Effects of Elevated Blood Alcohol Levels on Burn Patient Outcomes.

Background: Alcohol use has been associated with poor wound healing in traumatic injuries as it impairs immune function and lowers leukocyte production. The aim of this study is to describe the association of alcohol use on the outcomes of patients with burn injuries. It is proposed that the use of alcohol can have a detrimental effect on burn patient outcomes. Methods: A retrospective review of the American Burn Association Burn Registry from 2002 through 2011 was conducted. Patients were stratified into 2 groups: burn patients with a blood alcohol level above the legal limit 0.08 mg/dl on admission (group 1) vs burn patients with a blood alcohol level below the legal limit of 0.08 mg/dl on admission (group 2). The outcome measures included in-hospital mortality rate, hospital length of stay (LOS), intensive care unit (ICU) LOS, and total days on a ventilator. Results: A total of 11,286 burn patients met the inclusion criteria. There were a total of 1,544 patients in group 1 and a total of 9,742 patients in group 2. The percentage of total body surface area (TBSA) involvement of the burns was statistically similar in both groups, with an average of 2.08% in group 1 and 2.32% in group 2. There was a significantly higher ICU LOS at 5.91 days in group 1 compared to 3.66 in group 2. The days on a ventilator were significantly higher in group 1 at 5.67 days versus group 2 at 3.06 days. The in-hospital mortality was also significantly higher in group 1 at 4.86% compared to group 2 at 3.91%. Conclusion: Burn patients who tested above the legal limit for alcohol on admission were associated with increased inpatient mortality, as well as increased ICU LOS and total days on a ventilator. An elevated admission blood alcohol level may be an independent predictor of worse outcome in patients with burn injury, leading to an increase in resource needs and health care costs.

The Outcomes of Inhalation Injuries in Lesser Burns: Still a Deadly Injury.

Background: Although it has been widely proposed that inhalation injuries worsen burn outcomes, large-scale studies have yet to demonstrate the exact relationship. This study proposes inhalation injuries as an independent risk factor that worsens burn outcomes. Methods: A retrospective review of the American Burn Association Registry from 2002 to 2011 was conducted. Inclusion criteria included burn patients with a total body surface area (TBSA) of less than 15% and adequate data recording of the inhalation injury within the registry. Patients were stratified into 2 groups: inhalation injuries (group 1) vs non-inhalation injuries (group 2). Outcome measures included in-hospital mortality rate, hospital length of stay (LOS), intensive care unit (ICU) LOS, and days on a ventilator. Results: A total of 93781 burn patients met the inclusion criteria. There were 4204 patients in group 1 and 89577 patients in group 2. There was no statistically significant difference between the 2 groups in terms of TBSA, with 3.50% in group 1 and 3.58% in group 2. There was a significantly higher ICU LOS at 8.55 days in group 1 compared to 6.27 days in group 2. There was a significantly higher hospital LOS at 11.48 days in group 1 compared to 6.27 days in group 2. The in-hospital mortality was significantly higher in group 1 at 8.54% vs group 2 at 1.42%. Conclusion: The presence of inhalation injury may be a predictor of increased mortality and poor outcome in burn patients, even in those with small sized burns.

Comparison Between Human Amniotic/Chorionic Membrane and Cryopreserved Allografts in the Treatment of Genital Burns.

BACKGROUND: Genital burns have devastating effects on patient and have been classified by the American Burn Association as major burn injury. The management of these injuries continues to challenge reconstructive surgeons. Cryopreserved skin allografts have been successfully used to manage partial-thickness skin burns; however, dehydrated human amniotic/chorionic membrane (DHACM) represents novel technology. Dehydrated human amniotic/chorionic membrane outcomes have not been sufficiently studied to guide its use on genital burns. The objective of this study was to report on the outcomes of dehydrated amniotic membrane as a biologic skin dressing on genital burns injury compared with cryopreserved allografts. METHODS: Retrospective review of data collected from our institutional burn registry from 2012 to 2017. The study population included patients with partial-thickness genital burns admitted between 2012 and 2017 treated with either dehydrated human amniotic/chorionic membrane or cryopreserved allografts. Demographic characteristics and outcome measures were compared between the 2 groups. RESULTS: Thirty patients with genital burns who received DHACM skin and cryopreserved allografts were included in the analysis. The mean age for the DHACM group was 27.6 years compared with 33.5 years for the cryopreserved group. The mean total body surface area was 3.8% in the DHACM group compared with 7.2% in the cryopreserved group (P = non-significant (ns)). The mean injury severity score was not significantly different between groups. Patients receiving cadaveric allografts had a higher number of skin substitute surgical reapplications as compared with the DHACM group (28% vs 0%, P ≤ 0.05). All patients who received DHACM skin substitutes healed by 2 weeks postoperative compared with 76% of patients who received cryopreserved skin allografts (P = 0.03, χ). CONCLUSIONS: Dehydrated amniotic membrane skin substitutes are a safe alternative in the treatment of genital burns. Its use achieves comparable benefits with no major significant difference in terms of complication, supporting the safety of amniotic membrane to treat genital burns.

Admission Carboxyhemoglobin: Is It a Marker for Burn Patient Outcomes?

BACKGROUND: Carbon monoxide is a gas produced by the combustion of hydrocarbon products that binds to heme molecules, 240 times more than oxygen, producing carboxyhemoglobin (COHb). As a result of its high affinity, there is shift of the oxyhemoglobin dissociation curve, compromising oxygen transport and delivery to tissues. Our study aim was to evaluate COHb elevation on admission as a predictor of worse outcomes in burn patients. METHODS: This is a 10-year retrospective review of the American Burn Association Burn Registry from 2002 to 2011. We stratified the patients into 2 groups: adult patients with normal COHb on admission (group 1) versus elevated COHb (group 2). Elevated COHb levels were defined as greater than 10% on the first arterial blood gas. Outcome measures included in-hospital mortality rate, hospital length of stay (LOS), intensive care unit LOS (ICU-LOS), and ventilator days. χ and t test analyses were used with significance defined as a P value of less than 0.05. RESULTS: A total of 6365 burn patients meet our inclusion criteria. There were 5775 patients in group 1 and 590 patients in group 2. Group 1 had an average age of 39.29 years compared with 42.62 years in group 2. The total body surface area was higher in group 1 compared with group 2 (6.24 vs 4.65) and with a statistically significant increase in partial thickness burns at 4.97 in group 1 compared with 3.27 in group 2. There was no statistically significant difference between the 2 groups in terms of full thickness total body surface area. The hospital LOS was significantly higher in group 2 compared with group 1 (15.34 vs 9.66). There was a significantly higher ICU-LOS at 12.89 days in group 2 compared with 4.01 in the group 1 (P = 0.0001, t test). There were higher ventilator days in group 2 at 9.23 than those in group 1 at 2.05 (P < 0.0001, t test). The in-hospital mortality was also significantly higher in group 2 at 15.59% than in group 1 at 1.33% (P = 0.0001, χ). CONCLUSIONS: Elevated COHb on admission was associated with an increased hospital and ICU-LOS, average ventilator days, and in-hospital mortality. The presence of elevated COHb of greater than 10% on an initial arterial blood gas suggests worse outcomes and increased need of resource utilization during the index hospital admission.

The Use of Dehydrated Human Amniotic Membrane Versus Amniotic/Chorionic Membrane Allografts to Treat Partial Thickness Facial Burns.

BACKGROUND: Facial burns have significant physical and psychologic effects on patients. Human dehydrated amniotic membrane represents novel technology, yet its outcome has not been sufficiently studied to guide practice. The objective of our study is to compare the benefits of amniotic membrane (DHAM) to amniotic/chorionic membrane (DHACM) skin substitutes to treat partial thickness facial burns. METHODS: Retrospective review of data collected from our institutional burn registry from 2012 to 2016. Demographic characteristics including age, total body surface area (TBSA) burn and injury severity scores were collected and outcome measures were compared between the 2 groups. Paired sample t-test and Chi-squared were used with significance defined as P < 0.05. RESULTS: A total of 77 adult patients with partial thickness facial burns who received DHAM and DHACM skin substitutes were included in the analysis. The mean age for the DHAM group was 39.8 compared to 41.4 for the DHACM. Mean TBSA was similar, with 10.9% in the DHAM group compared to 8.3% in the DHACM. Patients receiving DHAM had higher requirement for skin substitute surgical reapplications as compared to the DHACM group (23.7% versus 5.1%, P ≤ 0.05). Remaining morbidities remained low and not significantly different between patients receiving DHAM and DHACM substitutes (P > 0.05). CONCLUSION: The DHAM and DHACM skin substitutes are valid and safe alternatives in the treatment of adult partial thickness facial burns.

Using Dehydrated Amniotic Membrane Skin Substitute in Facial Burns: Is There a Outcome Difference Between Adult and Pediatric Patients?

INTRODUCTION: Facial burns have significant physical and psychological effects on patients, and minimizing morbidity continues to be a challenge for reconstructive surgeons. Advancements have allowed the development of various skin substitutes. Among these, human dehydrated amniotic skin substitutes represent novel technology, yet their outcome has not been sufficiently studied to guide practice. The objective of our study is to compare the safety of amniotic membrane skin substitutes in the treatment of adult and pediatric facial burns. METHODS: The authors performed a retrospective review of our institutional burn registry, with 90 burn patients meeting the inclusion criteria. Demographic and outcome measures included age, percentage of total body surface area (TBSA), Injury Severity Score (ISS), and complications (eg, pigmentation, hypertrophic scar, infection, and delayed healing). Paired sample t test and Chi-squared test were used, with significance defined as P < 0.05. RESULTS: Seventy-seven adults and 13 pediatric patients with facial burns who had received dehydrated amniotic membrane skin substitutes were included in the analysis. The mean age was 40.8 years for adults and 5.6 years for children. Mean TBSA was similar, with 9.6% (1-57%) in adults and 6.0% (2-14%) in children. The mean ISS did not significantly differ between groups (4.0 versus 2.2, P = ns). Pediatric patients with facial burns treated with amniotic membranes had a higher incidence of dyspigmentation relative to adult patients (46.2% versus 9.1%, P ≤ 0.05). Remaining morbidities were not significantly different between adult and pediatric patients. All patients, irrespective of group, healed by the second post-operative week. CONCLUSION: Dehydrated amniotic membrane skin substitutes are a safe alternative in the treatment of facial burns across all ages.

Orbital Decompression for Treatment of Acute Visual Loss After Facial Trauma.

Injury to the orbital region represents a significant proportion of emergency department attendances and it is a common injury in patients with multisystem trauma. To date, trauma remains a leading cause of monocular blindness.Traumatic optic neuropathy may be caused by direct trauma to the optic nerve and from compression caused by foreign bodies and bone fragments. Indirect trauma can lead to visual loss from transmitted force to the optic canal by blunt facial trauma without associated fractures. Occasionally traumatic optic neuropathy is due to reversible changes, such as edema or contusion.High-dose intravenous steroids and surgical decompression of the optic canal have been advocated for the management of acute traumatic optic neuropathy, but the efficacy and safety of these treatments have been questioned.The authors present 3 patients with traumatic optic nerve injury, 1 due to a gunshot wound to the face and 2 caused by blunt facial trauma, where fragments of bone intrude into the orbit leading to compression of its content. These injuries where successfully treated with both preoperative intravenous steroids followed by acute surgical decompression of the orbit with return of visual function.

The Use of Dehydrated Human Amniotic/Chorionic Membrane Skin Substitute in the Treatment of Pediatric Facial Burn.

BACKGROUND: Facial burns have lasting physical and psychological effects on pediatric patients. Proper management to minimize morbidities challenges reconstructive surgeons. New technologies allowed the development of skin substitutes such as amniotic and chorionic membranes, yet the use of these skin dressings and their impact on burn outcomes have not been sufficiently studied to guide practices. The objective of this study is to report on the outcomes of dehydrated amniotic membrane as a biologic skin dressing in pediatric facial burn injury compared to cadaveric allografts. METHODS: Retrospective review of data collected from our institutional burn registry from 2012 to 2016. The study population included patients younger than 16 years with facial burns. Patients between 2012 and 2014 received cadaveric allografts, whereas during 2015 to 2016 patients received dehydrated human amniotic/chorionic membrane as standard treatment. Demographic characteristics and outcome measures were compared between the 2 groups. RESULTS: Included 30 patients with a mean age of 3.7 years and with an average total body surface area burn of 6.8% (2%-27%). Mean injury severity scores did not significantly differ between both groups, 1.8 in amniotic group versus 2.3 in cadaveric skin group (P > 0.05). There were 4 complications (3 hypertrophic scars and 1 wound infection) in the cadaveric allografts group versus no complications in the amniotic membrane group (P < 0.05). CONCLUSION: Dehydrated amniotic/chorionic membrane wound dressings are a safe alternative to cadaveric allografts in treating pediatric partial thickness facial burns.

Spontaneous Temporomandibular Joint Dislocation.

Dislocation of the temporomandibular joint (TMJ) is the displacement of the head of the condyle from its normal position in the glenoid fossa. Anterior dislocations are the most common type of TMJ dislocations. Prognathism of the lower jaw, anterior crossbite, and open bite are the classic features in bilateral TMJ dislocations.The treatment of acute TMJ dislocation involves manual reduction with or without general anesthesia. The use of maxillomandibular fixation is reserved for chronic, more complex dislocations. Determining the presence of a predisposing factor is very important in guiding the correct treatment and management for this condition.The authors present a case of acute spontaneous temporomandibular joint dislocation where multiple predisposing factors were recognized, requiring treatment with maxillomandibular fixation after manual reduction.

The Role of Overseas Missions in Plastic Surgery Resident Education.

Surgical mission work serves an important role in the education of plastic surgeons. Here, we examine the ways that participation in surgical mission work enhances resident education from the trainee's perspective.

N-acetyl-l-cysteine decreases intra-abdominal adhesion formation through the upregulation of peritoneal fibrinolytic activity and antioxidant defenses.

BACKGROUND: Intraperitoneal adhesions occur in more than 94% of patients after abdominal surgery. Mechanisms that decrease oxidative stress and upregulate peritoneal fibrinolysis reduce adhesions. N-acetyl-l-cysteine (NAC) is a clinically relevant antioxidant whose effect on peritoneal fibrinolysis and ability to decrease adhesions has not been established. The aims of this study were to determine if NAC reduces adhesions and to characterize its potential mechanism(s) of action. METHODS: Male Wistar rats (n = 92) received 0.9% saline (OP Control), intraperitoneal NAC (150 mg/kg, OP + NAC), or oral NAC (1200 mg/kg) twice daily on preoperative day 1, day of operation, and postoperative day 1. Adhesions were induced on the day of operation using our previously described ischemic button model. Animals were killed on postoperative day 7 for adhesion scoring. Peritoneal tissue and fluid from the intraperitoneal NAC group were measured at 24 hours for fibrinolytic activity, tissue plasminogen activator (tPA), plasminogen activator inhibitor-1 (PAI-1), total glutathione, and 8-isoprostane (8-IP). The effect of NAC on tPA and PAI-1 production was tested in vitro in human mesothelial cells. The effect of NAC on intestinal wound healing was measured using colonic anastomotic burst pressures. RESULTS: Intraperitoneal NAC reduced adhesions by 53% (P < .001) compared to OP Controls without affecting anastomotic wound healing. NAC increased the tPA/PAI-1 protein ratio and peritoneal fibrinolytic activity by 69% and 127%, respectively, compared to OP Controls (P < .05). NAC did not restore total glutathione levels in peritoneal adhesion tissue but decreased 8-IP by 46% and 65% (P < .05) in peritoneal tissue and fluid, respectively, compared to OP Controls. Human mesothelial cells incubated with NAC exhibited a concentration-dependent increase in the tPA/PAI-1 ratio, which supported in vivo observations (P < .05). Oral NAC did not decrease adhesions. CONCLUSION: NAC administered intraperitoneally decreased adhesion formation while upregulating peritoneal fibrinolytic activity and antioxidant defenses without affecting normal anastomotic wound healing. These data suggest a potential new therapeutic use for NAC in adhesion prevention.

The efficacy of a hyaluronate-carboxymethylcellulose bioresorbable membrane that reduces postoperative adhesions is increased by the intra-operative co-administration of a neurokinin 1 receptor antagonist in a rat model.

BACKGROUND: Bioresorbable membranes composed of hyaluronic acid and carboxymethylcellulose (HA/CMC) are the most effective method to prevent intra-abdominal adhesions; however, their efficacy may be limited to the site of application. Previous studies in our laboratory have shown that the intraperitoneal administration of a neurokinin-1 receptor antagonist (NK-1RA) reduces adhesions; however, the co-administration of HA/CMC plus an NK-1RA has not been studied. METHODS: Adhesions were induced in rats by creating ischemic buttons on the peritoneum. Rats received NK-1RA, HA/CMC, HA/CMC+NK-1RA or saline intraperitoneally at surgery. The HA/CMC was applied either bilaterally over all ischemic buttons or unilaterally over half the ischemic buttons. Animals were sacrificed and adhesions quantified at 7 days. Peritoneal fluid was collected at 24 hours to measure peritoneal tissue plasminogen activator (tPA) activity using a bioassay. RESULTS: The bilateral placement of HA/CMC alone reduced adhesions by 62% (P < .05) while the NK-1RA when administered alone reduced adhesions by 45% (P < .05), both groups compared with saline controls. The bilateral placement of HA/CMC+ NK-1RA decreased adhesions by 86% (P < .05) compared with saline controls and by 70% (P < .05) compared with either HA/CMC or NK-1RA alone. Unilateral application of HA/CMC resulted in a 41% decrease (P < .05) in adhesions where placed compared with the distal unprotected buttons in the same animal. However, the unilateral placement of HA/CMC+NK-1RA reduced adhesions by nearly 75% (P < .05) at the site of HA/CMC application compared with HA/CMC + saline, and by 45% (P < .05) at the distal unprotected buttons compared with saline controls. HA/CMC and the NK-1RA alone as well as HA/CMC+NK-1RA increased peritoneal tPA activity by 124%, 432%, and 192%, respectively (P < .05) compared with saline controls. CONCLUSION: The co-administration of HA/CMC plus NK-1RA not only increases the efficacy of the membrane at the site of application, but significantly reduces adhesions formation at distal unprotected sites. This combination may represent an emerging concept in more effective adhesion prevention throughout the peritoneum.

Practical limitations of bioresorbable membranes in the prevention of intra-abdominal adhesions.

INTRODUCTION: Intra-abdominal adhesions are a significant source of postoperative morbidity. Bioresorbable barriers composed of hyaluronic acid and carboxymethylcellulose (HA/CMC) reduce adhesion formation by physically separating injured or healing peritoneal surfaces. To assess whether the efficacy of a physical barrier can extend beyond the site of application, we evaluated the effectiveness of an HA/CMC barrier in preventing adhesions distal to the site of placement. METHODS: Adhesions were induced in rats by creating peritoneal ischemic buttons on either side of a midline incision. An HA/CMC barrier (Seprafilm Genzyme) was intraoperatively placed either under the midline incision, unilaterally over half the ischemic buttons, or bilaterally over all ischemic buttons. Control buttons received no HA/CMC. On day 7 adhesions were scored. In similar experiments, peritoneal fluid was collected at 24 h to assess the effects of HA/CMC on tissue plasminogen activator activity. RESULTS: Placement of HA/CMC under the midline incision did not reduce adhesion formation to distal ischemic buttons (72 +/- 7%) compared to controls (80 +/- 8%). Unilateral placement of HA/CMC significantly (p < 0.05) reduced adhesion formation to those ischemic buttons over which the barrier was applied (35 +/- 7%) compared to both contralateral (83 +/- 9%) and control (80 +/- 8%) ischemic buttons. The bilateral application of HA/CMC also significantly (p < 0.05) reduced adhesion formation to all ischemic buttons compared to controls (22 +/- 7% vs. 66 +/- 7%, respectively). HA/CMC did not affect peritoneal tPA activity. CONCLUSIONS: Effective adhesion reduction by the physical barrier HA/CMC appears to be limited to the site of application in this rat model. Despite the presence of a bioresorbable membrane at predicted sites of adhesion formation in the peritoneal cavity, adhesions readily form to distal unprotected sites.

An FDA approved neurokinin-1 receptor antagonist is effective in reducing intraabdominal adhesions when administered intraperitoneally, but not orally.

INTRODUCTION: Postoperative adhesions pose a continued healthcare problem. We previously demonstrated that intraperitoneal (i.p.) administration of a neurokinin-1 receptor antagonist (NK-1RA) at surgery reduces intraabdominal adhesions in rats. The NK-1RA aprepitant (Emend, Merck) is clinically approved for preventing postoperative nausea and vomiting; however, its effects on adhesion formation are unknown. Thus, we determined the effects of i.p. and oral administration of aprepitant on adhesion formation in a rat model. METHODS: Adhesions were surgically induced in rats that were randomized to receive either one or five oral preoperative doses or a single intraoperative i.p. dose of aprepitant (50 mg/kg). Adhesions were scored at 7 days. In similar experiments using i.p. dosing, animals were sacrificed at 24 h and peritoneal fluid, and tissue were collected to assess fibrinolytic activity and tissue plasminogen activator (tPA) and plasminogen activator inhibitor-1 (PAI-1) mRNA levels, respectively. RESULTS: I.p. aprepitant reduced adhesion formation by 33% (p < 0.05) compared with controls while oral aprepitant had no effect. Compared to controls i.p. aprepitant reduced tPA activity by 55% (p < 0.05), increased PAI-1 mRNA levels by 140% (p < 0.05), and had no affect on tPA mRNA levels. CONCLUSION: These data suggest that aprepitant maybe a useful pharmacologic agent for reducing adhesion formation clinically.