Inability to determine tissue health is main indication of allograft use in intermediate extent burns.

INTRODUCTION: Cutaneous allograft is commonly used in the early coverage of excised burns when autograft is unavailable. However, allograft is also applied in intermediate-extent burns (25-50%), during cases in which it is possible to autograft. In this population, there is a paucity of data on the indications for allograft use. This study explores the indications for allograft usage in moderate size burns. METHODS: Under an IRB-approved protocol, patients admitted to our burn unit between March 2003 and December 2010 were identified through a review of the burn registry. Data on allograft use, total burn surface area, operation performed, operative intent, number of operations, intensive care unit length of stay, and overall length of stay were collected and analyzed. Data are presented as means±standard deviations, except where noted. RESULTS: In the study period, 146 patients received allograft during their acute hospitalization. Twenty-five percent of allograft recipients sustained intermediate-extent burns. Patients with intermediate-extent burns received allograft later in their hospitalization than those with large-extent (50-75% TBSA) burns (6.8 days vs. 3.4 days, p=0.01). Allografted patients with intermediate-extent burns underwent more operations (10.8 vs. 6.1, p=0.002) and had longer hospitalizations (78.3 days vs. 40.9 days, p<0.001) than non-allografted patients, when controlled for TBSA. Clinical rationale for placement of allograft in this population included autograft failure, uncertain depth of excision, lack of autograft donor site, and wound complexity. When uncertain depth of excision was the indication, allograft was universally applied onto the face. In half of allografted intermediate-extent burn patients the inability to identify a viable recipient bed was the ultimate reason for allograft use. CONCLUSIONS: Unlike large body surface area burns, allograft skin use in intermediate-extent injury occurs later in the hospitalization and is driven by the inability to determine wound bed suitability for autograft application. Allograft application can be utilized to test recipient site viability in cases of autograft failure or uncertain depth of excision.

Elevations in inflammatory cytokines are associated with poor outcomes in mechanically ventilated burn patients.

BACKGROUND: The treatment of burn patients who undergo mechanical ventilation is complicated by many factors; patient outcomes and mortality could potentially be improved with predictive biomarkers. Severe burn provokes a systemic inflammatory response characterized by the release of a host of cytokines. Recent studies evaluated the prognostic value of temporal changes in cytokine levels in several patient populations, but few have compared differences in the cytokine profiles of survivors and nonsurvivors following severe burn. We previously compared high-frequency percussive ventilation and low-tidal-volume ventilation and found no difference in mortality or cytokine levels between the two treatments. Since it is unknown whether cytokine levels are predictive of mortality in these patients, we performed a post hoc analysis comparing cytokine levels in survivors and nonsurvivors. METHODS: We evaluated plasma levels of several cytokines (interleukin 1ß [IL-1ß], IL-6, IL-8, granulocyte-macrophage colony-stimulating factor, and tumor necrosis factor α) for their prognostic biomarker potential related to mortality at 0, 3, and 7 days in survivors and nonsurvivors of burns. RESULTS: While the majority of values for IL-1ß, granulocyte-macrophage colony-stimulating factor, and tumor necrosis factor α fell below the limit of quantification, univariate analysis demonstrated higher plasma levels of IL-6 and IL-8 in nonsurvivors on Day 7. Logistic regression revealed that elevated plasma IL-8 was independently associated with an increased likelihood of the composite end point of death or ventilator-associated pneumonia with odds ratios of 7.9, 26, and 7.3 on Days 0, 3, and 7, respectively. CONCLUSION: Early increases in plasma IL-8 are associated with a multifold increase in death or ventilator-associated pneumonia in mechanically ventilated burn patients. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level IV; therapeutic study, level IV.

Acute respiratory distress syndrome in wartime military burns: application of the Berlin criteria.

BACKGROUND: Acute respiratory distress syndrome (ARDS) prevalence and related outcomes in burned military casualties from Iraq and Afghanistan have not been described previously. The objective of this article was to report ARDS prevalence and its associated in-hospital mortality in military burn patients. METHODS: Demographic and physiologic data were collected retrospectively on mechanically ventilated military casualties admitted to our burn intensive care unit from January 2003 to December 2011. Patients with ARDS were identified in accordance with the new Berlin definition of ARDS. Subjects were categorized as having mild, moderate, or severe ARDS. Multivariate logistic regression identified independent risk factors for developing moderate-to-severe ARDS. The main outcome measure was the prevalence of ARDS in a cohort of patients burned as a result of recent combat operations. RESULTS: A total of 876 burned military casualties presented during the study period, of whom 291 (33.2%) required mechanical ventilation. Prevalence of ARDS in this cohort was 32.6%, with a crude overall mortality of 16.5%. Mortality increased significantly with ARDS severity: mild (11.1%), moderate (36.1%), and severe (43.8%) compared with no ARDS (8.7%) (p < 0.001). Predictors for the development of moderate or severe ARDS were inhalation injury (odds ratio [OR], 1.90; 95% confidence interval [CI], 1.01-3.54; p = 0.046), Injury Severity Score (ISS) (OR, 1.04; 95% CI, 1.01-1.07; p = 0.0021), pneumonia (OR, 198; 95% CI, 1.07-3.66; p = 0.03), and transfusion of fresh frozen plasma (OR, 1.32; 95% CI, 1.01-1.72; p = 0.04). Size of burn was associated with moderate or severe ARDS by univariate analysis but was not an independent predictor of ARDS by multivariate logistic regression (p > 0.05). Age, size of burn, and moderate or severe ARDS were independent predictors of mortality. CONCLUSION: In this cohort of military casualties with thermal injuries, nearly a third required mechanical ventilation; of those, nearly one third developed ARDS, and nearly one third of patients with ARDS did not survive. Moderate and severe ARDS increased the odds of death by more than fourfold and ninefold, respectively. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.

Silver-coated nylon dressing plus active DC microcurrent for healing of autogenous skin donor sites.

INTRODUCTION: Burn wounds are a significant cause of morbidity and mortality, and improved outcomes are demonstrated with early closure of both primary burn wounds and skin donor sites. Thus, technology that decreases the healing time of burns and donor sites would be potentially lifesaving. We present the results of a single-center, prospective, double-blinded, randomized controlled trial to evaluate the efficacy of silver-coated dressing with active microcurrent in comparison to silver-coated dressing with sham microcurrent on wound-closure time for autogenous skin donor sites. METHODS: Four hundred five patients were screened for treatment of their donor sites using a silver-coated nylon dressing with either sham or active microcurrent stimulation. Thirty patients were enrolled in the study and then randomized. Of these, 5 patients were removed from analysis due to protocol deviations. Differences in time-to-closure were analyzed using Kaplan-Meier analysis and the proportional hazard regression model. Subjective verbal pain rating scores (0-10; 0, no pain; 10, worst pain) were also recorded. All devices were blinded and programmed at an outside facility, so that every patient had either an active or sham device. The study was unblinded only after the final patient's donor site had healed. All patients achieved donor-site healing before postoperative day 20. The 14 patients in the active microcurrent group [mean, 10.8 (2.9) days; range, 7-15 days] experienced no difference in time to wound healing as compared to the remaining patients in the sham microcurrent group [mean, 11.1 (2.0) days; range, 8-14 days; P = 0.75]. There were no differences in pain from one group compared to the other. None of the donor sites exhibited clinical signs of infection. CONCLUSIONS: In a sample size of 25 burn patients, the addition of direct microcurrent to silver-nylon dressings did not decrease time to wound closure of skin donor sites, and it did not show a difference in reported pain levels.

Anaphylactoid reaction during first hemofiltrationwith a PUREMA polysulfone membrane.

Adverse reactions during hemodialysis are extremely common and include a wide range of clinical presentations from mild to life threatening. We present a case of a 34 year old woman in the Burn Intensive Care Unit, who developed acute kidney injury requiring renal replacement therapy. She was placed on continuous veno-venous hemofiltration with the NxStage machine which uses a synthetic PUREMA polyethersulfone filter sterilized by gamma radiation. Within two minutes of initiating hemofiltration, the patient complained of pruritus as well as dyspnea and became flushed and agitated. She subsequently developed hypotension ultimately resulting in cardiopulmonary arrest. Cardiopulmonary resuscitation was initiated and the patient was given epinephrine with return of spontaneous circulation. The following day, the patient was rechallenged with a PUREMA filter, and had a similar reaction with flushing, dyspnea, pruritus and hypotension requiring treatment to be discontinued. The patient was transitioned to the Prismaflex filter, another synthetic membrane, which she tolerated well and continued to utilize through the remainder of her hospital course without complication. Her clinical presentation was consistent with an anaphylactoid reaction, though a tryptase level was not obtained and a radioallergosorbent test performed with membrane material was negative. This case shows the difficulty of identifying the cause of hypersensitivity reactions involving synthetic membranes not sterilized by ethylene oxide, a commonly use sterilizing agent known to cause hypersensitivity reactions. This rare, but potentially fatal reaction has not previously been reported with a PUREMA filter and this case should raise awareness of hypersensitivity reactions with this widely used method of renal replacement therapy.

Prehospital interventions performed in a combat zone: a prospective multicenter study of 1,003 combat wounded.

BACKGROUND: Battlefield care given to a casualty before hospital arrival impacts clinical outcomes. To date, the published data regarding care given in the prehospital setting of a combat zone are limited. The purpose of this study was to describe the incidence and efficacy of specific prehospital lifesaving interventions (LSIs; interventions that could affect the outcome of the casualty), consistent with the Tactical Combat Casualty Care paradigm, performed during the resuscitation of casualties in a combat zone. METHODS: We performed a prospective observational study between November 2009 and November 2011. Casualties were enrolled as they were treated at six US surgical facilities in Afghanistan. Descriptive data were collected on a standardized data collection form and included mechanism of injury, airway management, chest and hemorrhage interventions, vascular access, type of fluid administered, and hypothermia prevention. On arrival to the military hospital, the treating physician determined whether an intervention was performed correctly and whether an intervention was not performed that should have been performed (missed LSI). RESULTS: A total of 1,003 patients met the inclusion criteria. Their mean (SD) age was 25 (8.5) years and 97% were male. The mechanism of injury was explosion in 60% of patients, penetrating in 24% of patients, blunt in 15% of patients, and burn in 0.8% of patients. The most commonly performed LSIs included hemorrhage control (n = 599), hypothermia prevention (n = 429), and vascular access (n = 388). Of the missed LSIs, 252 were identified with the highest percentage of missed opportunities being composed of endotracheal intubation, chest needle decompression, and hypotensive resuscitation. In contrast, tourniquet application had the lowest percentage of missed opportunities. CONCLUSIONS: In our prospective study of prehospital LSIs performed in a combat zone, we observed a higher rate of incorrectly performed and missed LSIs in airway and chest (breathing) interventions than hemorrhage control interventions. The most commonly performed LSIs had lower incorrect and missed LSI rates.

Prone positioning improves oxygenation in adult burn patients with severe acute respiratory distress syndrome.

BACKGROUND: Prone positioning (PP) improves oxygenation and may provide a benefit in patients with acute respiratory distress syndrome (ARDS). This approach adds significant challenges to patients in intensive care by limiting access to the endotracheal or tracheostomy tube and vascular access. PP also significantly complicates burn care by making skin protection and wound care more difficult. We hypothesize that PP improves oxygenation and can be performed safely in burn patients with ARDS. METHODS: PP was implemented in a burn intensive care unit for 18 patients with severe refractory ARDS. The characteristics of these patients were retrospectively reviewed to evaluate the impact of PP on Pao2:FiO2 ratio (PFR) during the first 48 hours of therapy. Each patient was considered his or her own control before initiation of PP, and trends in PFR were evaluated with one-way analysis of variance. Secondary measures of complications and mortality were also evaluated. RESULTS: Mean PFR before PP was 87 (± 38) with a mean sequential organ failure assessment score of 11 (± 4). PFR improved during 48 hours in 12 of 14 survivors (p < 0.05). Mean PFR was 133 (± 77) immediately after PP, 165 (± 118) at 6 hours, 170 (± 115) at 12 hours, 214 (± 126) at 24 hours, 236 (± 137) at 36 hours, and 210 (± 97) at 48 hours. At each measured time interval except the last, PFR significantly improved. There were no unintended extubations. Facial pressure ulcers developed in four patients (22%). Overall, 14 survived 48 hours (78%), 12 survived 28 days (67%), and six survived to hospital discharge (33%). CONCLUSIONS: PP improves oxygenation in burn patients with severe ARDS and was safely implemented in a burn intensive care unit. Mortality in this population remains high, warranting investigation into additional complementary rescue therapies. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Pneumatosis intestinalis in patients with severe thermal injury.

Severe thermal injury is associated with pronounced changes in intestinal physiology, which may cause ischemia, infarction, and pneumatosis intestinalis (PI). PI is a pathologic condition defined as infiltration of gas into the gastrointestinal tract wall. Historically, PI prompted urgent surgery, yet some surgeons "watch and wait" to avoid the risks of a negative laparotomy. The authors reviewed experience with PI at a single burn center. They retrospectively identified burn center intensive care unit patients with radiographic or pathologic evidence of PI. Data included demographics, injury severity score, TBSA burned, operative findings, length of stay, and mortality. From January 2003 through August 2009, 1129 patients were admitted to the authors' burn center intensive care unit. Fifteen had PI. Twelve had radiographic evidence of PI, and 10 had PI associated with intestinal infarction. Nonsurvivors had lower base deficits (P = .02), higher lactate levels (P = .05), and required vasopressor support (P = .02) within 24 hours of developing PI. Massive intestinal infarction (P = .004) and open abdomens (P = .004) were more common among nonsurvivors. PI can be identified by radiologic or pathologic findings. The authors' experience with PI among patients with burn injury revealed a high mortality rate. Because of the association of bowel ischemia with PI, exploratory laparotomy should be strongly considered in patients with burn injury with radiographic evidence of PI.

High-frequency percussive ventilation and low tidal volume ventilation in burns: a randomized controlled trial.

OBJECTIVES: In select burn intensive care units, high-frequency percussive ventilation is preferentially used to provide mechanical ventilation in support of patients with acute lung injury, acute respiratory distress syndrome, and inhalation injury. However, we found an absence of prospective studies comparing high-frequency percussive ventilation with contemporary low-tidal volume ventilation strategies. The purpose of this study was to prospectively compare the two ventilator modalities in a burn intensive care unit setting. DESIGN: Single-center, prospective, randomized, controlled clinical trial, comparing high-frequency percussive ventilation with low-tidal volume ventilation in patients admitted to our burn intensive care unit with respiratory failure. SETTING: A 16-bed burn intensive care unit at a tertiary military teaching hospital. PATIENTS: Adult patients ≥ 18 yrs of age requiring prolonged (> 24 hrs) mechanical ventilation were admitted to the burn intensive care unit. The study was conducted over a 3-yr period between April 2006 and May 2009. This trial was registered with ClinicalTrials.gov as NCT00351741. INTERVENTIONS: Subjects were randomly assigned to receive mechanical ventilation through a high-frequency percussive ventilation-based strategy (n = 31) or a low-tidal volume ventilation-based strategy (n = 31). MEASUREMENTS AND MAIN RESULTS: At baseline, both the high-frequency percussive ventilation group and the low-tidal volume ventilation group had similar demographics to include median age (interquartile range) (28 yrs [23-45] vs. 33 yrs [24-46], p = nonsignificant), percentage of total body surface area burn (34 [20-52] vs. 34 [23-50], p = nonsignificant), and clinical diagnosis of inhalation injury (39% vs. 35%, p = nonsignificant). The primary outcome was ventilator-free days in the first 28 days after randomization. Intent-to-treat analysis revealed no significant difference between the high-frequency percussive ventilation and the low-tidal volume ventilation groups in mean (± sd) ventilator-free days (12 ± 9 vs. 11 ± 9, p = nonsignificant). No significant difference was detected between groups for any of the secondary outcome measures to include mortality except the need for "rescue" mode application (p = .02). Nine (29%) in the low-tidal volume ventilation arm did not meet predetermined oxygenation or ventilation goals and required transition to a rescue mode. By contrast, two in the high-frequency percussive ventilation arm (6%) required rescue. CONCLUSIONS: A high-frequency percussive ventilation-based strategy resulted in similar clinical outcomes when compared with a low-tidal volume ventilation-based strategy in burn patients with respiratory failure. However, the low-tidal volume ventilation strategy failed to achieve ventilation and oxygenation goals in a higher percentage necessitating rescue ventilation.

Central nervous system infections in patients with severe burns.

BACKGROUND: Central nervous system (CNS) infections develop in 3-9% of neurosurgical ICU patients and 0.4-2% of all patients hospitalized with head trauma. CNS infection incidence in burn patients is unknown and this study sets out to identify the incidence and risk factors associated with CNS infections. METHODS: A retrospective electronic chart review was performed from 1 July 2003 to 30 June 2008 evaluating inpatient medical records along with cerebrospinal fluid (CSF) microbiological results for the presence of CNS infection. The presence of facial and head injuries and burns, along with intracranial interventions were reviewed for association with CNS infections. RESULTS: There were 1964 admissions with 2 patients (0.1%) found to have CNS infection; 1 each with MRSA and Acinetobacter baumannii. Both patients had facial burns and trauma to their head that required intracranial surgery. Of note, both patients had bacteremia with the same microorganisms isolated from their CSF and both survived. Of all patients, 29% had head or neck trauma and burns; 0.35% of those had a CNS infection. Scalp harvest for grafts or debridement of burned scalp was performed on 125 patients of which 9 had an invasive surgical procedure that involved penetration of the skull. The 2 infected patients were from these 9 intracranial surgical patients revealing a 22% infection rate. CONCLUSION: The incidence of CNS infections in patients with severe burns is extremely low at 0.1%. This rate was low even with head and face burns with trauma unless the patient underwent an intracranial procedure.

Burn center treatment of patients with severe anhydrous ammonia injury: case reports and literature review.

Anhydrous ammonia, a widespread industrial chemical, can cause severe inhalation and ophthalmic injuries, as well as cutaneous burns. We present five patients with ammonia injury treated at our burn center after an explosion in a warehouse. The challenges inherent in managing the pulmonary complications of this injury are emphasized.

A new method of continuous venovenous rewarming.

PURPOSE: Hypothermia is a significant problem in medicine and is part of a deadly triad, including hypothermia, acidosis, and coagulopathy. Multiple methods of rewarming are used to treat moderate hypothermia. The purpose of this study was to compare the effectiveness of continuous venovenous rewarming (CVVR) using the FMS 2000 (Belmont Instrument Corp., Billerica, Massachusetts) in conjunction with external rewarming techniques versus external rewarming alone in the porcine model. METHODS: Ten subject animals, each weighing approximately 40 kg, were evenly divided and randomly assigned to either a control group using external rewarming techniques alone or the CVVR group utilizing the FMS 2000 in addition to the external rewarming techniques used in the control group. Hypothermia was induced in the swine model using cold water immersion to achieve a core temperature of 30 degrees C. Both esophageal and rectal temperature probes were used to monitor and record core body temperatures every 15 minutes during the experiment. Each study animal was then rewarmed until a core temperature of at least 37 degrees C was recorded in both the esophageal and rectal probes. The animals were observed clinically for 3 days after the study. RESULTS: The average time required to rewarm the control group was 253 minutes, compared with 113 minutes in the CVVR group. After 30 minutes of rewarming, the difference between the 2 groups with respect to core temperature was statistically significant (p = 0.002). A drop in core temperature after the initiation of rewarming, or after-drop, was noted in the control group animals, but not in the CVVR group. This difference was statistically significant after 15 minutes of rewarming (p = 0.015) CONCLUSIONS: Venovenous rewarming utilizing the FMS 2000 fluid management system is more effective than is standard therapy alone for rewarming in the moderately hypothermic porcine model. This finding may prove clinically useful in the treatment of patients suffering from moderate hypothermia.

Laparoscopic repair of a large symptomatic epiphrenic esophageal diverticulum.

PURPOSE: The diagnosis of symptomatic epiphrenic esophageal diverticula is uncommon. Even less common are published reports regarding the efficacy of laparoscopic repair of this malady. METHODS: We report the case of a 59-year-old male patient with Parkinsonism found to have a large, symptomatic epiphrenic diverticulum and discuss the surgical treatment performed. The patient presented with a 6-month history of worsening dysphagia to both solids and liquids, regurgitation of undigested food, and weight loss. Barium esophagram identified the presence of a large distal esophageal diverticulum. Esophagoscopy confirmed the epiphrenic location of the diverticulum and the absence of other pathology. Laparoscopic transhiatal diverticulectomy was performed utilizing a gastrointestinal endoscopic stapler. Intraoperative esophagoscopy was performed to confirm resection of the diverticulum without constriction of the lumen. RESULTS: The patient resumed intake of liquids on postoperative day 1 after a water-soluble contrast esophagram revealed no extravasation. The patient was discharged on hospital day 3. He reported residual dysphagia to solids postoperatively, which appeared to resolve after pneumatic dilation. CONCLUSIONS: We conclude that laparoscopic epiphrenic diverticulectomy is technically feasible and safe. The comorbidity of Parkinsonism adds complexity to the diagnosis and treatment of this uncommon disorder.