Retrospective Review of Outcomes Related to Early Therapy Intervention Following Application of Cultured Epidermal Autografts in Severely Burned Patients.

Cultured epidermal autografts (CEA) have since become more prevalent in the treatment of burn-injured patients with limited available donor sites for adequate wound closure, resulting in decreased mortality rates and an increased number of these patients requiring burn therapy services to achieve optimal functional outcomes at discharge. However, the use and postoperative management of CEA continues to be controversial due in large to the physiological fragility and expense of CEA, leading to variable postoperative treatment practices across burn centers. As such, minimal research is available regarding patient outcomes following CEA application, specifically related to burn therapy intervention. Thus, a retrospective chart review was conducted on a series of 10 patients, 18 years of age or older, admitted to a single, American Burn Association (ABA) verified burn center, between April 2015 and April 2023, who required CEA, and received pre- and postoperative treatment by burn therapists in accordance with center-specific burn rehabilitation guidelines. The resulting patient outcomes, in response to early implementation of therapy interventions post-CEA surgery, demonstrated optimal functional status for patients upon discharge, and positive long-term implications.

Inhalation Injury, Respiratory Failure, and Ventilator Support in Acute Burn Care.

Sustaining an inhalation injury increases the risk of severe complications and mortality. Current evidential support to guide treatment of the injury or subsequent complications is lacking, as studies either exclude inhalation injury or design limit inferences that can be made. Conventional ventilator modes are most commonly used, but there is no consensus on optimal strategies. Settings should be customized to patient tolerance and response. Data for pharmacotherapy adjunctive treatments are limited.

Pharmacokinetic Analysis of Intravenous Push Cefepime in Burn Patients with Augmented Renal Clearance.

Patients with augmented renal clearance (ARC) are a subset of critically ill patients including burn patients that exhibit increased renal elimination of medications beyond that of similarly injured patients. Currently approved maximum regimens of medications primarily eliminated by the kidney, such as cefepime (>90% unchanged in the urine), may be inadequate (eg, compromising the bactericidal activity of cefepime) in patients with ARC. Due to recent resource limitations, centers have changed infusion practices of commonly prescribed medications to intravenous push (IVP), potentially exacerbating the problem of maintaining bactericidal cefepime concentrations. The hypothesis of the study was patients with ARC are not currently achieving adequate target attainment, when receiving cefepime 2 g every 8 h IVP. Eight blood samples were collected from each patient, and concentrations measured via LC-MS/MS. WinNonlin (version 8.3) was used to estimate the pharmacokinetic parameters of cefepime and simulate plasma concentrations of cefepime in each of the ten subjects. Simulations of cefepime plasma concentrations produced by a 2 g dose given every 8 h and a 1 g dose given every 4 h were performed and the time above a MIC of 4 mg/L, 8 mg/L, and 16 mg/L compared. The 2 g every 8 h regimen remained above the breakpoints for 92%, 85%, and 71% of the dosing interval, respectively. The 1 g every 4 h regimen remained above the same breakpoints at a frequency of 100%, 99%, and 92% of the dosing interval. Giving cefepime 1 g every 4 h is a simple approach to increase the likelihood of maintaining the optimal bactericidal activity of cefepime in patients with ARC.

A Regional Analysis of Potentially Preventable Injuries Sustained From Burning Garbage and Yard Waste.

Due to high prevalence in the south, understanding the injury pattern, healthcare burden, and cost of burn injuries associated with burning yard and trash debris are important for effective prevention. This 5-year retrospective, single-center study included patients sustaining an open flame burn injury due to burning brush or trash. Based on primary residence of the 136 patients, 56% had access to free municipal waste disposal, 25% could have had access with additional payment, and 18% did not have access. The median (Q1 and Q3) age and total body surface area (TBSA) burned was 50 (32, 66.5) years and 5% (2.5, 12), respectively, with 36% having some portion of full-thickness injury. One-third had some form of substance use. There were 151 total operations with a median of 1 (0, 1.5) per patient. There were 1,620 hospital days utilized (~6.6% of available bed-days per study period). Twenty-five percent were discharged with a paired functional status worse than pre-injury. Patients with some degree of pre-injury function limitations had a 3-fold higher length of stay (10 vs 3 days; P = .023). Patients with lower pre-injury functionality had almost four times higher mortality (23.7% vs 6.3%; P = .085). There were 9 (6.7%) deaths with an average (±SD) of 74.3 ± 13.1 years of age, median of 33% (31, 43) TBSA, and median full-thickness TBSA of 32% (21, 44). Total hospital charges exceeded $32.6 million with a median of $32,952.26 ($8,790.48, $103,113.95) per patient. Focusing future outreach efforts on education and resource availability may prevent future waste-burning injuries.

Burn Injury Cutaneous Functional Units: Allocating Occupational Therapy Resources and Influencing Practice.

Burn injury severity is currently determined by estimating the total body surface area (TBSA) burned, but this method fails to capture the severity of subsequent functional consequences. Alternatively, cutaneous functional units (CFUs)--skin segments that accommodate for movement and commonly become contracted--can be used to more accurately estimate burn severity based on functional consequences. Bilateral hands account for 81.3% of the body's CFUs, though only account for 5% of TBSA. However, hand burn survivors can have worse physical outcomes (ie, contractures, deformities) after burn injury, leading to subsequent loss of function, global occupational participation deficits, and poor psychosocial outcomes. This study, conducted at a verified American Burn Association burn center, explores how CFU involvement among adult burn survivors with uni and bilateral hand and upper extremity burns influenced occupational therapy practice in regards to time spent completing scar and soft tissue elongation techniques from the elbow to the digit tips per patient. The data showed, on average, burn occupational therapists require 0.8 minutes per CFU for an average total of 38.7 (SD = 29.5) minutes each session to complete scar and soft tissue elongation techniques to the upper extremities. The results of this study can be used to educate burn centers on the clinical utility of CFUs, burn occupational therapists regarding best-practice in terms of utilization of therapist time and resources, as well as support the justification for increasing occupational therapy services for patients with upper extremity and hand burns, and increasing staffing to meet patient need.

Efficacy of a Novel LAM Femoral Cutaneous Block Technique for Acute Donor Site Pain.

Patients with severe burn injuries often require split-thickness skin grafting to expedite wound healing with the thigh being a common donor site. Uncontrolled pain is associated with increased opioid consumption, longer lengths of stay, and delay in functional recovery. Peripheral nerve blocks are increasing in popularity although supportive literature is limited, and techniques vary. The purpose of this case series is to assess the safety, feasibility, and clinical efficacy of a recently demonstrated novel continuous LAM (lateral, anterior, medial) femoral cutaneous block technique in a larger cohort. The study was a dual IRB approved, observational case series from a single verified burn center. The electronic health record was retrospectively reviewed for patients admitted between June 2018 and May 2021 who had the continuous LAM block performed for donor site pain by the acute pain service team. Demographics were reported with descriptive statistics and morphine milligram equivalents (MME) were analyzed via Friedman analysis of variance. Forty-seven patients had a total of 53 blocks placed, where 2 patients received the LAM block on two separate occasions and 4 patients had bilateral LAM blocks placed. Most were African-American males, but mechanism of injury varied. Over half had a neurologic (17%) or psychiatric history (34%) outside of substance use. Almost three-quarters had a history of substance use with 17% being opioids, and a quarter had a history of polysubstance use. Median day from admission to LAM was 7 (2.5, 11.5) with a median duration of 4 (3, 5) days. Temperature and pressure sensation were reduced at the donor site. Quadricep strength remained intact, and median day until first ambulation after LAM placement was 2 (1, 3) days. Pain was adequately controlled, and there were no significant adverse events associated with the block. There was a significant reduction in MME after block placement (p < .001). Continuous peripheral nerve blocks offer an advantageous means of analgesia, while reducing potential adverse events associated with opioids or multimodal regimens. The novel LAM technique reduced sensation and pain without inhibiting early ambulation, and patients were able to fully participate in their rehabilitation.

A Retrospective Chart Review to Determine Hypophosphatemia Incidence and Phosphorus Supplementation Requirements in Patients With Severe Thermal Cutaneous Injuries Receiving High-Volume Hemofiltration.

Patients with severe thermal injuries have increased metabolic demands necessitating frequent phosphate supplementation. Patients with acute renal failure may have less requirements, due to reduced elimination. However, patients being supported with renal replacement therapy have varying degree of requirements. Little published evidence depicts the incidence of hypophosphatemia and repletion requirements in patients with severe thermal injuries treated with high-volume hemofiltration (HVHF) and a high-flux membrane. The objective of this retrospective chart review was to determine the incidence of hypophosphatemia and characterize repletion requirements and response in this population. Enrolled patients had at least 20% TBSA thermal injuries and required continuous hemofiltration with prefilter replacement fluid doses ≥35 mL/kg IBW/hr. A randomly selected cohort without acute kidney injury (AKI) and matched based on age and extent of TBSA was used to compare phosphorus requirements over an initial 14-day period. Demographics, diet, and variables affecting phosphorus concentrations were collected. Sixteen patients were included in the retrospective HVHF group and 16 patients in a case-control cohort to better depict the impact of HVHF. The average age was 60.2 ± 15.1 years and median TBSA was 30% (23.4, 56.3) in the HVHF group, compared to 53.3 ± 16.4 years (P = .22) and TBSA 29% (26.4, 33.9; P = .73). All patients in the HVHF group were started on HVHF with a 1.6 m2 polyethersulfone membrane for AKI. As expected, the HVHF group exhibited statistically higher than normal baseline potassium and phosphorous laboratory values. The HVHF group experienced more days with hypophosphatemia (49.6 ± 12.4% vs 29.3 ± 16.3%, P = .012), despite 0.75 mmol/kg/day phosphorous supplementation (compared to 0.66 mmol/kg/day for the control group, P = .45). Patients with longer durations of HVHF therapy experienced increasing risk of hypophosphatemia, reaching 100% by the end of the study period. This study demonstrates severe thermally injured patients receiving HVHF for AKI are at increased risk for hypophosphatemia, and require high phosphate supplementation.

A Retrospective, Observational Study of Catheter-Associated Urinary Tract Infection Events Post-Implementation of a Novel Urinary Catheter System with Active Drain Line Clearance and Automated Intra-Abdominal Pressure Monitoring.

Objective: A quality improvement study to assess catheter-associated urinary tract infection (CAUTI) rate post-implementation of a bladder catheter with integrated active drain line urine clearance and automated intra-abdominal pressure monitoring in a burn intensive care unit (ICU). DESIGN: Eight-year retrospective before and after study (2015−2022). Setting: A single American Burn Association-verified Burn Center with 14 inpatient beds. Patients: Patients meeting criteria for admission to a Burn Center. Methods: Retrospective cohort study following the implementation of a novel urine output monitoring system with integrated drain line and urine clearance. Data from a 48-month (from January 2015−December 2018) historical control (period 1) were compared to data from a 28-month (from January 2020 to April 2022) post-implementation period (period 2). Pre- and post-implementation CAUTI event incidences were compared. Patients were transferred from outside hospitals with gravity bladder. A distinction in the chart between catheter types was impossible. Charts were reviewed to characterize patients with CAUTI events. Results: A total of 42 CAUTIs in 2243 patients were identified using the National Health and Safety Network (NHSN) definition during the analyzed period. There were 40 CAUTI events in period 1 and two CAUTIs in period 2. The incidence of CAUTI events pre-implementation was 0.030 (mean of 10 CAUTI events per year) compared to 0.002 (mean of 1 CAUTI event per year) post-implementation of an automatic drain line clearing UO monitoring system showing a significant reduction in CAUTI events (p < 0.01, risk ratio novel vs. gravity bladder catheter 0.071, 95% confidence interval: 0.017−0.294). Conclusions: CAUTIs were reduced in the period following the implementation of a novel urinary catheter system with an integrated active drain line and urine clearance in burn patients.

A Randomized Trial of Enteral Glutamine for Treatment of Burn Injuries.

BACKGROUND: Glutamine is thought to have beneficial effects on the metabolic and stress response to severe injury. Clinical trials involving patients with burns and other critically ill patients have shown conflicting results regarding the benefits and risks of glutamine supplementation. METHODS: In a double-blind, randomized, placebo-controlled trial, we assigned patients with deep second- or third-degree burns (affecting ≥10% to ≥20% of total body-surface area, depending on age) within 72 hours after hospital admission to receive 0.5 g per kilogram of body weight per day of enterally delivered glutamine or placebo. Trial agents were given every 4 hours through a feeding tube or three or four times a day by mouth until 7 days after the last skin grafting procedure, discharge from the acute care unit, or 3 months after admission, whichever came first. The primary outcome was the time to discharge alive from the hospital, with data censored at 90 days. We calculated subdistribution hazard ratios for discharge alive, which took into account death as a competing risk. RESULTS: A total of 1209 patients with severe burns (mean burn size, 33% of total body-surface area) underwent randomization, and 1200 were included in the analysis (596 patients in the glutamine group and 604 in the placebo group). The median time to discharge alive from the hospital was 40 days (interquartile range, 24 to 87) in the glutamine group and 38 days (interquartile range, 22 to 75) in the placebo group (subdistribution hazard ratio for discharge alive, 0.91; 95% confidence interval [CI], 0.80 to 1.04; P = 0.17). Mortality at 6 months was 17.2% in the glutamine group and 16.2% in the placebo group (hazard ratio for death, 1.06; 95% CI, 0.80 to 1.41). No substantial between-group differences in serious adverse events were observed. CONCLUSIONS: In patients with severe burns, supplemental glutamine did not reduce the time to discharge alive from the hospital. (Funded by the U.S. Department of Defense and the Canadian Institutes of Health Research; RE-ENERGIZE ClinicalTrials.gov number, NCT00985205.).

Analysis of Ceftazidime/Avibactam Use for Treating Carbapenem-Resistant Infections in Critically Ill Patients With Thermal or Inhalation Injuries.

Rising antimicrobial resistance is a pressing public health concern. An increase in carbapenem-resistant organisms has led to increased use of novel antibiotics, such as ceftazidime/avibactam (CZ/AV). However, recent studies have shown increasing treatment failures and resistance rates associated with ceftazidime/avibactam use. The efficacy of CZ/AV has not been studied in patients with thermal or inhalation injuries, where pharmacokinetic derangements are common and patients are often subject to longer lengths of stay and several antimicrobial courses that may lead to higher resistance rates. The objective of this study was to evaluate the outcomes of patients with thermal and inhalation injuries including clinical success, the frequency of adverse effects, and emergence of resistance. In the 17 courses of CZ/AV evaluated, clinical success occurred in 71% (12/17) of courses. Enterobacter cloacae was the most commonly treated pathogen. Resistance developed in 18% (3/17) of courses, but follow-up sensitivities were not evaluable for every case. Although lower than desired, clinical success rates in this sample were similar to other reported populations treated with CZ/AV. However, the emergence of resistance occurred more frequently and was likely underreported in this sample. Although limited by its small sample size, this study emphasizes the concern of growing antimicrobial resistance among even novel antibiotics. Resistance can develop during the initial course, stressing the importance of infection prevention and antimicrobial stewardship. Furthermore, attention and resources should be given to proper pharmacokinetic analysis of medications given in severely ill, hypermetabolic populations.

Approaching trauma analgesia using prolonged and novel continuous peripheral nerve blocks - A case report.

BACKGROUND: A supraclavicular brachial plexus nerve block provides analgesia for the shoulder, arm, and hand; however, the maximum safe duration for a continuous infusion remains controversial. A novel continuous peripheral nerve block (CPNB) technique combining the Lateral, Intermediate, and Medial femoral cutaneous nerves (termed the 'LIM' block) to provide analgesia to the lateral, anterior, and medial cutaneous areas of the thigh while preserving quadriceps strength will also be described in detail here. CASE: We present a complex case in which simultaneous utilization of an unilateral supraclavicular CPNB (5 weeks) and bilateral LIM CPNB (5 days) are successfully performed to provide analgesia for a traumatic degloving injury resulting in multiple surgeries. CONCLUSIONS: The analgesic plan in this case study eliminated previous episodes of opioid-induced delirium, facilitated participation in recovery, and removed concerns for respiratory depression and chronic opioid use in a patient at particular risk for both issues.

Chemical Burns from Secondary Exposure to Paraquat Through Mishandling Urine of a Patient with Toxic Exposure.

Paraquat is used throughout the world as an herbicide due to its efficacy and relative safety with proper handling. Accidents and misuse still occur, leading to countries banning its use or employing extra safeguards and special handling certifications. Severe toxicity is primarily associated with ingestion, but skin exposure leads to corrosive injury to the dermis, occurs rapidly, and progresses for up to 24 h. Prolonged skin exposure or the presence of open wounds can lead to systemic absorption. This is the first known report of burn injury and treatment due to secondary exposure to the urine of a patient who had accidental ingestion of paraquat. A 50-year-old Caucasian male presented to the emergency room after accidental ingestion of eight ounces of Gramoxone extra (Paraquat 30% concentration). During the initial care of the patient, the bedside registered nurse was placing an indwelling foley catheter when her forearms were contaminated with urine while wearing basic personal protective equipment (gloves). The registered nurse noticed bullae to bilateral forearms a short time after exposure to the urine. She presented to the burn center for evaluation and treatment. Poison Control was contacted but was unable to offer advise due to a lack of supportive literature. The risk and effects of primary exposure to Paraquat is described throughout the literature and documented in Material Safety Data Sheets (MSDS), but data regarding risk and treatment of secondary exposure is lacking. This case will aid outreach efforts for the prevention and treatment of burn injuries from secondary exposure to paraquat.

A non-inferiority study comparing efficacy of preoperative prophylactic antibiotics for preventing infectious complications in patients with less severe burns.

While international burn injury guidelines discourage prophylactic antibiotics on admission, current surgery guidelines focusing on antimicrobial prophylaxis place thermal injury under a general plastics procedure umbrella, and require significant evidential extrapolation. The purpose of this study was to determine if withholding systemic antibiotics in patients with <20% total body surface area (TBSA) burns without invasive wound infections and undergo wound excision is non-inferior to patients that receive preoperative antibiotics. Success was defined as lack of graft loss, bacteremia, or surgical site infection. One-thousand and eighty-three patients were screened and 100 patients undergoing 133 operations remained after exclusions. Seventy-four percent were male. Median age and %TBSA was 41 years (30, 55) and 5 (1.5, 8.3), respectively. We found no differences in demographics between patients that did and did not receive preoperative antibiotics. The success rates were 81.7% and 84.3%, respectively. There was one clinically significant bacteremia in each group. Withholding preoperative antibiotics was non-inferior with a percent difference of 2.6 (95% CI; -10.4, 15.6). Patients that did not receive antibiotics were no more likely to incur infection-related complications. In patients with <20% TBSA burns and without active wound infections, withholding preoperative systemic antibiotics will preserve unneeded antimicrobial exposure without increasing risk of infection-related complications.

Esterified Hyaluronic Acid Matrix in Lower Extremity Reconstruction With Exposed Tendon and Bone: A Retrospective Review.

Lower extremity wounds with exposed bone and tendon often need coverage to allow the underlying tissue to regenerate prior to skin graft. The surgeon is limited in his or her choices to augment tissue regeneration in these types of complicated cases; for instance, autologous skin should not be placed on exposed bone or tendon and is at risk for contracture when placed over the joints. Therefore, novel technologies are necessary to provide a scaffolding for tissue to regenerate and allow for a successful graft. One such technology is an esterified hyaluronic acid matrix (eHAM), which can provide a proper scaffold for endothelial cell migration and aid in angiogenesis. The eHAM is made of two layers: a layer of hyaluronic acid covered with a silicone layer. In this retrospective chart review, we describe our usage of eHAM to provide scaffolding for tissue regeneration prior to grafting in 15 cases of complicated lower extremity wounds with exposed bone and tendon. The average patient age was 45.8 years, and all patients had multiple medical comorbidities, such as poorly controlled diabetes mellitus, hypertension, and nicotine addiction. Patient wound types were diverse, including traumatic wounds, chronic diabetic foot ulcers, and thermal or electric burns. Thirteen of the 15 cases were treated successfully with eHAM. In these cases, definitive coverage with split-thickness skin grafting was effective and limb salvage was successful. In the 13 successful cases, the mean time to split-thickness skin graft was 22.9 ± 7.0 days. All patients continue to do well at follow-up (ranging from 6 to 48 weeks), with minimal complications reported. Given the success rate with eHAM in this challenging population, we conclude that eHAM can be a treatment option for similar cases.

Simplified Approach to Incorporating Glycemic Response Within a Continuous Insulin Infusion Algorithm to Improve the Incidence of Hypoglycemia in a Single Burn Center.

Attaining adequate glycemic control in burn patients has been shown to reduce infection-related mortality. Previous internal evaluation of continuous insulin infusion (CII) use revealed a hypoglycemia rate of 0.6% and an average time within goal glycemic range (70-149 mg/dl) of 13.8 h/day. A new algorithm, designed to adjust dosage based on glycemic response, underwent six iterations over 2 years before the final version was implemented. The purpose of this retrospective study was to assess the post-implementation performance of the newly developed CII algorithm. The current study was powered to detect a 50% reduction in hypoglycemic events, as compared to a pre-implementation historical control. The cohort was 62% male with a mean age of 54.5 ± 17.4. Sixty-five percent had thermal injuries with a median 23.5 (11-45) %TBSA. There were no differences in demographics between groups. Among the 20 records reviewed, 5239 point-of-care glucose values were assessed. Post-implementation, hypoglycemia rates were significantly lower (0.6% vs 0.2%; P < .001). There was no difference in median blood glucose between groups (149.9 vs 146.5 mg/dl; P = .56). Time spent within goal glycemic range was not significantly different (13.8 vs 14.7 h/day; P = 0.23). There were no differences in infection, length of stay, or survival. The consolidation, education, and implementation of a single, dynamic CII algorithm reduced the incidence of hypoglycemia. The authors expect that education and diligence with follow-up glucose monitoring will further improve time within goal glycemic range by preventing rebound hyperglycemia.

Heterotopic ossification: a preventable case of gossypiboma in spinal cord injury.

OBJECTIVE: Heterotopic ossification is the formation of ectopic bone in soft tissues. It has three established aetiologies: genetic, traumatic and neurogenic. A gossypiboma is defined as a retained foreign body, such as a mass or sponge, usually after a surgical procedure. In this article, we present a unique, preventable case of a patient admitted for newly developed heterotopic ossification in the gluteus maximus muscle caused by a retained piece of foam from negative pressure wound therapy (NPWT). The heterotopic ossification lesion, together with the retained foreign body, was completely excised and reconstructed using a posterior thigh fasciocutaneous advancement flap. This is the first reported case of heterotopic ossification caused by a retained foreign body and may be helpful to better understanding of the aetiology of heterotopic ossification.

The Ethics of Facial Allotransplantation: A Systematic Review.

BACKGROUND: Currently, there are more than 40 cases of facial allotransplantation performed by 13 different groups in 10 countries. Although it has become a potential option to reconstruct and restore the function and appearance of severely facially disfigured individuals, the ethical concerns of facial allotransplantation remain unsolved. We conducted a systematic review to better understand the ethical concerns on facial allotransplantation and the changing trends of the ethical debate over time. METHODS: A systematic review of 3 databases was performed to identify articles related to ethical topics on facial allotransplantation. The inclusion criteria were peer-reviewed articles written since 1995 on the topics of ethics and facial allotransplantation in English, French, and Chinese languages. The ethical concerns extracted from the included articles were categorized into 4 core principles of ethics: autonomy, beneficence, nonmaleficence, and justice. The different themes under these 4 principles were extracted and subgrouped. The positions of the included articles were collected. Joinpoint regression was applied to compare the frequency of themes and positions by publication year. We presented the main topics on ethical concerns and the changing trends in ethical themes and principles of facial allotransplantation. RESULTS: There were 889 articles identified initially. After excluding 265 duplicated articles, 624 articles were included for title/abstract review process, and 148 articles were included in final data analysis. The publication year was from 2002 to 2018 with 136 articles in English, 11 in French, and 1 in Chinese. The most addressed principle was nonmaleficence (117/148, 79.1%), followed by beneficence (116/148, 78.4%), justice (103/148, 69.6%), and autonomy (86/148, 58.1%). The themes on immunosuppression/rejection, quality of life, and identity were the top 3 addressed ethical concerns. Twelve of 13 most addressed ethical themes demonstrated a decreasing trend after 2004. The themes of identity under beneficence showed a significant decrease after 2004. Ethical concerns on the cost/financial topic were the only one showing consistently increase trends from 2002 to 2018. There was a significant increase of the papers in favor of facial allotransplantation procedure comparing to those were against or neutral before and after 2008. CONCLUSIONS: More and more articles support facial allotransplantation as a feasible option to reconstruct and restore the function and appearance of severely facially disfigured individuals. The requirement of life-long immunosuppression therapy, quality of life, and identity center the ethical debates. Supported by favorable short-term results, 12 of 13 most addressed ethical concerns have trended down. The theme of cost/financial topic becomes more frequently addressed in recent years.

Analysis of factors impacting length of stay in thermal and inhalation injury.

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.

Optimization of an empiric vancomycin dosing algorithm for improved target concentration attainment in patients with thermal injury.

OBJECTIVE: Vancomycin empirical dosing studies in thermally injured patients have netted low successful target attainment and most excluded renal dysfunction, limiting applicability. In a previous study, the authors performed a retrospective analysis of 124 patients' measured pharmacokinetic parameters to calculate optimal dose and interval for intermittent infusion regimens and find predictors of clearance and total daily dose. The objective of this study was to improve the accuracy of attaining goal therapeutic targets with initial vancomycin regimens in patients with thermal injury through retrospective modeling. METHODS: In this phase 2 study, variables collected and calculated regimens in phase 1 were utilized to try and create an improved empiric vancomycin dosing algorithm in patients with thermal injury. Logistic regression was utilized to determine best predictors of dosing vancomycin every 6 and 8h. The strongest models were built as individual algorithms and tested for accuracy of target attainment. Each algorithm produced a regimen for each patient that was then tested utilizing each patient's actual measured pharmacokinetic parameters. RESULTS: Univariable logistic regression of 41 variables identified 27 and 23 to be predictive of dosing every 8 or 6h, respectively. The most predictive multivariable model for dosing every 8h consisted of creatinine clearance (CrCl)≥80ml/min, Acute Kidney Injury Network classification <1, and total body surface area burned≥10 percent. For dosing every 6h, CrCl≥80ml/min, age≤40years old, days since injury≤6, and serum creatinine (SCr)≤0.8 were most predictive. Based on the top 5 multivariable models for each dosing interval, 7 algorithms were built to produce recommended regimens. The highest performing algorithm resulted in trough concentrations of <10mg/L (23%), 10-20mg/L (65%), 15-20mg/L (26%), and >20mg/L (11%); area under the concentration curve (AUC)>400mghr/L (83%); and AUC >400mghr/L without having a trough >20mg/L (72%). CONCLUSIONS: The algorithm that resulted in the highest target attainment without overdosing recommended 15mg/kg dosed every 24h for CrCl≥30, every 12h for CrCl 31-79, every 8h for patients with CrCl≥80ml/min, and every 6h only if the patient with a CrCl≥80ml/min is also≤40 years old and has a SCr≤0.8. Caution is warranted for groups underrepresented in this study, such as those with very low CrCl, a low BMI, or receiving renal replacement therapy. This algorithm should be validated in other centers for patients with thermal injuries.