Enoxaparin dose adjustment is associated with low incidence of venous thromboembolic events in acute burn patients.

BACKGROUND: Inadequate antifactor Xa levels have been documented in critically ill patients given prophylactic enoxaparin and may result in increased risk of venous thromboembolic (VTE) events. The objective of this study was to examine the impact of dose adjustment of enoxaparin and associated incidence of VTE in acute burn patients. METHODS: All acute burn patients who were treated with prophylactic enoxaparin on a burn/trauma intensive care unit were prospectively followed. Patients with subtherapeutic antifactor Xa levels had enoxaparin doses increased as per unit protocol with the goal of obtaining a therapeutic antifactor Xa level. RESULTS: Eighty-four acute burn patients who were treated with enoxaparin had at least one appropriately obtained antifactor Xa level between June 2009 and October 2010. Initial antifactor Xa levels in 64 patients (76.2%) were below 0.2 U/mL, resulting in increased enoxaparin dose. Fifteen patients never achieved the target antifactor Xa level before enoxaparin was discontinued. Median final enoxaparin dose required to achieve therapeutic antifactor Xa levels was 40 mg every 12 hours (range, 20-70 mg). Using linear regression, final enoxaparin dose correlated with burn size (%total body surface area) and weight. No episodes of hemorrhage, thrombocytopenia, or heparin sensitivity were documented. Two patients (2.4%) had VTE complications despite adequate prophylaxis. CONCLUSIONS: Frequent occurrence of low antifactor Xa levels observed in this study demonstrated the inadequacy of standard dosing of enoxaparin for VTE prophylaxis in many patients with acute burns. Enoxaparin dose adjustment was associated with a low incidence of VTE events and no bleeding complications.

Executive summary: Guidelines for the prevention of infections associated with combat-related injuries: 2011 update: endorsed by the Infectious Diseases Society of America and the Surgical Infection Society.

Despite advances in resuscitation and surgical management of combat wounds, infection remains a concerning and potentially preventable complication of combat-related injuries. Interventions currently used to prevent these infections have not been either clearly defined or subjected to rigorous clinical trials. Current infection prevention measures and wound management practices are derived from retrospective review of wartime experiences, from civilian trauma data, and from in vitro and animal data. This update to the guidelines published in 2008 incorporates evidence that has become available since 2007. These guidelines focus on care provided within hours to days of injury, chiefly within the combat zone, to those combat-injured patients with open wounds or burns. New in this update are a consolidation of antimicrobial agent recommendations to a backbone of high-dose cefazolin with or without metronidazole for most postinjury indications and recommendations for redosing of antimicrobial agents, for use of negative pressure wound therapy, and for oxygen supplementation in flight.

Guidelines for the prevention of infections associated with combat-related injuries: 2011 update: endorsed by the Infectious Diseases Society of America and the Surgical Infection Society.

Despite advances in resuscitation and surgical management of combat wounds, infection remains a concerning and potentially preventable complication of combat-related injuries. Interventions currently used to prevent these infections have not been either clearly defined or subjected to rigorous clinical trials. Current infection prevention measures and wound management practices are derived from retrospective review of wartime experiences, from civilian trauma data, and from in vitro and animal data. This update to the guidelines published in 2008 incorporates evidence that has become available since 2007. These guidelines focus on care provided within hours to days of injury, chiefly within the combat zone, to those combat-injured patients with open wounds or burns. New in this update are a consolidation of antimicrobial agent recommendations to a backbone of high-dose cefazolin with or without metronidazole for most postinjury indications, and recommendations for redosing of antimicrobial agents, for use of negative pressure wound therapy, and for oxygen supplementation in flight.

Telemedicine evaluation of acute burns is accurate and cost-effective.

BACKGROUND: As the number of US burn centers has declined, access to burn care is increasingly limited. Inexperience in burn wound assessment by referring physicians often results in overtriage or undertriage. In an effort to improve access to burn care in our region, we instituted a program of telemedicine evaluation of acute burns. METHODS: We created a telemedicine network linking our burn center to three hospitals located 298 to 350 air miles away. Participants agreed to perform telemedicine consultation for acutely burned patients admitted to their emergency departments. We compared consults and referrals from these facilities during the period July 2005 to August 2007 (TELE) to those during a 2-year period before instituting telemedicine (PRE-TELE). RESULTS: During the TELE period, 80 patients were referred, of whom 70 were seen acutely by telemedicine, compared with 28 PRE-TELE referrals. The groups did not differ in age or burn size. Only 31 patients seen by telemedicine received emergency air transport (44.3%), compared with 100% of PRE-TELE patients (p < 0.05). Nine other TELE patients were transported by family; 30 other patients were treated locally. Ten remaining patients were transported without telemedicine evaluation. TELE patients transported by air had somewhat larger burn sizes (9.0% vs. 6.5% total body surface area; p = NS) and longer length of stay (13.0 days vs. 8.0 days; p = NS) than PRE-TELE patients. Burn size estimates by burn center physicians made either by telemedicine or direct inspection correlated closely but both differed significantly from those of referring physicians. Providers and patients expressed a high level of satisfaction with the telemedicine experience. CONCLUSIONS: Acute evaluation of burn patients can be performed accurately by telemedicine. This can reduce undertriage or overtriage for air transport, improve resource utilization, and both enhance and extend burn center expertise to many rural communities at low cost.

Prevention and management of infections associated with burns in the combat casualty.

Burns complicate 5% to 10% of combat associated injuries with infections being the leading cause of mortality. Given the long term complications and rehabilitation needs after initial recovery from the acute burns, these patients are often cared for in dedicated burn units such as the Department of Defense referral burn center at the United States Army Institute of Surgical Research in San Antonio, TX. This review highlights the evidence-based recommendations using military and civilian data to provide the most comprehensive, up-to-date management strategies for burned casualties. Areas of emphasis include antimicrobial prophylaxis, debridement of devitalized tissue, topical antimicrobial therapy, and optimal time to wound coverage.

Guidelines for the prevention of infection after combat-related injuries.

Management of combat-related trauma is derived from skills and data collected in past conflicts and civilian trauma, and from information and experience obtained during ongoing conflicts. The best methods to prevent infections associated with injuries observed in military combat are not fully established. Current methods to prevent infections in these types of injuries are derived primarily from controlled trials of elective surgery and civilian trauma as well as retrospective studies of civilian and military trauma interventions. The following guidelines integrate available evidence and expert opinion, from within and outside of the US military medical community, to provide guidance to US military health care providers (deployed and in permanent medical treatment facilities) in the diagnosis, treatment, and prevention of infections in those individuals wounded in combat. These guidelines may be applicable to noncombat traumatic injuries under certain circumstances. Early wound cleansing and surgical debridement, antibiotics, bony stabilization, and maintenance of infection control measures are the essential components to diminish or prevent these infections. Future research should be directed at ideal treatment strategies for prevention of combat-related injury infections, including investigation of unique infection control techniques, more rapid diagnostic strategies for infection, and better defining the role of antimicrobial agents, including the appropriate spectrum of activity and duration.

Reduction of the incidence of amputation in frostbite injury with thrombolytic therapy.

HYPOTHESIS: Thrombolytic therapy will decrease the incidence of amputation when administered within 24 hours of exposure. DESIGN: Single institution retrospective review of clinical outcomes and resource use. SETTING: Burn unit of a tertiary academic referral center. PATIENTS: From 2001 to 2006, patients with severe frostbite admitted within 48 hours of injury underwent digital angiography and treatment with intra-arterial tissue plasminogen activator (tPA) if abnormal perfusion was demonstrated. These patients were compared with those treated from 1995 to 2006 who did not receive tPA. INTERVENTIONS: Tissue plasminogen activator vs traditional management of frostbite injury. MAIN OUTCOME MEASURES: Number and type of surgery were recorded, along with amputations of digits (fingers or toes) and more proximal (ray, transmetatarsal, or below-knee) amputations. Resource utilization including length of stay, total costs, cost per involved digit, and cost per saved digit were analyzed. RESULTS: Thirty-two patients with digital involvement (hands, 19%; feet, 62%; both, 19%) were identified. Seven patients received tPA, 6 within 24 hours of injury. The incidence of digital amputation in patients who did not receive tPA was 41%. In those patients who received tPA within 24 hours of injury, the incidence of amputation was reduced to 10% (P<.05). CONCLUSIONS: Tissue plasminogen activator improved tissue perfusion and reduced amputations when administered within 24 hours of injury. This modality represents the first clinically significant advancement in the treatment of frostbite in more than 25 years.

Burn patient characteristics and outcomes following resuscitation with albumin.

BACKGROUND: Use of colloids in acute burn resuscitation may reduce fluid requirements, but effect on mortality is unknown. We hypothesized that patients who received albumin would have similar mortality to patients who did not receive albumin. METHODS: We performed a case-controlled study of inpatients who sustained burns of > or =20% total body surface area (TBSA). Patients who received albumin during resuscitation because of increased fluid requirements (ALB) were compared to a cohort of patients matched for age and TBSA who did not receive albumin (CON). RESULTS: Patients with inhalation injury were significantly more likely to receive albumin (OR 4.89, 95% CI 2.58-9.30). ALB patients had significantly higher mean initial lactate (3.64 versus 2.29, p=0.01), longer mean time to resuscitation (52.8 h versus 36.3 h; p=0.001), and higher resuscitation volume (9.4 mL/kg/%TBSA versus 6.4 mL/kg/%TBSA for CON). Mortality was not significantly different between the two groups (OR 1.90, 95% CI 0.85-4.22). Albumin was protective in a multivariate model of mortality (OR 0.27, 95% CI 0.07-0.97). CONCLUSIONS: Despite more severe systemic dysfunction, burn patients who received albumin did not suffer increased mortality. A novel finding is the decreased likelihood of mortality associated with the administration of albumin during burn resuscitation.

Telemedicine for acute burn treatment: the time has come.

This brief paper sets out the arguments for the routine use of telemedicine in the evaluation of burns. Two cases are reported from the author's practice that show the need for it.

Fluid Creep and Over-resuscitation.

Fluid creep is the term applied to a burn resuscitation, which requires more fluid than predicted by standard formulas. Fluid creep is common today and is linked to several serious edema-related complications. Increased fluid requirements may accompany the appropriate resuscitation of massive injuries but dangerous fluid creep is also caused by overly permissive fluid infusion and the lack of colloid supplementation. Several strategies for recognizing and treating fluid creep are presented.

Caloric requirements in patients with necrotizing fasciitis.

Patients with necrotizing fasciitis (NF) and other soft tissue infections are often treated in burn centers due to the extent of wound care and surgical intervention needed. Sepsis and surgery increase metabolic needs and may limit oral intake and necessitate enteral (TEN) or parenteral (TPN) nutrition. We reviewed the records of patients admitted with necrotizing fasciitis or surgical soft tissue infections from January 1993 to June 1998 who had indirect calorimetry (IC) measurements performed. Records were also reviewed for surgical/medical management and nutritional intervention. Twenty-six patients were admitted with 17 of these having IC measurements (133 total IC measurements). The IC group had more surgeries (mean 4.9 versus 2.7) and 82% required mechanical ventilation (mean 17.9 days). Energy expenditure showed a moderate but significant increase in energy needs (mean 23.8 kcal/kg/day, 124% BEE) with large variations (10.7-42.4 kcal/kg/day, 60%-199% BEE) in individual energy requirements. Caloric intake averaged 73% of needs based on IC (range 53%-104%). Nearly all patients (94%) required TEN (82%) and/or TPN (41%) nutrition for a mean of 24 days (range 1-68 days). NF presents a broad range of metabolic and surgical needs. Our data indicates patients with NF have increased energy requirements and suggests provision of calories at 124% basal or 25 kcal/kg actual wt/d; but due to the large individual variation, routine assessment using IC is recommended. Clinicians need to recognize the likely need for nutritional support and possibly lengthy clinical course for these patients.

Gender influences on burn outcomes in the elderly.

BACKGROUND: Women, aged 65 and older, now comprise a larger number of injuries requiring hospitalization than do young men. The purpose of this study was to evaluate gender differences in outcome and disposition of elderly (>65 years) burn patients. METHODS: We compared demographic, etiologic, and outcome differences between male and female patients 65 years of age and older admitted for acute burn treatment during a five-year period. RESULTS: Elderly patients comprised 8.5% of burn admissions. Women, who accounted for 33% of burns occurring in this group, tended to have smaller (12.0% versus 17.2% total body surface area (TBSA); p = 0.20) and less severe (3.6% versus 9.7% 3rd TBSA; p < 0.05) injuries, but mortality did not differ from men. Although not significant, elderly women, who were less likely to be married, tended to stay in the hospital longer and were significantly less likely to be discharged home than men (41.7% versus 66.7%; p < 0.05). CONCLUSIONS: Elderly burn patients, particularly women, utilize more resources than younger patients. Further research on the social and economic resources available to the elderly burn population, particularly women, is warranted in order to provide cost effective quality care during acute hospitalization and upon discharge.

Comparison of urine urea nitrogen collection times in critically ill patients.

Twenty-four-hour urine urea nitrogen (UUN) collections are used to assess nitrogen loss in critically ill patients but are often difficult to obtain accurately. This prospective study compared 6- and 12-hour UUN collections with 24-hour UUN collections in critically ill patients receiving continuous nutrition support. ICU patients admitted from September 1999 through January 2003 who had UUN collections as part of routine care were recruited into the study. Patients were not receiving oral diets, were receiving continuous parenteral or enteral nutrition, and had indwelling urinary catheters. We excluded patients with hepatic or renal failure. Urine samples were collected every 6 hours starting at 6:00 am and kept refrigerated until the 24-hour collection was complete. Samples were analyzed using an automated urease enzymatic reaction. Samples were multiplied by a factor of 4 (6-hour samples) or 2 (12-hour samples) to estimate 24-hour totals and then compared with actual 24-hour totals. Twenty-four patients (18 men) completed the study; 21 patients had 6-hour samples (84 samples), and 24 patients had 12-hour samples (24 samples). Estimated 24-hour UUN from 6-hour (14.7-15.7 g/d) and 12-hour (15.2 g/d) samples did not differ significantly (p > .5) from actual 24-hour totals (15.1 g/d). Shortened UUN collection times may be used to estimate 24-hour nitrogen losses in critically ill patients receiving continuous nutrition support.

Defining the ratio of outcomes to resources for triage of burn patients in mass casualties.

Management of a mass casualty involving burn patients that overwhelms local resources will likely require a triage process in which limited resources are devoted to the patients with the highest likelihood of survival. No objective criteria exist which define how patients could be categorized in such a situation. A table that classifies patients according to their anticipated survival from burn injury, and the resources required to achieve that survival, is presented here. The limitations and restrictions of applying such a guideline are discussed in detail.

Transition from grant funding to a self-supporting burn telemedicine program in the western United States.

BACKGROUND: Many Americans have limited access to specialty burn care, and telemedicine has been proposed as a means to address this disparity. However, many telemedicine programs have been founded on grant support and then fail once the grant support expires. Our objective was to demonstrate that a burn telemedicine program can be financially viable. METHODS: This retrospective review from 2005 to 2014 evaluated burn telemedicine visits and financial reimbursement during and after a Technology Opportunities Program grant to a regional burn center. RESULTS: In 2005, we had 12 telemedicine visits, which increased to 458 in 2014. In terms of how this compares to in-person clinic visits, we saw a consistent increase in telemedicine visits as a percentage of total clinic visits from .26% in 2005 to 14% in 2014. Median telemedicine reimbursement has been equivalent to in-person visits. CONCLUSIONS: Specialty telemedicine programs can successfully transition from grant-funded enterprises to self-sustaining. The availability of telemedicine services allows access to specialty expertise in a large and sparsely populated region without imposing an undue financial burden.

Systemic Candida infection in burn patients: a case-control study of management patterns and outcomes.

BACKGROUND: Burn patients are ideal hosts for opportunistic infections. Candida infection in burn patients has a reported mortality ranging from 14% to 90%. This retrospective case-control study compares management patterns and outcomes of burn patients who develop systemic Candida with those who do not. METHODS: Inpatients at our burn center with two or more positive culture sites for Candida from January 1, 1995, through December 31, 2000 and who sustained burn injury of >/=10% total body surface area (TBSA) were identified. A cohort of patients without Candida was matched for age and size of burn injury using our institution's TRACS/ABA trade mark registry. Management variables included days to burn wound coverage; use of artificial dermis; number of antibiotic days; treatment with imipenem, vancomycin, or aminoglycosides; need for abdominal surgery; and receipt of tracheostomy. Outcome measures were hospital length of stay (LOS) and mortality. RESULTS: Candida patients (n = 44) had a mean age of 39.8 years, and sustained an average burn size of 47.2% TBSA with 28.6% full-thickness injury. Controls (n = 44) had a mean age of 39.8 years, and sustained an average burn size of 46.0% TBSA with 26.6% full-thickness injury. Patients with multiple Candida sites required 36 days to achieve burn wound coverage with autograft versus 21 days for the control group (P = 0.004). Candida patients were significantly more likely to be managed with artificial dermis than were controls (Odds Ratio = 9.56, 95% Confidence Interval = 1.64-181.53). Patients with Candida infection averaged 72 days of treatment with systemic antibiotics, whereas the controls averaged only 36 days of antibiotic treatment (P = 0.001). Further, patients with multiple sites of Candida were more likely to have received imipenem, vancomycin, or an aminoglycoside (Odds Ratio = 11.99, 95% Confidence Interval = 3.10-79.71). Mean LOS was 62 days for patients with Candida and 30 days for the controls (P < 0.001). The mortality rate in patients with Candida was 23%, which did not differ significantly from the 27% mortality rate of the controls. CONCLUSION: Early wound coverage with autograft clearly decreases the likelihood of systemic Candida infection in burn patients. Patients who received artificial dermis as a component of their wound management strategy more often developed systemic Candida infection in this series. Burn patients who require prolonged courses of antibiotics or treatment with broad-spectrum antibiotics should be carefully monitored for the development of Candida. Survival of burn patients who develop systemic Candida infection is no different from survival in comparable burn patients who do not acquire Candida. Future research should address optimal management of Candida infection in burn patients.

Effective limitation of blood culture use in the burn unit.

UNLABELLED: There is little data to support the use of blood culture (BC) testing in the burn patient. Clinical signs (fever, leukocytosis) may not reliably indicate infection; moreover, BC's are expensive, invasive and plagued by false positive results. A policy of critical evaluation of lab utilization was instituted in our burn unit in 1993. By 1997 the use of blood culture testing had decreased by 50%. A retrospective analysis of our change in BC utilization was undertaken to derive practice guidelines for usage of this test. METHODS: 47 patients with BC testing in 1997 were compared to a cohort of 47 patients from 1993, representing a total of 441 BC episodes. RESULTS: Comparison of 1993 and 1997 patients revealed no significant differences in patient characteristics or outcomes. The mean white blood cell count and maximum temperature on the day of culture were identical for both positive and negative BC episodes. However, BC's drawn during a state of shock were twice as likely to be positive. Patients who experienced positive BC's had larger burns, received more antibiotics, had more indwelling catheters, and had longer lengths of ventilator support and hospital stays. CONCLUSIONS: Higher patient acuity or the presence of indwelling catheters increases the likelihood of a positive BC. Substantial limitation of BC's without observed changes in length of stay, ventilator days, or mortality suggests that this test can be safely limited without compromising patient outcomes.

Early tracheostomy does not improve outcome in burn patients.

Early tracheostomy (ET) has been claimed to reduce ventilator support or intensive care unit or hospital length of stay in intensive care unit patients. This study was performed to assess the potential benefits of ET in burn patients. From October 1996 to July 2001, we evaluated all intubated and acutely burned adults using a formula to predict the probability of prolonged ventilator dependence. We randomized each patient with a probability of prolonged ventilator dependence more than 0.5 to ET, performed on the next operative day, or to conventional therapy (CON), which consisted of continued endotracheal intubation as needed, with tracheostomy (TRACH) performed on postburn day (PBD) 14 if necessary. During this period, 44 patients were randomized, 23 to CON and 21 to ET. Groups did not differ in age, total burn size, or inhalation injury, although ET patients had larger full-thickness burns. ET patients underwent TRACH at a mean of PBD 4 vs PBD 14.8 for CON patients (P <.01). ET patients had a significant improvement in PaO2 /FiO2 ratios within 24 hours following TRACH (139 +/- 15 vs 190 +/- 12; P <.01). There were no differences in ventilator support, length of stay, incidence of pneumonia, or survival. However, six CON patients (26%) were successfully extubated by PBD 14 compared with one ET patient (P <.01). Although tracheostomy offers some advantages in terms of patient comfort and security, routine performance of ET in burn patients does not improve outcomes, nor does it result in earlier extubation. This may be partly caused by the comfort and convenience of tracheostomy.