversial issue.