Evaluation of patient-reported outcome measures in burn-specific tools: A systematic review.

INTRODUCTION: Patient-reported outcome measures (PROMs) are now well-established tools to evaluate the quality of patient-centred care. Due to the multi-faceted and multi-disciplinary nature of the practice of burn care, as well as the range of significant potential sequelae, PROM's should form a fundamental component of burn quality improvement programs. We aim to 1. Explore biological, psychological, and social considerations that are currently listed in burn-specific PROM tools, as well as their efficacy, 2. Evaluate biological, psychological, and social factors that are considered in new burn-specific PROM tools or those under development, and 3. Identify any opportunities with respect to burn-specific PROM tools, in order to inform future investigation in this area. METHODS: A search was performed of MEDLINE (Ovid), EMBASE, CINAHL, and the Cochrane Library databases. Two independent reviewers screened article titles/abstracts and then the full texts using Covidence. All studies were graded independently according to the Quality Rating Scheme for Studies and Other Evidences. RESULTS: The initial search yielded 552 references. Based on ab initio inclusion and exclusion criteria, 133 full-text studies were assessed for eligibility, and 21 articles were ultimately included in the systematic review. Due to study heterogeneity, a qualitative synthesis was conducted. Existing burn-specific PROMs covered a range of biological, psychological, and social factors affecting adult and paediatric patients with burn injury, but several studies required additional PROMs for a thorough evaluation. Burn-specific PROM tools under development are poised to fill this deficit. CONCLUSION: Major burn injuries are a unique form of trauma, requiring coordinated management that considers numerous factors not relevant to other patient populations. Further research is necessary to validate existing burn-specific PROM tools and to develop more comprehensive burn-specific PROM measures that more comprehensively incorporate the bio-psycho-social model of health.

The Africa Temporal Scalp Flap: A Novel Flap for Facial Reconstruction.

Although a number of flaps exist for nasal reconstruction, severe scarring of the forehead after burn injury led to the development of a novel two-stage flap based on the superficial temporal artery. The Africa Temporal Scalp (ATS) flap is composed of an axial ascending part on the superficial temporal artery, and a descending anterior extension for reconstruction of the midface. This is a retrospective analysis of all patients who underwent ATS flap surgery on the MV Africa Mercy. During the 7.5-year period, the ATS flap was applied to 45 facial reconstructions, with a median age of 28 years (range 19 months to 51 years). The main indications were previous burn injury (n = 27, 60%) and noma (n = 15, 33.3%). The majority of the flaps were used to reconstruct the lower third of the nose (n = 39, 86.7%), and the remaining six were for the lips or cheek. Experience allowed for earlier division than 3 weeks depending on the length of the flap, and the recipient site. There was one partial flap loss, one infection requiring revision, and two injuries to frontal branch of the facial nerve. The ATS flap is a novel two-stage flap that has proved especially versatile when forehead flaps are unavailable for nasal reconstruction due to extensive forehead scarring. The ATS flap reliably provides ample supple skin, and the donor site is effectively obscured from view, located in the periphery of the face.

The radial recurrent artery propeller flap for elbow coverage in an extensive burn.

Obtaining durable coverage of the elbow may be challenging when surrounding tissue as well as standard free flap donor sites are not available for use. Here we describe the application of the radial recurrent artery perforator propeller flap to good effect for the coverage of the elbow joint and ulnar nerve in the context of an extensive flame burn injury of over 80% of the body surface area. Despite few descriptions of its use in the literature, it is a relatively straightforward flap to elevate and inset, the donor area was effectively autografted and there were no postoperative complications.

A Systematic Review of Quality Improvement Interventions in Burn Care.

Quality improvement interventions (QIIs) are intended to improve the care of patients. Unlike most traditional clinical research, these endeavors emphasize the sustainable implementation of scientific evidence rather than the establishment of evidence. Our purpose was to conduct a systematic review of QII publications in the field of burn care. A systematic review was conducted utilizing electronic databases (MEDLINE, Embase, and Cochrane Library) of all studies relating to "quality improvement" in burn care published until March 31, 2020. Studies were excluded if no baseline data were reported, or if no intervention was applied and tested. Studies were scored using a novel 10-point evaluation system for QII. We evaluated 414 studies involving "quality improvement" in burn care. Only 82 studies contained a QII while 332 studies were categorized as traditional research. Several traditional research studies made claims to be QIIs, but few met the criteria. Of the 82 QII references, only 20 (24%) were accessible as full-text manuscripts, the remainder were published as abstracts only. The mean score was 7.95 for full-text studies (range 6-10) and 7.4 for abstract-only studies (range 5.5-9.5). Despite the importance of quality improvement (QI) in burn care, very few studies have been published that employ true QI methodology, and many QII studies never advance beyond publication as abstracts in conference proceedings. Based on this systematic review, we propose guidelines to improve the quality of QII submissions.

The use of vasopressors during acute burn resuscitation.

BACKGROUND: Vasopressors may be required during acute burn resuscitation to support mean arterial blood pressure, but their use is not well-described in the burn literature. The purpose of this study was to examine vasopressor use during acute fluid resuscitation. METHODS: Retrospective review of adults with burns ≥ 20% TBSA admitted to an ABA-verified regional burn center. Patients administered an infusion of a vasopressor for at least 30 min during the 1 st 48 h post-burn formed the PRESSOR group while patients who did not receive vasopressors formed the NoPRESSOR group. RESULTS: We studied 52 burned adults, 85% of which had flame burns. Vasopressors were administered during resuscitation to 31% of patients. Vasopressor infusions began at 20.9 ± 10.9 h post burn and were continued for 16.8 ± 10.8 h. PRESSOR patients (N = 16) had significantly greater total (p = 0.001) and full thickness burn size (p < 0.001), and need for mechanical ventilation (p = 0.005) than NoPRESSOR patients (N = 36). PRESSOR and NoPRESSOR patients did not differ significantly in per cent predicted fluid volume received in the first 24 h (143 ± 58 Vs. 125 ± 46 respectively). PRESSOR patients compared to NoPRESSOR patients tended to have been administered 5% albumin (Alb) less often (38% Vs 47%) and high dose vitamin C (HDVC) more often during resuscitation (69% vs 17%). Multivariate regression analysis found that patient age (OR 1.189, 95% CI: 1.047, 1.351) and HDVC (OR 24.701, 95% CI: 1.558, 391.551) were independently associated with greater use of vasopressors. An inverse probability weighted propensity analysis also identified a significant association between HDVC and increased use of vasopressors (OR 6.902, 95 % CI: 2.503, 19.026), and significantly decreased vasopressor administration following Alb administration (OR 0.310, 95% CI: 0.130, 0.739). CONCLUSION: Advanced age appears to be the most important determinant of vasopressor use during resuscitation. While vasopressor requirements appear to have been increased by HDVC and decreased by Alb, this needs to be formally evaluated in a large randomized study.

Burns associated with e-cigarette batteries: A case series and literature review.

Electronic cigarettes, often referred to as e-cigarettes, have established a considerable market in North America over the last decade. In parallel to this trend, there has been a surge of e-cigarette battery explosions reported in the general media. Given the growing number of such events, acute care physicians should recognize the associated risks and injury patterns and initiate appropriate treatment. This report presents two cases of burn injuries from e-cigarette battery explosions requiring surgical management. The accompanying comprehensive literature review highlights the emerging importance of e-cigarettes as an aetiology of burn injury.

The Use of Intravenous and Inhaled Colistin Therapy During a Burn Center Outbreak of Multidrug-Resistant Acinetobacter baumannii.

The authors report on the use of combination intravenous and inhaled colistin therapy in 2 patients with major burns admitted to an American Burn Association-verified burn center during a multidrug-resistant (MDR) Acinetobacter baumannii outbreak. Both patients had documented, culture-proven MDR Acinetobacter ventilator-associated pneumonia and bacteremia leading to sepsis. Both patients were successfully extubated and subsequently discharged from hospital. In this article, the authors provide the timeline of events and treatments that were used in these 2 cases. Combination intravenous and inhaled colistin therapy may be a valuable tool against MDR Acinetobacter infections.

The use of Biobrane® for wound coverage in Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis.

INTRODUCTION: Published experience describing the use of Biobrane® for wound management in Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis (SJS-TEN) is limited to case reports and case series involving ten or fewer patients. We have used Biobrane® in the care of SJS-TEN since 2000, and the purpose of this study was to review our experience with the application of Biobrane® for wound coverage in SJS-TEN. METHODS: A retrospective review of all cases of SJS-TEN admitted to an adult regional ABA-verified burn center between January 1, 2000 and June 1, 2015 was conducted. Biobrane® application was performed at burn center admission. Values are presented as the median (IQR), or mean±SD where appropriate. RESULTS: We identified 42 eligible subjects with SJS-TEN. Biobrane® was applied in 24 subjects. Biobrane®-treated subjects had an age of 51.4±21.7years, with a %TBSA epidermal detachment of 39.5 (30-46), 63% were female and the admission SCORTEN was 3 (2-4, range 1-5). Biobrane® was applied at burn center (BC) admission in 18/24 subjects (82%), and between post admission days 1-4 in four subjects. Biobrane® was applied to 35 (22-40) % of the TBSA (range 7-90) involving all anatomic areas including the head and neck. There were no complications, infections, premature removals, or Biobrane®-associated sepsis in 24/25 applications (96%). In one subject a sheet of the TBSS was removed due to sub-Biobrane® fluid collection, but with negative microbiological cultures. Time to healing was 13 (12-16) days, and burn center length of stay was 34 (15.3-62.3) days. Subjects treated with dressings only (n=18) had a significantly smaller %TBSA epidermal detachment [10 (5-22), p<0.001], and were predominantly diagnosed with SJS (50%) or SJS-TEN overlap (33%). Time to healing among dressing-only subjects was not significantly different [12 (10-14.5) days] than among the Biobrane®-treated subjects, (p=0.127). CONCLUSION: Biobrane® was applied to SJS-TEN subjects with more extensive epidermal detachment, had no significant complications, and generally facilitated epidermal healing in under 2 weeks from application.