Factors Associated With Mechanical Ventilation Duration in Pediatric Burn Patients in a Regional Burn Center in the United States.

OBJECTIVES: Among burned children who arrive at a burn center and require invasive mechanical ventilation (IMV), some may have prolonged IMV needs. This has implications for patient-centered outcomes as well as triage and resource allocation decisions. Our objective was to identify factors associated with the duration of mechanical ventilation in pediatric patients with acute burn injury in this setting. DESIGN: Single-center, retrospective cohort study. SETTING: Registry data from a regional, pediatric burn center in the United States. PATIENTS: Children less than or equal to 18 years old admitted with acute burn injury who received IMV between January 2005 and December 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Ventilator days were defined as any full or partial day having received IMV via an endotracheal tube or tracheostomy, not inclusive of time spent ventilated for procedures. Of 5,766 admissions for acute burn care, 4.3% ( n = 249) required IMV with a median duration of 10 days. A multivariable model for freedom from mechanical ventilation showed that the presence of inhalational injury (subhazard ratio [sHR], 0.62; 95% CI, 0.46-0.85) and burns to the head and neck region (sHR, 0.94; 95% CI, 0.90-0.98) were associated with increased risk of remaining mechanically ventilated at any time point. Older (sHR, 1.03; 95% CI, 1.01-1.04) and male children (sHR, 1.39; 95% CI, 1.05-1.84) were more likely to discontinue mechanical ventilation. A majority of children (94.8%) survived to hospital discharge. CONCLUSIONS: The presence of inhalational injury and burns to the head and neck region were associated with a longer duration of mechanical ventilation. Older age and male gender were associated with a shorter duration of mechanical ventilation. These factors should help clinicians better estimate a burned child's expected trajectory and resource-intensive needs upon arrival to a burn center.

Antegrade Foreheadplasty: A Novel Surgical Approach for Upper Eyelid Contracture Deformities in Pediatric Patients.

The intricate and delicate structure of the periorbital region, particularly in pediatric patients, presents challenges to eyelid reconstruction. Much like the more common lower eyelid ectropion, upper eyelid ectropion can result from lack of tissue, scar contracture, or over-resection as in blepharoplasty. In burns and trauma, the cause of cicatricial ectropion is typically direct scar contracture from injuries to the eyelid. However, in some cases, extrinsic wounds involving contracture to the forehead or eyebrow can result in upper eyelid cicatricial ectropion. Direct reconstruction and skin grafting of the eyelid present complex challenges, especially in the acute inflammatory phase of traumatic injury and burn care. Furthermore, in many of these cases the periorbital and lamellae anatomy is preserved, but rather severely displaced due to scar contracture forces. The authors discuss our experience with treatment of extrinsic upper eyelid cicatricial ectropion in a series of 4 pediatric patients with burns or trauma to the forehead and periorbital regions. In all 4 cases, the antegrade foreheadplasty procedure helped to provide globe coverage, while avoiding skin matching difficulties and the intrinsic risks of operating on the eyelid during the acute phase of recovery. There is currently very limited data for the use of this technique to correct such defects. With this study, the authors hope to establish the antegrade foreheadplasty as a reconstructive option for a select patient population.

Invasive Infection and Outcomes in a Humanitarian Surgical Burn Program in Haiti.

BACKGROUND: Compare to high-income settings, survival in burn units in low-income settings is lower with invasive infections one leading cause of death. Médecins Sans Frontières is involved in the treatment of large burns in adults and children in Haiti. METHODS: In 2014, we performed a review of 228 patients admitted consecutively with burn injury during a 6-month period to determine patient outcomes and infectious complications. Microbiology was available through a linkage with a Haitian organization. Regression analysis was performed to determine covariates associated with bloodstream infection and mortality. RESULTS: 102 (45 %) patients were male, the median age was 8 years (IQR, 2-28), and the majority of patients (60 %) were admitted to the unit within 6 h of injury. There were 20 patients (9 %) with culture-proven bacteremia. Among organisms in blood, common isolates were Staphylococcus aureus (42 %), Pseudomonas aeruginosa (23 %), and Acinetobacter baumannii (15 %). Among patients with burns involving <40 % total body area, 4 (2 %) of 192 died and 20 (65 %) of 31 with ≥40 % body surface area involvement died. Factors associated with mortality included involvement of ≥40 % of body surface, depth, and flame as the mechanism. Multidrug-resistant infections were common; 18 % of S. aureus isolates were methicillin resistant, and 83 % of P. aeruginosa isolates were imipenem resistant. CONCLUSIONS: A low mortality rate was observed in a humanitarian burn surgery project in patients with burns involving <40 % of total body surface. Invasive infection was common and alarming rates of antibiotic resistance were observed, including infections not treatable with antibiotics available locally.

An automated image processing method to quantify collagen fibre organization within cutaneous scar tissue.

Standard approaches to evaluate scar formation within histological sections rely on qualitative evaluations and scoring, which limits our understanding of the remodelling process. We have recently developed an image analysis technique for the rapid quantification of fibre alignment at each pixel location. The goal of this study was to evaluate its application for quantitatively mapping scar formation in histological sections of cutaneous burns. To this end, we utilized directional statistics to define maps of fibre density and directional variance from Masson's trichrome-stained sections for quantifying changes in collagen organization during scar remodelling. Significant increases in collagen fibre density are detectable soon after burn injury in a rat model. Decreased fibre directional variance in the scar was also detectable between 3 weeks and 6 months after injury, indicating increasing fibre alignment. This automated analysis of fibre organization can provide objective surrogate endpoints for evaluating cutaneous wound repair and regeneration.

Fractional CO2 Laser for Burn Scars: A Comparison of Patient Reported Outcomes Between Those With and Without Laser Treatment.

Burn reconstruction outcomes are an area of growing investigation. Although there is evidence of measured physical improvements in scar characteristics after laser treatment, there is little information on patient reported outcomes. The purpose of this study is to compare patient reported outcomes between burn survivors with and without laser treatment. The study included participants in the Burn Model Systems National Database at a single center; participants that received outpatient laser treatment for burn scars were compared to a matched group of burn survivors that did not receive laser. The following outcomes were examined: Satisfaction With Life Scale, Mental and Physical Component Summary of the Veterans Rand Survey, and the PROMIS Pain Intensity Scale. Regression analyses examined the associations between laser treatment and each outcome at 12 and 24 months. The study population included 287 adult burn survivors (65 laser group, 222 control group). The significant differences found between the two groups included: burn size (laser: 14.9, 13.5 SD, control: 8.9, 11.1 SD; p<0.001), insurance type (p=0.036), inhalation injury (laser: 17.2%, control: 2.7%; p<0.001), and ventilator requirement (laser: 27.7%, control: 13.5%; p=0.013). Laser treatment was not associated with any of the outcomes at both follow-up time points. Further research is needed to develop patient reported outcome measures that are more sensitive to the clinical changes experienced by burn survivors receiving laser treatment.

Regeneration and control of human fibroblast cell density by intermittently delivered pulsed electric fields.

Proliferative scarring is a human disease with neither available effective treatment nor relevant animal model. One of the hypotheses for scar formation involves deregulation of fibroblast signaling and delayed apoptosis. Here, we introduce a new chemical-free method for fibroblast density control in culture by intermittently delivered pulsed electric fields (IDPEF), which cause irreversible damage to cell membranes. Using 5-100 pulses with electric field strength of 150 V/mm, pulse duration 70 µs, and frequency of 1 Hz, we investigated the effects of PEF application on growth, death, and regeneration of normal human dermal fibroblasts in culture. We found that the fraction of fibroblasts that survive depends on the number of pulses applied and follows a Weibull distribution. We have successfully developed an IDPEF protocol that controls fibroblasts density in culture. Specifically, through application of IDPEF every 72 h for 12 days, we maintain a normal human dermal fibroblast density in the 3.1 ± 0.2 × 10(5) -1.4 ± 0.2 × 10(5) cell/mL range. Our results suggest that IDPEFs may prove useful as a non-chemical method for fibroblast density control in human wound healing.

The safety and efficacy of parenteral nutrition among pediatric patients with burn injuries.

OBJECTIVE: Although enteral nutrition is the ideal mode of nutritional support following burn injury, it is often interrupted during episodes of severe sepsis and hemodynamic instability, leading to significant energy and protein deficits. Parenteral nutrition is not commonly used in burn centers due to concerns that it will lead to hyperglycemia, infection, and increased mortality. However, parenteral nutrition is often utilized in our burn unit when goal rate enteral nutrition is not feasible.To determine the safety and efficacy of a standardized protein-sparing parenteral nutrition protocol in which glucose infusion is limited to 5-7 mg/kg/hour. DESIGN: Retrospective observational study. SETTING: Pediatric burn hospital. PATIENTS: A retrospective medical record review of all children admitted to our hospital with burns ≥ 30% total body surface area was conducted. Only patients admitted within one week of injury and who survived > 24 hours after admission were included in this study. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 105 patients who met the inclusion criteria, 96 (91%) received parenteral nutrition or a combination of parenteral nutrition and enteral nutrition at some point during their care. Nine patients received only enteral nutrition. Demographic data were similar between groups. Protein intake was significantly higher in the parenteral nutrition group. Incidence of catheter-related blood infections did not differ between groups. Use of parenteral nutrition was not associated with blood or respiratory infections. Overall mortality rate was low (4%), as most patients (96%) achieved wound closure and were discharged home. CONCLUSIONS: Judicious use of parenteral nutrition is a safe and effective means of nutritional support when goal enteral nutrition cannot be achieved. A hypocaloric, high-nitrogen parenteral nutrition solution can reduce energy and protein deficits while minimizing complications commonly associated with parenteral nutrition usage.

A PREVENTIVE TOOL FOR PREDICTING BLOODSTREAM INFECTIONS IN CHILDREN WITH BURNS.

ABSTRACT: Introduction: Despite significant advances in pediatric burn care, bloodstream infections (BSIs) remain a compelling challenge during recovery. A personalized medicine approach for accurate prediction of BSIs before they occur would contribute to prevention efforts and improve patient outcomes. Methods: We analyzed the blood transcriptome of severely burned (total burn surface area [TBSA] ≥20%) patients in the multicenter Inflammation and Host Response to Injury ("Glue Grant") cohort. Our study included 82 pediatric (aged <16 years) patients, with blood samples at least 3 days before the observed BSI episode. We applied the least absolute shrinkage and selection operator (LASSO) machine-learning algorithm to select a panel of biomarkers predictive of BSI outcome. Results: We developed a panel of 10 probe sets corresponding to six annotated genes ( ARG2 [ arginase 2 ], CPT1A [ carnitine palmitoyltransferase 1A ], FYB [ FYN binding protein ], ITCH [ itchy E3 ubiquitin protein ligase ], MACF1 [ microtubule actin crosslinking factor 1 ], and SSH2 [ slingshot protein phosphatase 2 ]), two uncharacterized ( LOC101928635 , LOC101929599 ), and two unannotated regions. Our multibiomarker panel model yielded highly accurate prediction (area under the receiver operating characteristic curve, 0.938; 95% confidence interval [CI], 0.881-0.981) compared with models with TBSA (0.708; 95% CI, 0.588-0.824) or TBSA and inhalation injury status (0.792; 95% CI, 0.676-0.892). A model combining the multibiomarker panel with TBSA and inhalation injury status further improved prediction (0.978; 95% CI, 0.941-1.000). Conclusions: The multibiomarker panel model yielded a highly accurate prediction of BSIs before their onset. Knowing patients' risk profile early will guide clinicians to take rapid preventive measures for limiting infections, promote antibiotic stewardship that may aid in alleviating the current antibiotic resistance crisis, shorten hospital length of stay and burden on health care resources, reduce health care costs, and significantly improve patients' outcomes. In addition, the biomarkers' identity and molecular functions may contribute to developing novel preventive interventions.

Evaluating Burn Recovery Outcomes in Children With Neurodevelopmental Symptoms.

Neurodevelopmental symptoms (NS) including attention and behavioral problems, developmental delays, intellectual disabilities, and learning problems are prevalent in children with burn injuries. The presence of NS may predispose children to poorer burn injury recovery outcomes compared to children without these symptoms (non-NS). The Multicenter Benchmarking Study (MCBS) monitored recovery outcomes in children with burn injuries in real time using the Burn Outcomes Questionnaire (BOQ). The objective of this study was to retrospectively assess the long-term burn recovery outcomes in NS patients vs non-NS patients from the MCBS population. This study assessed parent-reported BOQ outcomes in a sample of 563 patients aged 5 to 18 years who were admitted for burn injuries to a pediatric burn center. A subsample of patients had reported NS (n = 181). Analyses compared BOQ outcomes within the NS subsample and the non-NS subsample (n = 382) across three longitudinal points postdischarge. The prevalence rate of NS was 32.1% in the full sample. Findings revealed statistically significant improvement in the recovery curves in all five BOQ subscales for the non-NS group and all subscales except for Compliance for the NS group across all longitudinal points. When compared to non-NS patients, NS patients had significantly poorer burn recovery outcomes on the Satisfaction and Compliance subscales. Although it is important to educate all clinicians, parents, and children on burn prevention efforts, targeted education is necessary for children with NS because they may be at greater risk for burn injury as well as worse recovery outcomes.

Reconstruction of the Upper Extremity High-Voltage Electrical Injury: A Pediatric Burn Hospital's 13-Year Experience.

High-voltage electrical injury is a rare yet destructive class of burn injury that persists as a serious public health issue. High-voltage exposure is commonly associated with complex wounds to the upper extremities, which can be a significant challenge for burn and plastic surgeons to reconstruct. This intensive and multistage reconstructive process is especially difficult in the growing child. Maximizing upper extremity function is a top priority, as it can have a significant impact on a patient's quality of life. Therefore, the purpose of this retrospective review was to describe lessons learned during a 13-year experience at a specialized pediatric burn hospital with reconstruction of the upper extremity after severe high-voltage injury in 37 children. We found that adherence to the following principles can help promote meaningful functional recovery. These include 1) frequent assessment during early acute care for the evolving need of decompression or amputation; 2) serial surgical debridement that follows a tissue-sparing technique; 3) wound closure by skin grafting or use of flaps (particularly groin or abdominal pedicled flaps) when deep musculoskeletal structures are involved; 4) early multidisciplinary intervention for contracture prevention and management, including physical and occupational therapy, splinting, and fixation; 5) reconstructive care that focuses on the simplest possible techniques to repair chronic skin defects such as laser therapy, local tissue rearrangements, and skin grafting; 6) complex reconstruction to address deeper tissue contractures or tendon and peripheral nerve deficits; and 7) amputation with preservation of growth plates, tissue transfer, and long-term prosthetic management when limb salvage is unlikely.

Multiorgan Metabolomics and Lipidomics Provide New Insights Into Fat Infiltration in the Liver, Muscle Wasting, and Liver-Muscle Crosstalk Following Burn Injury.

Burn injury mediated hypermetabolic syndrome leads to increased mortality among severe burn victims, due to liver failure and muscle wasting. Metabolic changes may persist up to 2 years following the injury. Thus, understanding the underlying mechanisms of the pathology is crucially important to develop appropriate therapeutic approaches. We present detailed metabolomic and lipidomic analyses of the liver and muscle tissues in a rat model with a 30% body surface area burn injury located at the dorsal skin. Three hundred and thirty-eight of 1587 detected metabolites and lipids in the liver and 119 of 1504 in the muscle tissue exhibited statistically significant alterations. We observed excessive accumulation of triacylglycerols, decreased levels of S-adenosylmethionine, increased levels of glutamine and xenobiotics in the liver tissue. Additionally, the levels of gluconeogenesis, glycolysis, and tricarboxylic acid cycle metabolites are generally decreased in the liver. On the other hand, burn injury muscle tissue exhibits increased levels of acyl-carnitines, alpha-hydroxyisovalerate, ophthalmate, alpha-hydroxybutyrate, and decreased levels of reduced glutathione. The results of this preliminary study provide compelling observations that liver and muscle tissues undergo distinctly different changes during hypermetabolism, possibly reflecting liver-muscle crosstalk. The liver and muscle tissues might be exacerbating each other's metabolic pathologies, via excessive utilization of certain metabolites produced by each other.

Appearance Concerns, Psychosocial Outcomes, and the Feasibility of Implementing an Online Intervention for Adolescents Receiving Outpatient Burn Care.

The current study assessed the prevalence of appearance concerns, psychosocial difficulty, and use of an appearance-focused social and psychological support resource (Young Person's Face IT; YPF) within a population of teens (12-17 year-olds) receiving outpatient burn care with the goal to assess the feasibility of routine use of the resource in outpatient burn care. The study sample included 78 patients ages 12 to 17 receiving outpatient care for burns at one hospital. Appearance concerns were measured via the Burn Outcomes Questionnaire Appearance Subscale, the Appearance Subscale of the Body Esteem Scale for Adolescents, and a 2-part question which asked participants directly about appearance concerns related to the burn injury. A large majority (70.0%) of study participants reported appearance concerns on at least one appearance measure and girls reported more burn-related appearance concerns compared with boys. Psychosocial difficulty was measured via the Pediatric Symptom Checklist-17 (PSC-17) and measures of social functioning were collected and compared within the sample by burn size, burn location, sex, and appearance concerns. Internalizing symptoms were prevalent on the PSC-17 (18.6% risk) and decreased self-worth and increased social anxiety symptoms were significantly associated with having appearance concerns. Although interest in YPF was high (78.3%), actual use of the resource among those who signed up to pilot it (n = 46 participants) was low (19.4% use). Results indicate that there is a need for and interest in appearance-focused social anxiety resources for adolescents with burn injuries such as YPF, but more research is needed to understand its feasibility in clinical practice.