Randomized, Paired-Site Comparison of Autologous Engineered Skin Substitutes and Split-Thickness Skin Graft for Closure of Extensive, Full-Thickness Burns.

Stable closure of full-thickness burn wounds remains a limitation to recovery from burns of greater than 50% of the total body surface area (TBSA). Hypothetically, engineered skin substitutes (ESS) consisting of autologous keratinocytes and fibroblasts attached to collagen-based scaffolds may reduce requirements for donor skin, and decrease mortality. ESS were prepared from split-thickness skin biopsies collected after enrollment of 16 pediatric burn patients into an approved study protocol. ESS and split-thickness autograft (AG) were applied to 15 subjects with full-thickness burns involving a mean of 76.9% TBSA. Data consisted of photographs, tracings of donor skin and healed wounds, comparison of mortality with the National Burn Repository, correlation of TBSA closed wounds with TBSA full-thickness burn, frequencies of regrafting, and immunoreactivity to the biopolymer scaffold. One subject expired before ESS application, and 15 subjects received 2056 ESS grafts. The ratio of closed wound to donor areas was 108.7 ± 9.7 for ESS compared with a maximum of 4.0 ± 0.0 for AG. Mortality for enrolled subjects was 6.25%, and 30.3% for a comparable population from the National Burn Repository (P < .05). Engraftment was 83.5 ± 2.0% for ESS and 96.5 ± 0.9% for AG. Percentage TBSA closed was 29.9 ± 3.3% for ESS, and 47.0 ± 2.0% for AG. These values were significantly different between the graft types. Correlation of % TBSA closed with ESS with % TBSA full-thickness burn generated an R value of 0.65 (P < .001). These results indicate that autologous ESS reduce mortality and requirements for donor skin harvesting, for grafting of full-thickness burns of greater than 50% TBSA.

A performance improvement initiative to determine the impact of increasing the time interval between changing centrally placed intravascular catheters.

Existing practice guidelines designed to minimize invasive catheter infections and insertion-related complications in general intensive care unit patients are difficult to apply to the burn population. Burn-specific guidelines for optimal frequency for catheter exchange do not exist, and great variation exists among institutions. Previously, the authors' practice was to follow a new site insertion at 48 hours by an exchange over a guidewire, which was followed 48 hours later by a second guidewire exchange (48h group). As a performance improvement initiative, the authors attempted to determine whether there would be any advantage or disadvantage to extending these intervals to 72 hours (72h). All patients with centrally placed intravascular catheters from October 2007 to August 2008 were included in the 48h group, and all patients with catheters placed from September 2008 to December 2009 comprised the 72h group. Catheter infection rates were determined using the National Healthcare Safety Network definition for central line-associated bloodstream infections (CLABSIs) and calculated as CLABSIs/1000 catheter days. The two groups were not significantly different for age, sex, burn etiology, total burn size, or percent third-degree burn. There were 3.1 CLABSIs/1000 catheter days for the 48h group and 2.8 CLABSIs/1000 catheter days for the 72h group (NS). The authors conclude that increasing the central catheter change interval from 48 to 72 hours did not result in any increase in their CLABSI rate. Implementation of this change in practice is expected to decrease supply costs by $28,000 annually in addition to reducing clinical support services needed to perform these procedures.

Amish burn ointment and burdock leaf dressings: assessments of antimicrobial and cytotoxic activities.

Amish burn wound ointment (ABO) contains honey, lanolin, oils, glycerin, bees wax, and other natural additives. Although there are many anecdotal reports that this ointment covered with a burdock leaf (BL) dressing promotes burn wound healing, little scientific testing of this treatment has occurred. The goal of this study was to evaluate in vitro some of the components of this treatment modality for antimicrobial and cytotoxic activities. The ABO was tested for sterility using standard microbiological techniques. Because of the semisolid, lipid-based nature of the salve, the at-use product could not be tested in bioassays. Samples of BL and the dry ingredients (DI) used in the ointment were provided by the Amish vendor. Aqueous extracts of the DI and of the BL were prepared and freeze dried. The freeze-dried extracts were reconstituted, filtered, and tested separately on keratinocyte and fibroblast cell cultures for cytotoxicity (growth inhibition assay) and against a panel of susceptible and resistant microbes for antimicrobial activity (Nathan's agar-well diffusion assay) in a series of concentrations (% wt/vol). Neither DI nor BL extracts demonstrated antimicrobial activity against any of organisms tested. The DI extract inhibited growth of both keratinocytes and fibroblasts at the 0.1% concentration. The 0.1 and 0.03% concentrations of the BL extract were cytotoxic to both keratinocytes and fibroblasts. Although tests for microbial growth from the at-use preparation of the ABO were negative, extracts of the DI and BL did not demonstrate any antimicrobial activity. Additionally, both extracts inhibited the growth of skin cells in vitro at higher concentrations. These results suggest caution in the use of ABO and BL dressings if there is more than a minimal risk of complications from the burn injury.

Multicenter testing of a burn prevention teaching tool for Amish children.

Burn prevention is not taught in Amish schools despite significant cultural risks for burn injuries related to scalds, ignition of clothing, and ignition of highly flammable materials. A culturally appropriate and acceptable burn prevention teaching tool was previously developed and pilot-tested in one Amish school. The purpose of this study was to perform further evaluation of this burn prevention teaching tool for Amish children. Following institutional review board approval, private schools were recruited via invitation in Amish newsletters. A teaching tool, which includes a magnetic story board, burn safety curriculum, and test questions, was provided to each school. Teachers obtained parental permission and informed assent for the children to participate. Teaching was guided by the curriculum and involved arranging magnetic pieces to illustrate and tell stories about burn hazards. The children were challenged to rearrange the magnets for a safer situation. Pretests and posttests were used to capture baseline knowledge and measure improvement. Scores were expressed as a percentage of the 33 test items answered correctly. Teachers provided recommendations and a written evaluation of the tool's usefulness. The participants were 294 students from 15 private Amish schools across eight states. Test scores were significantly improved by the lessons, without regard to gender or grade groups. Teachers valued the tool and recommended no changes. This multicenter study demonstrated that a culturally appropriate burn prevention teaching tool was highly effective for improving burn prevention knowledge among Amish school children. These results support expansion of burn prevention education to other Amish communities.

Pilot testing of a burn prevention teaching tool for Amish children.

Burn prevention education for Amish children is warranted as there are unique risks associated with the Amish lifestyle. Specific educational opportunities are related to scalds, ignition of clothing, and ignition of highly flammable materials. A culturally sensitive burn prevention teaching tool, consisting of a magnetic storyboard, burn safety curriculum, and tests, was developed with the cooperation of one Old Order Amish community. The purpose of this study was to test the effectiveness of the tool in an Amish school. The teacher obtained parental permission and informed assent for the participation of the children. Pretesting was completed before the lessons began. The teacher told stories and arranged the magnets on the storyboard to show burn hazards involving lighters, stoves, kerosene heaters, gasoline-powered engines, and hot liquids used for canning, butchering, mopping, washing clothes, and making lye soap. The children were challenged to rearrange the pieces for a safer situation. Posttesting was performed 2 months after the pretest. Twenty-seven students (grades 1-8) participated. Tests were scored as a percentage of the 33 items answered correctly. The mean pretest score was 62 and the mean posttest score was 83. Statistical analysis using paired t-test demonstrated a highly significant improvement in test scores (P < .0001), with a power of more than 99%. This pilot study demonstrated that the burn prevention teaching tool was effective for improving knowledge in one classroom of Amish children. These results support expanded use and testing of this tool in other Amish schools.

Development of a burn prevention teaching tool for Amish children.

Although there are inherent risks for burn injury associated with the Amish lifestyle, burn prevention is not taught in Amish schools. The purpose of this study was to develop a burn prevention teaching tool for Amish children. An anonymous parental survey was designed to explore the content and acceptability of a teaching tool within an Old Order Amish community. After institutional review board approval, the Amish teacher distributed surveys to 16 families of the 30 children attending the one-room school. Fourteen (88%) of the families responded to identify these burn risks in and around their homes, barns, and shops: lighters, wood and coal stoves, kerosene heaters, gasoline-powered engines, and hot liquids used for canning, butchering, mopping, washing clothes, and making lye soap. All respondents were in favor of teaching familiar safety precautions, fire escape plans, burn first aid, and emergency care to the children. There was some minor objection to more modern devices such as bath tub thermometers (25%), fire extinguishers (19%), and smoke detectors (6%). The teacher was interested in a magnetic teaching board depicting Amish children and typical objects in their home environment. Movable pieces could afford the opportunity to identify hazards and to rearrange them for a safer situation. This survey served to introduce burn prevention to one Amish community and to develop an appropriate teaching tool for the school. It is anticipated that community participation would support its acceptance and eventual utilization within this tenaciously traditional culture.

Pharmacokinetics of colistin in an adolescent boy with extensive burn injury.

Multidrug resistance in Gram-negative bacteria has led to a resurgence in colistin use. No pharmacokinetic data exist for burn patients. A 17-year-old boy suffered a 71% TBSA full-thickness burn with deep necrosis and compartment syndrome. He developed multidrug-resistant Acinetobacter baumannii burn wound sepsis/septic shock with acute renal failure requiring dialysis. The organism was resistant to all tested antibiotics except colistin. He received colistin 2.5 mg/kg every 24 hours. Peak and trough serum concentrations, area under the concentration-time curve, and elimination half-lives of colistin were 3.6 ± 1.0 µg/ml, 0.9 ± 0.5 µg/ml, 47.1 ± 14.4 mg · hr/L, and 12.3 ± 9.4 hours (mean ± SD), respectively. Serum levels were at or above the minimum inhibitory concentration for >90% of therapy. Nevertheless, salvage therapy with colistin proved futile as the patient developed acidosis, coagulopathy, and was vasopressor-dependent without any wound healing. He died on hospital day 52. Microbiologically, the serum levels of colistin were seemingly adequate, as repeat cultures were negative. Given the peak and trough levels of colistin relative to the minimum inhibitory concentration for the organism (0.5 µg/ml), it would seem that the dosage of 2.5 mg/kg administered every 24 hours for this patient on dialysis was appropriate. Patients on dialysis infected with an organism possessing a higher inhibitory concentration (≥1 µg/ml) should probably receive the same dosage every 12 hours to avoid subtherapeutic concentrations. Large-scale study of the pharmacokinetics of colistin in patients with burn injury is urgently needed.

Is there an increased risk of burns to Amish children?

The purpose of this study was to examine the incidence, causes, and demographics of burn injuries in Amish children, treated at a pediatric burn center located in close proximity to the Midwestern Amish country. After Institutional Review Board approval, we used our TRACS Burn Registry to identify burn injuries in Amish and non-Amish children. We then compared the groups formed by gender and culture. We identified 37 Amish children (1.25%) among the 2972 acute burn patients admitted over the 12-year period of review. Importantly, Amish girls sustained significantly more extensive and deeper burns than Amish boys or non-Amish children of either gender (P < .05). Ventilator days were also greater for Amish girls than for the non-Amish groups (P < .05). A greater length of hospital stay for the Amish girls was likely because of their significantly larger burn size. There were also overall significant differences in burn causes among Amish and non-Amish children (P = .002). Amish patients had a higher incidence of burns, by hot liquids not related to cooking, ignition of clothing, or ignition of flammable materials, than non-Amish children. Of note, Amish girls had a relatively shorter delay in admission to our burn center than did Amish boys and non-Amish children. Burn injuries to Amish children requiring inpatient treatment seem to be quite uncommon. When they do occur, burns in Amish children tend to be more extensive than similar injuries in non-Amish children. The data suggest that there may be significant and specific educational opportunities for burn prevention in Amish children in our burn center's referral area.

Pediatric nurses' knowledge and attitudes survey regarding pain: a competency tool modification.

Nurses' knowledge and attitudes about pain affect their ability to manage patients' pain. A mechanism was sought to evaluate nursing competency in pain management at eight pediatric hospitals. Several pain survey tools were reviewed, considering the patient population around which they were designed, the basis for survey content, and format. A survey with established validity and reliability, the Pediatric Nurses' Knowledge and Attitude Survey Regarding Pain (PNKAS) (Manworren 1999) was chosen as the most appropriate for this group. The tool was modified for applicability to the nurses caring for pediatric populations that do not include oncology. Revisions were made with the concurrence of Manworren to assure that neither the content being tested, nor the integrity of the tool, was affected. Stability of the modified tool (PNKAS-Shriners Version 2002) was verified by retesting 6-8 weeks after initial survey.

Pain management competency evidenced by a survey of pediatric nurses' knowledge and attitudes.

Nurses' knowledge and attitudes about pain management affect their capability to attend to children in pain. A modified version of the Pediatric Nurses' Knowledge and Attitude Survey (PNKAS--Manworren and Shriners Hospitals for Children Version, 2002) was used to evaluate nursing competency to manage pain at eight pediatric hospitals. A convenience sample of 295 nurses attained a mean individual test score of 74% correct. Scores were correlated with demographic data. The novice group with 0-2 years nursing experience had significantly (p<0.05) lower scores (fewer correct answers) than the other five groups with more than 2 years of nursing experience. The nurses who participated in professional nursing organizations or nursing committees had significantly higher scores than those who did not participate. Nursing education, professional activity, and years of clinical experience contribute to the knowledge necessary for competency in pain management, as evidenced by higher scores using this survey tool.

Prophylactic intravenous immune globulin and polymixin B decrease the incidence of septic episodes and hospital length of stay in severely burned children.

After burn shock resuscitation, serum gamma globulin levels decrease well below normal before slowly recovering over the course of 1 to 2 months. During this period, patients are vulnerable to further insult as a result of this immunocompromise. We hypothesized that intravenous immune globulin and subtherapeutic polymixin B (IVIG-B) could decrease the incidence and/or severity of sepsis after major thermal injury. A retrospective chart review from 1997 through 2003 at two hospitals compared patients who received IVIG-B (Hospital A) with those who did not (Hospital B). Patients with burns 40% or greater TBSA were included, whereas patients with nonsurvivable injuries were excluded from data analysis. A total of 152 patients were included in the study. One hundred two patients received IVIG-B, and 50 did not. Total burn size was 63.4% TBSA at Hospital A and 63.1% TBSA at Hospital B, with full-thickness burns of 54.4 and 61.7% TBSA, respectively (P < .05). Patients treated at Hospital A had a 51.9% incidence of inhalation injury compared with 28% of the patients at Hospital B (P < .05). There was an average of 1.2 and 1.9 septic episodes for patients treated at Hospital A and Hospital B, respectively (P < .05). Length of hospital stay was 77.1 days at Hospital A compared with 103.8 days at Hospital B (P < .05). Mortality was 17.6% and 18% at Hospitals A and B, respectively, and was not significantly different. Our data suggest that prophylactic IVIG-B is associated with a reduction in the incidence of septic episodes and decreased hospital length of stay following major thermal injury.

Cultured skin substitutes reduce donor skin harvesting for closure of excised, full-thickness burns.

OBJECTIVE: Comparison of cultured skin substitutes (CSS) and split-thickness skin autograft (AG) was performed to assess whether donor-site harvesting can be reduced quantitatively and whether functional and cosmetic outcome is similar qualitatively in the treatment of patients with massive cutaneous burns. SUMMARY BACKGROUND DATA: Cultured skin substitutes consisting of collagen-glycosaminoglycan substrates populated with autologous fibroblasts and keratinocytes have been shown to close full-thickness skin wounds in preclinical and clinical studies with acceptable functional and cosmetic results. METHODS: Qualitative outcome was compared between CSS and AG in 45 patients on an ordinal scale (0, worst; 10, best) with primary analyses at postoperative day 28 and after about 1 year for erythema, pigmentation, pliability, raised scar, epithelial blistering, and surface texture. In the latest 12 of the 45 patients, tracings were performed of donor skin biopsies and wounds treated with CSS at postoperative days 14 and 28 to calculate percentage engraftment, the ratio of closed wound:donor skin areas, and the percentage of total body surface area closed with CSS. RESULTS: Measures of qualitative outcome of CSS or AG were not different statistically at 1 year after grafting. Engraftment at postoperative day 14 exceeded 75% in the 12 patients evaluated. The ratio of closed wound:donor skin areas for CSS at postoperative day 28 was significantly greater than for conventional 4:1 meshed autografts. The percentage of total body surface area closed with CSS at postoperative day 28 was significantly less than with AG. CONCLUSIONS: The requirement for harvesting of donor skin for CSS was less than for conventional skin autografts. These results suggest that acute-phase recovery of patients with extensive burns is facilitated and that complications are reduced by the use of CSS together with conventional skin grafting.