Neonatal abdominal support to address CPAP belly: Two cases report and literature review.

Gaseous distension of the abdomen from the use of continuous positive airway pressure (CPAP) in the preterm population is of increasing concern for its unintended consequences. Methods to treat and prevent CPAP belly deserve further investigation. An intervention to provide abdominal support to address CPAP belly is presented in these case studies.

The impact of antithrombin (H) concentrate infusions on pulmonary function in the acute phase of thermal injury.

BACKGROUND: Pulmonary complications occur frequently after thermal injury. OBJECTIVE: This open pilot study was performed as an initial assessment of the safety and efficacy of antithrombin H [AT(H)] concentrate in ameliorating the respiratory morbidity during the acute phase of injury. MATERIALS & METHODS: Thirty-two patients were eligible for the study; of these, nine opted for treatment with q8 h [AT(H)]. The mean daily peak values of pulmonary parameters such as PaO(2)/FiO(2) ratio, and RAW scores were computed for days 1-8. RESULTS: Control and AT(H)-treated patients were similar in age, % total burn surface area, inhalation injury, and mortality. Forty-three percent of the burn controls, and 23% of the AT(H)-treated patients had pneumonia, p<0.01. The median hospital stay for both groups was 42 days; however, the median number of ventilatory days for burn controls was 23 days vs 10 days for AT(H)-treated patients. The AT(H)-treated patients had admission AT plasma levels of 46+/-14% vs 49+/-18% in burn controls, (normal=100+/-20%). The AT plasma level was maintained at 120+/-24% in the AT(H)-treated patients vs 50+/-15% in the burn control group for the first four days following the acute injury, p<0.002. Thrombate(R) concentrate infusions were, in general, well tolerated by patients. The median dose was 97 u/kg/dose q8 h. Compared to burn controls, AT(H)-treated patients had higher PaO(2)/FiO(2) ratios between days 4-6, p<0.01. In comparing these two groups with and without inhalation, airway resistance (assessed by the RAW score) was significantly lower in the AT(H)-treated group with inhalation compared to the burn controls with inhalation on days 2 and 6, p<0.02. CONCLUSIONS: With a trend toward decreased airway resistance during AT(H) concentrate infusions, and increased oxygenation, AT(H)-treated patients had significantly fewer episodes of pneumonia compared to controls. AT(H) concentrates may modify the impact of thrombin on acute inflammation, and improve respiratory function in the acute phase of thermal injury.

hsp70, hsp32, and grp78 are increased in thermally injured skin with and without antithrombin(human) concentrate infusion.

An acquired deficiency of antithrombin (AT), an anti-inflammatory protein, develops in patients with thermal injuries. Skin thermotolerance is regulated by heat shock protein (hsp) genes. hsp70, hsp32, hsp27, and glucose-regulated protein78 (grp78) were studied in burned and unburned human skin to determine whether correction of the AT deficiency modulated the intensity of expression of these proteins. Fifty-four human skin samples were prepared by Western blot analysis: 11 unburned and 22 burned control skin samples and 7 unburned and 14 burned skin samples from patients treated with AT(Human), or AT(H). The intensity of hsp32 expression in burned AT(H)-treated skin (P < .001) and in burned control skin (P < .01) was significantly increased compared with unburned control skin. The intensity of expression of hsp70 was statistically significant in burned AT(H)-treated skin compared with unburned control skin (P < .02), as was that of grp78 (P < .01). Thermally injured skin with or without AT(H) treatment had an increased expression of hsp70, hsp32, and grp78 compared with unburned control skin.

Outcome for older burn patients.

BACKGROUND: Physicians will be increasingly responsible for an aging society whose members demonstrate a notable striving for independence. HYPOTHESIS: With standard treatment of burns, older patients will have a survival rate of more than 70%, with at least 60% of patients becoming fully functional 6 months after hospital discharge. METHODS: A 7-year retrospective medical review of burn unit patients was performed, and 221 ( 11%) of 1957 patients who were at least 59 years old were identified. RESULTS: Of 97 women (44%) and 124 men (56%), 64 (29%) had an associated smoke inhalation injury; 146 (66%), flame injury; and 44 (20%), scald injury. The bedroom and/or living room were the most common areas of injury (90 [41%]), followed by outdoors and the workplace (62 [28%]), the kitchen (40 [18%]), the bathroom ( 18 [8%]), and the garage or basement (11 [5%]) (P<.005). One hundred twenty-six injuries (57%) were associated with impaired judgment, mobility, or both. On hospital admission, 74 patients (36%) were intubated, 60 (30%) required intubation postoperatively, and 34 (18%) required both. The survival rate was 159 patients (72%) overall. Findings from an ethanol screening and a drug toxicology screening were positive in 22 and 32 patients (10% and 29%) on admission, respectively. Of the survivors, most were discharged to home with (87 [64%) or without visiting nurse supervision, and at 6 months after discharge, 16 patients (50%) in transitional care facilities were able to return to an independent level of functioning. Of the 59- to 69-year-old age group, 83 (86%) survived compared with 59 (69%) in the 70- to 79-year-old age group and 18 (47%) in the 80 years and older age group. CONCLUSIONS: In contrast to the usual male preponderance in patients with thermal injury, older women, many of whom are widowed, constituted almost half of the older patients admitted to the hospital. Modalities for injury prevention are necessary to provide optimal and safe household environments for a growing population of older persons.

Antithrombin III concentrate in the acute phase of thermal injury.

BACKGROUND: Thermal injury disrupts homeostasis by inducing subclinical disseminated intravascular coagulation, fibrinolysis. and an acquired deficiency of Antithrombin III (ATIII), a natural anticoagulant. As a result, thermally injured patients have a high incidence of hypercoagulability and thrombosis. OBJECTIVE: ATIII (Human) concentrate was given to a thermally injured patient to evaluate safety, and dosage requirements in this setting. DESIGN: The patient was a 40 yr old male with a 68% total burn surface area, right femoral comminuted fracture, and C5-C6 subluxation sustained in a vehicular crash. He received nine infusions of AT III (H) concentrate (100-50 u/kg) within the first four days of injury. RESULT: The ATIII plasma level increased from 45% on admission (normal = 100+/-20%) to 120+/-25% in the next four days. During the 64 day hospitalization, there were 11 grafting procedures with an estimated blood loss (EBL)/procedure: 1140 cc; and EBL/grafted surface area ratio: 0.6 cc cm2. The average time to healing of the meshed autograft was 6.4 days. CONCLUSION: ATIII (H) concentrate can be safely utilized in the acute phase of thermal injury: no excessive bleeding or prolongation of wound healing was documented.

Antithrombin(H) concentrate infusions are safe and effective in patients with thermal injuries.

An antithrombin (AT) deficiency develops in patients with thermal injuries as a result of the subclinical disseminated intravascular coagulation. We conducted a pilot study to assess AT(Human [H]) concentrate infusions for safety and efficacy in thermal injury. Nine patients with burns who received Thrombate (Bayer Corporation, Berkeley, Calif) AT(H) concentrate infusions every 8 hours to raise the plasma level to 175% in the first 72 hours after injury were compared with 9 control patients with burns. Admission AT plasma levels were 45%+/-10% in patients treated with AT(H) versus 49%+/-18% in control patients (normal, 100%+/-20%). Day-2 to day-4 levels were 120%+/-25% in patients treated with AT(H) patients versus 50%+/-12% in the control patients (P < .002). In the group treated with AT(H), the time to wound healing was shorter for all body regions and was significantly shorter for the hand (P < .02). Compared with control patients, patients treated with AT(H) had similar blood loss per grafted area. A trend toward fewer autografting procedures, a shorter meshed autograft healing time, and a decreased hospital stay was found for the patients treated with AT(H). AT(H) concentrate infusions are safe with thermal injury and are a viable option to shorten the length of hospitalization and to promote graft viability and survival. Clinical trials to confirm the benefit of this medication in the acute phase of thermal injury would be worthwhile.

Effect of topical local anesthetic application to skin harvest sites for pain management in burn patients undergoing skin-grafting procedures.

OBJECTIVE: To determine if topical administration of local anesthesia, applied to fresh skin-harvest sites, reduces pain and analgesic requirements after surgery. SUMMARY BACKGROUND DATA: Nonopioid treatments for pain after therapeutic procedures on patients with burns have become popular because of the side effects associated with narcotics. The topical administration of local anesthesia originally offered little advantage because of poor epidermal penetration. METHODS: This study compares 2% lidocaine with 0.5% bupivacaine or saline, topically applied after skin harvest, to determine what effect this may have on pain and narcotic use. Sixty patients with partial- or full-thickness burns to approximately 10% to 15% of their body were randomly divided into three groups: group 1 received normal saline, group 2 had 0.5% bupivacaine, and group 3 had 2% lidocaine sprayed onto areas immediately after skin harvest. Blood samples were subsequently obtained to measure concentrations of the local anesthetic. Hemodynamic variables after surgery, wake-up times, emetic symptoms, pain, and narcotic use were compared. RESULTS: Higher heart rates were noted in the placebo group than in those receiving lidocaine or bupivacaine. No differences were noted in recovery from anesthesia or emetic symptoms. Pain scores were lower and 24-hour narcotic use was less in patients who received lidocaine. Plasma lidocaine levels were greater than bupivacaine at all time points measured. CONCLUSIONS: Topical lidocaine applied to skin-harvest sites produced an analgesic effect that reduced narcotic requirements compared with patients who received bupivacaine or placebo. Local anesthetic solutions aerosolized onto skin-harvest sites did not affect healing or produce toxic blood concentrations.

Use of fibrin sealant in thermal injury.

Fibrin glue is hemostatic in skin grafting and other therapeutic situations. This prospective, open-labeled comparative study involved thermally injured patients: 34 patients received fibrin sealant (FS) and 61 did not, at Loyola University Medical Center, Maywood, Illinois, and Shriners Burn Institute, Cincinnati, Ohio. FS-treated patients were 23.6 +/- 16.8 years old, versus 20.8 +/- 16.8 years for controls. The percentage of total body surface areas burn was 10.0% +/- 4.5% in the study patients versus 10.9% +/- 7.9% in the controls. The FS group did not receive packed red blood cell transfusions, albumin infusion, or topical bovine thrombin (TBT). The control group received 1.56 +/- 2.1 units of packed red blood cells, 186 +/- 194 ml 5% albumin, and TBT (20,000 units) 2.6 +/- 0.8 kits during excision and grafting procedures. The estimated blood loss/graft ration was 0.50 +/- 0.30 ml/cm2 (median = 0.46) for the study group versus 0.98 +/- 2.4 ml/cm2 (median = 0.56) for the control group (p = 0.14); for patients more than 16 years of age, this difference was significant (p = 0.03). FS may be a viable alternative to standard hemostatic techniques, because it reduced the need for blood transfusion, alloantigen exposure, and blood-borne viral infection risk. FS also eliminated the need for TBT and epinephrine, did not have an adverse impact on the surgical outcome, and tended to improve the cost differential.

Quality assurance for synovial fluid examination for crystals: an improved method.

OBJECTIVE: To determine the best method of preparing synovial fluid specimens for use in quality assurance (QA) surveys designed to assess accuracy of crystal identification. METHODS: A previously published method (A) was compared with a new method (B) in the setting of a QA survey. Ten Australian, one New Zealand, and one Hong Kong hospital laboratories took part in the survey. Each laboratory examined six different synovial fluid specimens prepared using method A (first round) and a separate six specimens using method B (second round). In method A, a drop of synovial fluid on a glass slide was surrounded by a rim of Ultramount, sealed with a coverslip, and distributed. The participating laboratory did not need to perform any processing of the specimen before examination. In method B, a capillary tip was filled with synovial fluid, heat sealed, and distributed. The fluid was expelled onto a glass slide in preparation for examination after arrival in the participating laboratory. RESULTS: Using method A 36 of 71 (51%) of the specimens were rated as satisfactory, compared with 53 of 61 (87%) of the specimens using method B (Fisher's exact test, p < 0.001). CONCLUSIONS: An improved method of preparation of synovial fluid specimens for QA surveys is described. Using the new method it is feasible to perform a synovial fluid QA survey covering a large area (Australasia).

Ischemic necrotic bowel disease in thermal injury.

BACKGROUND: Gastrointestinal tract (GI) complications are a well-recognized entity following burn injury. OBJECTIVE: To determine whether there was a change in the incidence and type of GI complications in individuals with thermal injuries requiring operative intervention and whether this might be related to changes in patient management. DESIGN: A retrospective 8-year study of patients admitted with burn injuries. SETTING: A university medical center burn unit. METHODS: Statistical analysis and pathological review of 2 groups of patients: those with ischemic necrotic bowel disease (INBD group) and those with other GI complications (other GI complication group), identified among 2114 patients admitted with burn injuries during an 8-year period (1988-1995). RESULTS: Of 2114 patients admitted with burn injuries, 19 patients were identified retrospectively as having had either INBD (n = 10) or other GI complications (n = 9). Statistical analysis showed no difference between the 2 groups in duration of hospitalization, age, sex, pneumonia, mortality, peritonitis or gastric ulcer disease, inhalation injury, ventilator use, grafting procedures, or infections. The patients in the INBD group had a statistically significant mean (+/- SD) increase in the percentage of total burn surface area compared with those in the other GI complication group (53% +/- 10% vs 22% +/- 7%; P < .02) and sepsis prior to the GI complication (32% vs 5%; P < .03). A statistically significant decrease was noted in the incidence of paralytic ileus (17% vs 69%; P < .03). Enteral nutritional support became the primary mode of treatment, and GI hemorrhage and ulcer disease decreased during this period. Patients with total burn surface area greater than 40% and sepsis were at increased risk of INBD during their hospitalization. CONCLUSIONS: The severity of thermal injury and systemic infection are risk factors for the development of INBD. This entity is more frequent currently because of increased survival of the more severely injured patients. Systemic infection may alter the integrity of the bowel, which becomes less "tolerant" of enteral feedings. The role of large-volume high-density enteral feedings as a usually associated event in these patients remains speculative.

A conservative thermal injury treatment protocol for the appropriate Jehovah's Witness candidate.

The Jehovah's Witness (JW) members abstain from receiving blood transfusions or blood product infusions because these treatments are considered an extension of life. A JW who incurs significant thermal injury requires a protocol defining good clinical practices in life-threatening predicaments acceptable to JW members to avoid legal proceedings. Assessment of religious commitment, competency, family resources, and respect for the patient's refusal of treatments is required. Detailed documentation of the patient's position is necessary. Medical management should include standard critical care measures, blood conservation, restricted laboratory work, utilization of pediatric blood collection tubes, nonblood plasma expanders, erythropoietin administration, iron supplements, and aggressive nutritional support with appropriate surgical conservation measures during skin grafting procedures. With conservative management, a positive outcome can be attained without recourse to the legal system.

The impact of substance use on mortality and morbidity from thermal injury.

Alcohol and drug use have been associated with increased mortality and morbidity from thermal injury. To determine whether substance users (SUs) differed from controls, 398 burn patients were studied, of whom, 161 had a positive drug screen for either ethanol, cannabinoids, cocaine metabolites, amphetamines, phencyclidine, or benzodiazepines. SUs versus controls showed no difference in age, but had a significantly greater percentage of total burn surface area (TBSA) (25 vs. 17%), inhalation injury (29 vs. 7%), and mortality (14 vs. 3%). The alcohol users (AUs) and drug users (DUs) were similar in relation to sex, age, inhalation injury, percentage of TBSA, and type of burn. DU patients experienced the same increase in inhalation injury as the AU group compared to controls. The mortality of AU patients was twice that of DU patients and six times that of controls. The best independent predictors of death were age, inhalation injury, percentage of TBSA (p < 0.001), and ethanol use (p < 0.02).