Recent advances in burn care.

Over the past few decades, the mortality related to thermal injuries has been significantly reduced. This has been accomplished through an increased understanding and subsequent management of inhalation injury, the postburn hypermetabolic response, and immunocompromise. In addition, the prompt excision of the burn wound and early permanent closure has decreased the length of hospital stay and has facilitated timely social reintegration of the burned patient.

The effect of erythropoietin in normal healthy volunteers and pediatric patients with burn injuries.

BACKGROUND: Surgical procedures result in blood loss that can require replacement transfusions. Such therapy may result in multiple adverse sequelae, including transmission of infectious diseases and immune impairment. Alternative therapies are therefore desirable. METHODS: We evaluated the ability of recombinant human erythropoietin (rEPO) to increase red blood cell production in both normal healthy volunteers and patients with burn injuries. The effect of rEPO on immune function in the volunteers was also evaluated. The volunteers received 150 units/kg rEPO daily for 7 days, with immune function and hematopoiesis assayed on days 0, 7, and 14. The patients with burn injuries received either 500 units/kg/day rEPO with iron supplementation or merely the iron. RESULTS: rEPO increased erythropoiesis in both the volunteers and the patients with burn injuries. Failure to provide iron supplementation to the volunteers resulted in significant depletion of iron stores with a concomitant impairment in immune function that paralleled the iron depletion. CONCLUSIONS: rEPO therapy offers the potential to increase red blood cell production in surgical patients. Failure to provide iron supplementation in patients receiving rEPO can lead to a rapid depletion of iron stores and may contribute to an immune dysfunction.

Extravascular lung water changes following smoke inhalation and massive burn injury.

During a 3-year period (1984 through 1987), 40 patients with smoke inhalation, cutaneous burns, or a combination of both injuries were studied. Injuries were assigned to the three categories on the basis of bronchoscopic findings and clinical history. Eleven patients had simultaneously sustained a common smoke-inhalation injury without burns while trapped in a burning ship; twelve patients had massive cutaneous burns over 50% of the total body surface area (TBSA); and seventeen patients had cutaneous burns over more than 30% of the TBSA and inhalation injury. Colloid oncotic pressure was maintained with salt-poor albumin infusion. Central venous pressure, arterial saturation, inspired oxygen, arterial pressure, and urine output were continuously monitored. Extravascular lung water (EVLW) and cardiac output were measured by the double indicator (thermal dye dilution) technique. EVLW remained normal throughout the study period in the group of patients with burns alone. In the first 24 hours after injury, EVLW increased in both groups with smoke injury and remained elevated for more than 48 hours after injury in patients with smoke injury only. The group with both smoke-inhalation and burn injuries showed an early increase in EVLW, which returned to normal by 28 hours after injury and which remained normal until 5 days after injury. The EVLW level then increased again until the end of the study period. In this study, lung edema formation is attributed to the toxic effect of smoke inhalation.

Growth delay in postburn pediatric patients.

Dampened height and weight velocities have been observed in our postburn pediatric population. To validate this phenomenon, the medical records of 80 patients who had sustained a greater than 40% total body surface area burn, were older than 2 years of age at the time of the burn, and were at least 1 year post burn were reviewed. All patients were treated with early excision of the burn wound within 72 hours of injury and received standard post burn resuscitational and nutritional support. Admission height and weight plots were within normal distribution parameters. Yearly growth velocities were calculated for up to 3 years after the burn. Despite adequate nutritional support and maximal exercise and/or long-bone stresses, a profound growth arrest was noted during postburn year 1, which slowly resolved to near normal distribution by postburn year 3. This retrospective study demonstrates that severe thermal injury is associated with a growth delay in the pediatric population. The exact cause of this phenomenon remains unknown.

Academic surgeons' knowledge of Food and Drug Administration regulations for clinical trials.

OBJECTIVES: To identify knowledge levels of academic surgeons about Food and Drug Administration (FDA) and Institutional Review Board (IRB) regulations for clinical research and to determine whether being a member in an IRB, conducting or participating in clinical trials, or being a member in surgical societies affected knowledge levels. DESIGN: Survey of surgical department faculty members in 20 universities. RESULTS: Sixty-five responses were received from 14 sites. Overall mean (+/- SEM) correct score was 6.7 +/- 0.2 of a possible 20 points. The best predictor of overall score was being a primary investigator of a clinical trial (P < .001), followed by being or having been a member of an IRB (P < or = .02). The total mean score of members of the Surgical Infection Society (8.2 +/- 0.5) was significantly higher (P < .001) than that of nonmembers (6.1 +/- 0.2), a phenomenon not observed with other surgical societies. In certain hypothetical clinical scenarios, all respondents were mistakenly willing to conduct clinical trials without obtaining appropriate approval from the FDA. Four (22%) of 18 IRB member respondents and 16 (25%) of the 65 respondents were willing to conduct human research without appropriate approval from patients, the IRB, or both. CONCLUSIONS: Knowledge deficits exist in the academic surgical community about the role and requirements of the FDA and local IRBs for conducting clinical research. Further study is required to determine the reasons for this deficit and to identify appropriate interventions.

Candida infection with and without nystatin prophylaxis. A 11-year experience with patients with burn injury.

The incidence of opportunistic infections after thermal injury is high. Since 1985, we have been practicing Candida prophylaxis using nystatin "swish-and-swallow" and topical therapy. Patients treated between 1980 and 1984 served as controls and received no Candida prophylaxis. Although mean burn size, full-thickness injury, and age were comparable, the incidence of Candida colonization (26.7% vs 15.6%), infection (21.3% vs 10.0%), and sepsis (12.2% vs none) was significantly different between control and nystatin-treated groups, respectively. With prophylaxis, the incidence of Candida wound infection has been significantly reduced, and systemic candidiasis has been eradicated, eliminating the need for toxic systemic antifungal agents.

Incidence of HIV seroconversion in paediatric burn patients.

A retrospective review of paediatric patients treated for acute burn injuries and receiving blood/blood products between 1978 and 1985, identified 52 patients at risk for HIV infection. Over 50 per cent of the identified population had received 3 or more units of blood/blood products during their acute hospital stay. A total of 214 patients (36.8 per cent) have been tested for HIV seroconversions: five tested HIV positive by ELISA and four were confirmed by Western Blot, yielding a 1.9 per cent incidence. The four confirmed patients received 2-9 total body blood volume turnovers during their postburn period in hospital. At 4 years post-exposure, two patients show active disease, one is currently asymptomatic and one has died from AIDS-related sepsis.

Longitudinal assessment of breast development in adolescent female patients with burns involving the nipple-areolar complex.

Long-term follow-up of breast development in adolescent female patients with burns of the anterior chest wall is poorly documented. Between 1971 and 1976, 28 female patients with photographic documentation of burns to the anterior chest wall involving the nipple-areolar complex were reviewed. All patients were followed at least until their early teens. The mean age at the time of thermal injury was 5.9 +/- 2.5 years, with a mean follow-up time of 8.9 +/- 2.6 years. Thirteen patients (46 percent) were admitted to the Shriners Burns Institute in Galveston for acute care of their burns. Fifteen patients (54 percent) were referred for long-term follow-up or specific reconstructive procedures following care of the acute burns. In spite of significant thermal injury to the anterior chest wall with involvement of the nipple-areolar complex, no patient failed to develop breasts. Twenty patients (71 percent) required releases of the anterior chest wall to assist breast development. All anterior chest wall releases were accomplished with the use of skin grafts or local skin flaps.

A nineteen-year review of nurse-authored abstracts presented to the American Burn Association. Implications for the future.

The previous investigations of nurse authors have impact on and provide guidance for the future paths of research endeavors. A review of the past 19 years of American Burn Association abstract presentations was performed to identify nurse-authored presentations and describe their nature and content. Nurse authors were identified on 18% of all abstracts presented and were primary authors of 7.7% of all abstracts presented. Those who collaborated most frequently with nurse authors were other nurses (41%) and physicians (37%). Descriptive studies were most frequently presented, followed first by reports and then by experimental designs. Fewer than one half of the reported studies possessed statistical support for their findings. Nurse authors are most frequently investigating issues of direct patient care, such as wound management, medications, complications, and psychosocial issues.

Comparison of cultured epidermal autograft and massive excision with serial autografting plus homograft overlay.

The chief determinant of mortality in severe burn injuries has been the size and severity of the wound. Early massive excision of the wound has increased the median lethal dose to 98% of total body surface area burn but presents the problem of wound closure. Autograft substitutes must be used for a large burn. We report our experience with early massive excision in the treatment of 47 pediatric patients with burns who had greater than 80% total body surface area burn and greater than 80% full-thickness burn. Four patients died within hours of admission. Fifteen patients died of sepsis and multiorgan failure; the primary source of bacterial contamination was the open wound. The 28 survivors received approximately 2.0 m2 2:1 homograft until autograft became available. A case report of a 10-year-old boy illustrates the use of two types of cultured epidermal autograft, one "homegrown" and one commercially produced.

Conservative treatment of scald burns is superior to early excision.

Early excision of deep burns has been advocated; however, it is difficult to clinically determine the depth of scald burns during the early postburn period. This prospective, randomized study was designed to determine whether early excision was superior to conservative treatment of scald injuries. Patients with scald injuries (which were not caused by grease) of clinically indeterminant depth were randomized to early (n = 12) or late (n = 12) excision; all patients with obvious superficial and full-thickness injuries were excluded. In the early excision group, all deep wounds were tangentially excised and grafted within 72 hours of admission, whereas in the late treatment group wounds were excised and grafted after 2 weeks had passed since injury. Area excised, postburn day of excision, percent graft take, operating-room time, blood replacement, incidence of infection, and length of hospital stay were compared. No patient experienced a significant wound infection or systemic sepsis. A significantly smaller area of excision was necessary for those patients who were treated with delayed surgery, and concomitant decreases in operating-room time and blood loss were observed. Notably, only one half of the patients who were randomized to the delayed excision group ultimately required surgical intervention to achieve wound closure. Graft take was comparable for both groups, as was length of hospital stay. Early clinical evaluation of scald injuries appears to be equivocal, and later evaluations reveal a less severe injury. Financial gains can be made when surgical excision of scald injuries is delayed until 2 weeks after injury because of a related reduction in hospital expenditures.

An unusual donor site, a lifesaver in extensive burns.

The availability of donor sites is a limiting factor in autologous skin grafting and, therefore, the survival of patients with large total body surface area (TBSA) burns. Of 19 males admitted to our facilities with burns greater than 80% TBSA, eight had the scrotum spared injury. The remaining 11 patients served as a control population to study the efficacy of scrotal donor harvests. The scrotal skin was expanded using the Pitkin syringe and harvested at a depth of 5/1000 to 8/1000 in, with a mean yield of 73 +/- 8 sq cm. Expanded 4:1, this tissue covered an area of 280 +/- 33 sq cm. The scrotum was harvested 2 +/- 0.4 times, compared to 4 +/- 1 harvests of the other donor group. There were no statistical differences in the number of surgical procedures or the length of hospitalization between the two groups. The scrotal donor sites healed within the same length of time as other donor sites and were harvestable as frequently. Due to the natural expandability of scrotal skin, a large surface area of usable donor site is available and their harvest may be lifesaving in male patients with large TBSA burns.

Thermal injuries caused by ignition of volatile substances by gas water heaters.

Based on the cumulative data of this tertiary care facility over the past 25 years, one out of every 70 pediatric patients admitted to our institution sustained their injuries during an explosive event instigated by the ignition of volatile substances from gas water heaters. The majority of injuries related to gas water heaters can be prevented by decreasing the temperature setpoint of the heater, by protecting the heater element itself, and by elevating the water heater to 18 inches above the floor. The first two issues have been adequately addressed; however, gas-fueled water heaters continue to be installed at floor level. Current national guidelines are too rigid and do not adequately address water-heater installation in private residences. Although general prevention campaigns target appropriate storage of volatile substances, they rarely address the explosive potential of gas water heaters in combination with combustible fumes.

Management of the pediatric patient with burns.

Two million people in the United States receive medical treatment each year for burn injuries. One hundred thousand of these patients are hospitalized, and 7800 die as a direct result of their injuries. Of the patients that are hospitalized 30% to 40% are under 15 years of age. Sixty-seven percent are male. The average age of children with burns is 32 months. Flame burns account for approximately 13% of accidents, scalds account for 85%, and electrical and chemical burns account for approximately 2%. The majority of scald injuries are small. Sixteen percent of burn injuries are not accidental, and approximately half of these are a result of documentable, inflicted abuse.

Research priorities for burn nursing: report of the psychosocial issues group.

This study was designed to identify nursing research priorities in burn care. The Delphi technique of sequential questionnaires was used for data collection. Ninety-four participants completed four rounds of questionnaires. One hundred and one research questions were identified, and priorities were assigned according to their impact on patient welfare and on the profession of burn nursing. Twenty-two of these research questions concerned psychosocial issues. This group of questions was then analyzed for priority research issues. The top five ranked questions in the psychosocial issues group for impact on patient welfare concerned: (1) stress reduction techniques, (2) social reentry strategies, (3) management of psychosis and post-traumatic stress disorder, (4) strategies to assist patients with impaired communication capabilities, and (5) the role of recovered burn survivors in encouraging patient compliance with treatments. Similarly, the top five ranked questions for impact on the profession of burn nursing concerned: (1) stress reduction strategies, (2) coping techniques for burn survivors, (3) management of psychosis and post-traumatic stress disorder, (4) nursing's supportive role in regard to "do not resuscitate" orders, and (5) coping strategies to be used with patients who express a desire to die.

Management of pediatric perineal and genital burns: twenty-year review.

Between 1966 and 1986, fifty-seven pediatric patients with partial and/or full-thickness perineal and genital burns with a minimum of 1-year follow-up were identified. Fifty percent of the patients with genital burns and 20% of the patients with perineal and/or buttock burns required skin grafting in the acute stage. No patient required suprapubic cystostomies, diverting colostomies, or local flap coverage of exposed testicles. Burn scar contractures were the most frequent complications. Thirty-two patients (56%) required contracture release of the perineum and coverage with either skin grafts or local skin flaps. In three patients (6%) contracture required release of the penis and scrotum. One patient lost a testicle. Three patients developed rectal prolapse and were treated without surgery. Four patients developed rectal stenosis with fecal incontinence because of burn scar contracture and were treated by anal dilatation, local transposition flaps, and/or excision of the scar and primary closure. Acute management of pediatric patients with such injuries can be conservative. Delayed complications of contractures of the perineum and genitals can be easily corrected with scar excisions, skin grafts, or the use of local skin flaps.

Analysis of materials for splinting of the thermally injured patient.

Good results have been achieved in the treatment of patients with burns with new splinting materials and proper splinting techniques. This article focuses on the thermoplastic splinting materials Clinic and Spectrum (Northcoast Medical Inc., San Jose, Calif.) and the comparable thermoplastic products Polyform (Smith & Nephew Rolyan, Inc., Menomonee Falls, Wis.) and Orthoplast (Johnson & Johnson Orthopedics, New Brunswick, N.J.). Qualities such as self-bonding, recyclability, and rigidity were tested for these materials. Splint rigidity was measured by a calibrated hook scale and determined by the force per pound needed to bend the material 20 degrees. Spectrum and Clinic products were judged more economical and, we contend, they are therefore better choices for splinting the thermally injured patient.

Research priorities for burn nursing. Report of the Wound Care and Infection Control Group.

This study was designed to identify research priorities in burn nursing. The Delphi technique of sequential questionnaires was used for data collection. Ninety-four participants completed four rounds of questionnaires. One hundred one research questions were identified and prioritized according to impact on the welfare of patients with burns and impact on the profession of burn nursing. Twenty-three of these research questions concerned issues of wound care or infection control. This group of questions was further analyzed to determine priority research issues. The five most highly ranked questions in the category of wound care/infection control with regard to impact on patient welfare concerned healing of donor sites and skin grafts, wound cleansing, and the effect of pressure garments on wound healing. Similarly, the five most highly ranked questions with regard to impact on the profession of burn nursing concerned the impact of combining patients with burns and patients without burns in the same unit, healing of donor sites and skin grafts, care of the patient with burns who also has acquired immune deficiency syndrome, infection control, and dressing of the burn wound.

Research priorities for burn nursing: patient, nurse, and burn prevention education.

Fifteen of the 101 research questions that were assigned priorities in the Burn Nursing Delphi study by Marvin et al. (Marvin JA, Carrougher GJ, Bayley EW, Weber B, Knighton J, Rutan RL. Burn nursing Delphi study: setting research priorities. J BURN CARE REHABIL 1991;12:190-7) addressed education from the perspectives of patients, their families, and burn nurses; the study also addressed the issue of burn prevention education. Questions concerning patient education were assigned the highest priority in this education subgroup with respect to the potential for research that would have an impact on patient welfare. The question that rated highest as a priority for its potential impact on the profession of burn nursing addressed the core competencies needed for safe and effective burn nursing practice. Prevention education was generally found to be a low priority in the Delphi study. Many of the questions in the education subgroup can best be answered by comparative or experimental studies designed to explain and predict the effects of various teaching strategies on behavioral outcomes. Research on patient, nurse, and burn prevention education provides a fertile ground for nurse researchers and an opportunity to contribute knowledge of vital importance to clinicians, educators, managers, and the public.

Comparison of resting energy expenditures and caloric intake in children with severe burns.

Nutritional support is provided to children after severe burn injuries in amounts derived from empirical formulas or measurements of resting energy expenditure. To scrutinize these methods, indirect calorimetry measurements were performed on 74 survivors of burns (greater than or equal to 40% total body surface area) and compared to their actual caloric intake, percent weight change, and optimal caloric requirements formulated from the Curreri and Shriners' equations. These parameters showed that in spite of an initial deficit in actual caloric intake as compared to formulated goals, weight was maintained, whereas resting energy expenditures ranged from 30% to 40% below the actual caloric intake. Furthermore, a subgroup of patients (n = 42) who met +/- 20% of their formulated needs were stratified by extent of burn; this illustrated a significant weight gain in the more severely burned children. In conclusion, nutritional formulas in popular use overestimate caloric requirements in severe burns, whereas resting energy expenditure measurements require an additional factor of 30% to maintain body weight.