Mobilization with Femoral Catheters in the Burn ICU: A retrospective review following change in practice guidelines.

Femoral catheters are a known barrier for Burn ICU mobility progression due to the anatomical location and potential risk of complications. The purpose of this study was to examine outcomes and complication rates following implementation of femoral catheter mobilization guidelines, as well as determine safety and feasibility of mobilization with femoral catheters in place within the burn population. Retrospective review was completed on 17 patients prior to and following implementation of new femoral catheter mobility guidelines, 34 patients total. Burn therapy notes were reviewed for burn admissions with at least one femoral catheter in place, including arterial, central, and dialysis catheters. Demographic data, admission statistics, line placement timelines, and active mobility achieved during therapy sessions were recorded for both the non-mobilization (NMG) and mobilization groups (MG). The 34 patients reviewed had 99 total lines placed (30 NMG, 69 MG). Change in mobility protocols for the MG resulted in more therapy sessions (n=516 vs 281) and a significant increase in active mobility sessions (n=83 vs 5, p < 0.001), including 146 total mobility activities such as transitions to chairs, tilt table, sitting edge of bed (EOB), standing, active chair transfers, ambulation, and cycle ergometry. No catheter associated adverse events occurred during active mobility sessions and no complications were associated with participation in mobility. This study supports that the presence of femoral catheters alone should not limit the progression of mobility interventions. Using clinical judgement and specialty training, burn therapists can safely mobilize burn ICU patients with femoral catheters in place.

Five-Year Retrospective Analysis of a Vented Mobility Algorithm in the Burn ICU.

Early mobilization with mechanically ventilated patients has received significant attention within recent literature; however, limited research has focused specifically on the burn population. The purpose of this single-center, retrospective analysis was to review the use of a burn critical care mobility algorithm, to determine the safety and feasibility of a burn vented mobility program, share limitations preventing mobility progression at our facility, and discuss unique challenges to vented mobility with intubated burn patients. A retrospective review was completed for all intubated burn center admissions between January 2015 and December 2019. Burn therapy notes were then reviewed for data collection, during the intubation period, using stages of the mobility algorithm. In the 5-year period following initial implementation, the vented mobility algorithm was utilized on 127 patients with an average TBSA of 22.8%. No adverse events occurred. Stage 1 (range of motion) was completed with 100% of patients (n = 127). Chair mode of bed, stage 2a, was utilized in 39.4% (n = 50) of patients, while 15.8% (n = 20) of patients were dependently transferred to the cardiac chair in stage 2b. Stage 3 (sitting on the edge of the bed) was completed with 25% (n = 32) of patients, with 11% (n = 14) progressing to stage 5 (standing), and 3.9% (n = 5) actively transferring to a chair. In the 5 years, only 4.7% (n = 6) reached stage 6 (ambulation). The most common treatment limitations were medical complications (33%) and line placement (21%). Early mobilization during mechanical ventilation is safe and feasible within the burn population, despite challenges, including airway stability, sedation, and line limitations.

A comparative study of spray keratinocytes and autologous meshed split-thickness skin graft in the treatment of acute burn injuries.

BACKGROUND: ReCell (Avita Medical, Northridge, CA) is an autologous cell harvesting (ACH) device that enables a thin split-thickness skin biopsy to be processed to produce a cell population that includes a mixed population of keratinocytes, melanocytes, Langerhans cells, and papillary dermal fibroblasts for immediate delivery via a spray applicator onto a prepared skin surface. MATERIALS AND METHODS: In this Institutional Review Board-approved US Food and Drug Administration phase 2 study, the authors prospectively evaluated the treatment of partial-thickness burns in patients with two 320 cm2 areas, 1 area treated with the ACH device and the other with a meshed split-thickness skin graft (MSTSG) as a control. The authors compared the treatment areas for graft take, pigmentation, and color match to surrounding healthy tissue, scarring, and pain. RESULTS: In this preliminary study, 10 patients were treated with this protocol. Eight patients had 100% take to both treatment areas and 2 patients had significant non-take and graft loss attributable to underexcised wound beds and difficulty with the spray applicator. Pigmentation and color match ratings were identical at week 52 and the Modified Vancouver Scar Scale scores were comparable. One subject rated the autologous cell harvesting site as having a better appearance, while the remaining subjects rated their ACH and MSTSG sites' appearances as being comparable. In early follow-up visits, pain ratings were slightly elevated in the ACH group due to graft healing; however, in visits following week 2, pain ratings at the ACH and MSTSG sites were rated similarly by all patients. CONCLUSION: This preliminary report describes an early experience with the ACH device and the treatment of partial-thickness burn injuries. In this 10-patient series, patients benefitted from having a decreased donor site size and comparable outcomes with MSTSG treatment. While this preliminary underpowered study has provided positive results, there is a learning curve with choosing the proper wound for treatment with the ACH device, as well as with using the device.

The effectiveness of a computerized IV infusion protocol to treat hyperglycemia in burn patients.

Tight glucose control (TGC) in critical care settings is becoming increasingly the standard of care. However, TGC comes with the risk of hypoglycemia, as highlighted by some recent studies. Our aim was to establish TGC in burn patients without increasing rates of hypoglycemia. The authors used a computer-driven glucose control program (CGS) to achieve this goal. The computer program calculates insulin drip rates by using a multiplier that changes according to blood glucose (BG) values as well as trends and keeps a record of BG data and insulin infusion rates for future quality control analysis. CGS is also a useful adjunct in transitioning patients from an IV insulin drip to subcutaneous insulin. A retrospective review of the glucose control program database was performed to obtain information on length of time to goal glucose levels (set at 100-150 mg/dl), glucose level trends, and incidence of hypoglycemia when using the computer program. Over 18 months, we used CGS on 94 critical and noncritical burn patients. Mean time to target BG was 5.1 hours. Glucose levels of 100 to 150 mg/dl were maintained 63.3% of the time, and values within the wider range of 70 to 150 mg/dl were maintained 80.8% of the time. The incidence of hypoglycemia, defined as BG level below 70 mg/dl, was only 1.66% and was treated without any adverse sequelae. Hyperglycemic episodes were directly correlated with surgical interventions during which time the CGS was not utilized in the operating room. CGS offers a safe and effective means of rapidly achieving and maintaining glucose targets in burn patients. Further analysis of the data needs to be conducted to determine whether the BG targets used in our study offer a morbidity benefit to burn patients.

Cultured epithelial autografts for coverage of large burn wounds in eighty-eight patients: the Indiana University experience.

Since 1990, the authors have used a new technique for coverage of large burns, which begins with early tangential excision and coverage with cadaver allograft (A), followed by placement of cultured epithelial autograft (CEA) onto an allodermis base (CEA/A). They present their 18-year experience (1990-present) using CEA in 88 patients (20 children and 68 adults) with age range of 6 months to 73 years. A review of prospectively collected data was conducted on adult and pediatric patients grafted with CEA at the Indiana University Medical Center for definitive wound coverage (TBSA 28-98%). These patients were followed up for 3 to 90 months. Complications, take rates, and outpatient follow-ups were noted. The mean final take rate of CEA/A was 72.7%, and the overall patient survival rate was 91% (80 of 88 patients). Complications were classified as early and late, they included: (early) blistering and shearing (31%), pruritus and itching (4.7%), (late) CEA loss (2 patients, 2.3%), and wound contractures (66%). Contracture releases were performed on 32 patients (36%); of which, 18 were children (56%). Cultured keratinocytes provide an excellent alternative or adjunct to conventional split-thickness skin grafting in treating large burn wounds. A dedicated team of physicians, nurses, and therapists well rehearsed in CEA care are vital for success in keratinocyte grafting. The final graft take of 72.7% with a 91% overall survival rate gives much optimism for continuing to use CEA in critically burned patients.

Coverage of large pediatric wounds with cultured epithelial autografts in congenital nevi and burns: results and technique.

The use of cultured epithelial autografts (CEA) for the treatment of large burn wounds has gained popularity in recent years. This technique may circumvent the restrictions of limited donor site availability and hasten permanent wound coverage for large TBSA burns. The availability of a large amount of skin from a small donor site with the promise of permanent wound coverage suggests its use in other conditions such as giant congenital nevi (GCN) as well. The risk of malignant transformation of GCN to melanoma although somewhat controversial is significant enough to warrant early excision in childhood. Cultured keratinocytes may provide one-stage coverage of these large wounds, lessening the number of surgeries and the inherent staging problems of tissue expansion or autografting. A retrospective single institution review of was done for 29 children (20 burns and 9 patients with GCN) who underwent coverage of their large surface area wounds with CEA over an 18-year period. Excellent take rates were noted; 76.4% for burn patients and 66% for patients with GCN. Several strategies in preoperative, perioperative, and postoperative care have been standardized and have helped improve outcome. The keys to success with the CEA technique have been aggressive control of wound sepsis, surgical technique, specific use of topical antimicrobials, dressings, and the standardization of nursing and physiotherapy care. Although the cost of CEA is high, the benefits to patient care make this technique an appealing choice for large wound coverage in the pediatric population.