Intraoperative Near-infrared Spectroscopy Correlates with Skin Flap Necrosis: A Prospective Cohort Study.

BACKGROUND: Skin flap necrosis (SFN) is a morbid complication that is disfiguring, leads to acute and chronic wound issues, often requires further surgery, and can delay adjuvant chemotherapy. Although most surgeons rely on the clinical examination, near-infrared (NIR) spectroscopy can extrapolate tissue oxygenation and may serve as an important tool to assess flap perfusion intraoperatively. This cohort study was undertaken to evaluate the capacity of NIR spectroscopy to detect clinically relevant differences in tissue perfusion intraoperatively. METHODS: Patients undergoing oncologic resection of breast cancer, sarcomas, and cutaneous tumors requiring flap reconstruction (local, regional, or free) between January 2018 and January 2019 were analyzed in this study. Clinicians were blinded to device tissue oxygen saturation (StO2) measurements taken intraoperatively after closure and at follow-up appointments in the first 30 days. Measurements were categorized as (1) control areas not affected by the procedure, (2) areas at risk, and (3) areas of necrosis. These areas were retrospectively demarcated by 2 blinded assessors on follow-up images and transposed onto anatomically correlated intraoperative StO2 measurements. Mean StO2 values were compared using a single-sample t test and analysis of variance (ANOVA) to determine differences in oxygenation. RESULTS: Forty-two patients were enrolled, and 51 images were included in the analysis. Oncologic procedures were predominantly breast (22), postextirpative melanoma (13), and sarcoma (3) reconstructions. Flap reconstruction involved 30 regional skin flaps, 3 pedicled flaps, and 3 free flaps. Nine patients (20.9%) and 11 surgical sites developed SFN. Mean intraoperative StO2 measurements for control areas, areas at risk, and areas of SFN were 74.9%, 71.1%, and 58.3%, respectively. Relative to control areas, mean intraoperative StO2 measurements were lower by 17.5% (P = 0.01) in ultimate areas of SFN and in areas at risk by 5.8% (P = 0.003). Relative to areas at risk, mean StO2 measurements from areas of ultimate SFN were lower by 8.3% (P = 0.04). CONCLUSION: These preliminary data suggest that measuring skin flap tissue oxygenation intraoperatively, with NIR spectroscopy, can differentiate objective variations in perfusion that are associated with clinical outcomes.

Burn injury and multiple sclerosis: A retrospective case-control study.

OBJECTIVES: The purpose of this study was to determine whether having a previous diagnosis of multiple sclerosis (MS) changed acute care needs in burn-injured patients. METHODS: This was a retrospective case-control study that included adult (aged ≥18years) patients with an acute burn injury. Control patients were matched with eleven patients with a history of MS at a 4:1 ratio. Outcomes included fluid resuscitation volumes, temperature, heart rate, mean arterial pressure, in-hospital complications, and hospital length of stay (LOS). RESULTS: There were fifty-five patients included and of those, eleven had a documented history of MS. Fluid resuscitation volumes, temperature, heart rate, and mean arterial pressure were similar between groups during the resuscitation period (p>0.05). LOS was similar between both groups (12, IQR: 2-17 vs. median 16, IQR: 12-21; p=0.090). However, when normalized to % TBSA burn, patients with MS had a significantly higher median LOS/% TBSA burned (1.2, IQR: 0.7-2.0 vs. 2.1, IQR: 1.1-7.1; p=0.031). CONCLUSIONS: Patients with concurrent burn injuries and MS have a significantly longer LOS/% TBSA burn suggesting that more time is required to heal their wounds. Surprisingly, there were no other significant differences in the after the burn acute phase between these two cohorts.

Sepsis criteria versus clinical diagnosis of sepsis in burn patients: A validation of current sepsis scores.

BACKGROUND: Sepsis remains an ongoing diagnostic challenge in burns, especially with the signs of sepsis being ubiquitously present during the acute period after injury. We aimed to determine the predictive validity of 3 current sepsis criteria in the burn population. The criteria of interest included the American Burn Association sepsis criteria, Mann-Salinas et al predictors of sepsis, and the Sepsis-3 consensus definition. METHODS: Adult patients with an acute burn injury who were diagnosed prospectively with sepsis by the burn team using specific clinical markers were included in this cohort study. Sepsis predictors were collected from patient charts and used to calculate the results of the 3 criteria, then subsequently compared to the clinical diagnosis. RESULTS: Of the 418 patients in the study, which took place from 2000 until 2016, 88 (21%) were septic; the mean age was 50 ± 18 years with a mean percent total body surface area burn of 30% ± 17%. Inhalation injury was present in 50%, median length of stay was 49 (29-71) days, and mortality was 19%. The American Burn Association, Mann-Salinas, and Sepsis-3 criteria were positive in 59%, 28%, and 85% respectively, P < .05. The most reliable predictors included increased oxygen requirements, altered mental status, hypothermia, hyperthermia, tachycardia, and hypotension. CONCLUSION: The Sepsis-3 criteria was the most predictive, followed by the American Burn Association and Mann-Salinas criteria. However, no criterion alone had the accuracy to be a diagnostic standard within this burn population. We recommend sepsis is clinically assessed, diagnosed, and documented prospectively by the burn team, and not by the application of retrospective criteria.