Dear Program Directors: There Are Numerous Entrustable Professional Activities on a Burns Rotation!

Background: Burn care has long been an integral part of the scope of plastic surgery, but the time allocated to exposure for plastic surgery residents is under threat due to the range of sub-specialities competing for their time. As part of the Competence by Design approach to plastic surgical training, residents are provided with a list of 52 "Entrustable professional activities' (EPA's) to ensure that core skills and knowledge are acquired. Methods: This survey, distributed via email using a link to Survey MonkeyTM, sought to determine which EPA's were available for completion by plastic surgeons in training during the burn rotation at a major academic burn centre in Canada. Via investigator consensus, 26 of the 52 EPA's were included for assessment; the remaining 26 were not regarded as relevant to the burn centre rotation and therefore better acquired elsewhere. Results: Thirty two residents who underwent a burn rotation between 1 January 2015 and 31 December 2021 completed the anonymous survey. Seventeen of the 26 EPA's evaluated were judged by more than 75% of respondents as being readily amenable to completion during the burn rotation. Most of these EPA's relate to the comprehensive care of patients with acute burn injuries, the management of an in-patient plastic surgery service, and associated quality improvement processes. Residents who completed rotations less than three months in duration had less opportunity to complete a further 8 EPA's in comparison to those who had longer rotations, especially with respect to the care of patients undergoing complex wound care and burn reconstruction. Conclusions: In addition to threatening seamless service delivery at burn centres, reduced resident exposure to the burn rotation may compromise the delivery of burn care in the community. The results of this survey refute any argument that the burn service is a "low yield" rotation from an EPA acquisition perspective.

Historique: Les soins aux grands brûlés font partie intégrante de la chirurgie plastique depuis longtemps, mais le temps alloué à y exposer les résidents en chirurgie plastique est menacé en raison de l'éventail de surspécialités. Dans le cadre de l'approche de compétence par conception à la formation en chirurgie plastique, les résultats reçoivent une liste de 52 « activités professionnelles confiables ¼ (APC) pour assurer qu'ils acquièrent les compétences et le savoir de base. Méthodologie : Ce sondage, distribué par courriel grâce à un lien vers la plateforme Survey MonkeyMD, visait à déterminer quelles APC étaient offertes aux chirurgiens plastiques en formation pendant leur rotation dans un grand centre universitaire pour grands brûlés du Canada. Par consensus des chercheurs, 26 des 52 APC ont été incluses dans l'évaluation. Les 26 autres n'ont pas été considérées comme pertinentes pour la rotation au centre pour grands brûlés, mais mieux à même d'être acquises ailleurs. Résultats:  Au total, 32 résidents qui ont participé à une rotation auprès des grands brûlés entre le 1er janvier 2015 et le 31 décembre 2021 ont rempli le sondage anonyme. Selon plus de 75% d'entre eux, 17 des 26 APC évaluées peuvent facilement être effectuées pendant la rotation auprès des grands brûlés. La plupart de ces APC portent sur les soins complets aux patients atteints de brûlures aiguës, la gestion d'un service de chirurgie plastique aux patients hospitalisés et les processus d'amélioration de la qualité qui s'y associent. Les résidents qui ont effectué leur rotation en moins de trois mois avaient moins l'occasion d'effectuer huit APC de plus par rapport à ceux qui avaient vécu des rotations plus longues, particulièrement à l'égard des soins des plaies complexes aux patients et de la reconstruction après leurs brûlures. Conclusions : En plus de menacer la prestation harmonieuse des services dans les centres pour grands brûlés, la moins grande exposition des résidents à la rotation des grands brûlés peut compromettre la prestation des soins aux grands brûlés dans la communauté. Les résultats de ce sondage réfutent toute prétention selon laquelle les services aux grands brûlés est une rotation « à faible rendement ¼ selon le point de vue de l'acquisition des APC.

Ambient Room Temperatures in a Burn Intensive Care Unit-A Quality Improvement Project.

Introduction: Patients with major burn injuries are particularly susceptible to hypothermia. The ability to maintain and rapidly increase ambient temperatures may reduce the impact of hypothermia and the hypermetabolic response. The purpose of this study was to determine ambient patient room temperatures in a burn intensive care unit (ICU) and to evaluate our ability to adjust these temperatures. Methods: The ambient temperatures of 9 burn ICU patient rooms were recorded hourly over a 6-month period in an American Burn Association-verified burn centre. Temperatures were recorded using wall-mounted smart sensors, transmitted to a mobile smartphone application via Bluetooth, and then exported to Excel for analysis. On 2 predetermined dates, thermostats in all rooms were simultaneously set to maximum, and monitored over 3 h. This represented a sound change initiative, and replicated a medical order to increase the ambient temperature during critical stages of patient care. Results: We recorded 4394 individual hourly temperature measurements for each of the 9 rooms. The mean ambient temperature was 23.5 ± 0.3 °C (range 22.8-24). After intervention 1, ambient temperatures increased <2 °C in 7 rooms and by only 2 °C-3 °C in the other 2 rooms. The overall mean increase in temperature over 3 h across all rooms was 1.03 °C ± 1.19 °C (range -0.88 to 3.26). Following intervention 2, temperatures could be increased by ≥2 °C in only 2 rooms with an overall mean increase in temperature of only 0.76 °C ± 0.99 °C (range -0.29 to 2.43) across all rooms. Conclusions: The burn ICU rooms were relatively cool and our ability locally to adjust ambient temperatures quickly was limited. Burn centres should have regular facility assessments to assess whether ambient temperatures can be adjusted expeditiously when required.

Introduction : Les patients ayant des brûlures importantes (>20% de la surface corporelle totale) sont particulièrement exposés au risque d'hypothermie. La capacité à maintenir et à rapidement augmenter la température ambiante peut réduire la répercussion négative de l'hypothermie et de la réponse hypermétabolique. L'objectif de cette étude était de déterminer la température ambiante des chambres de patients dans une unité de soins intensifs (USI) pour brûlés et d'évaluer notre capacité à ajuster ces températures. Méthodes : La température ambiante de neuf chambres de patients en USI pour brûlés a été enregistrée heure par heure pendant une période de 6 mois dans un centre pour brûlés vérifié par l'ABA. Les températures ont été consignées en utilisant des capteurs intelligents montés sur les murs avec transmission par Bluetooth à une application mobile pour téléphone intelligent, puis exportées dans un tableau Excel pour analyse. À deux dates prédéterminées, les thermostats de toutes les chambres ont été simultanément réglés au maximum et contrôlés pendant 3 heures. Cela représentait une initiative de changement réfléchie, répliquant une consigne médicale d'augmentation de la température ambiante pendant les phases critiques de soins aux patients. Résultats : Nous avons enregistré 4394 relevés horaires de la température pour chacune des neuf chambres. La température ambiante moyenne était de 23,5 ± 0,3 °C (écart : 22,8 à 24). Après la première intervention, les températures ambiantes ont augmenté de moins de 2 °C dans 7 chambres et de seulement 2 °C à 3 °C dans les deux autres chambres. L'augmentation moyenne globale pendant les 3 heures dans toutes les chambres était de 1,03 °C ± 1,19 °C (écart : −0,88 à 3,26). Après la deuxième intervention, les températures ont pu être augmentées de ≥ 2 °C dans seulement deux chambres avec une augmentation globale moyenne de la température de seulement 0,76 °C ± 0,99 °C (écart : −0,29 à 2,43) pour l'ensemble des chambres. Conclusions : Les chambres de l'USI pour brûlés étaient relativement fraîches et notre capacité à ajuster rapidement les températures ambiantes était limitée. Les centres pour brûlés devraient faire l'objet d'évaluations régulières d'établissement pour déterminer si la température ambiante peut être ajustée dans des délais très brefs en cas de besoin.

Pressure in the Operating Room: A Potential Contributor to Hospital-Acquired Pressure Injuries.

Burn patients are at risk for hospital-acquired pressure injuries (HAPIs). An unexamined factor that may contribute to HAPI development is the effect of pressure from the operating table during surgery. The purpose of this study was to measure pressure on the buttocks and sacral area during burn surgery under general anesthesia (GA). Prospective study of consecutive adult burn patients admitted to an ABA-verified burn center who required surgery under GA between January 06, 2022 and December 08, 2022. We studied only cases that were supine, including those with both legs down (LD), one leg suspended (1LU), or both legs suspended (2LU). Interface pressures on the buttocks and sacral area were measured using a commercial sensor mat. Thousands of individual pressure measurements were integrated to show average and peak pressures over repetitive 10-minute intervals during the entire operation. Recordings were completed in 41 procedures among 28 patients (48.3 ± 16.9 years, % TBSA burn 19.2 ± 17.1, weight 80.2 ± 19.7 kg, BMI 26.7 ± 6.2). Both average pressure (Pave) and peak pressure (Ppeak) increased significantly with greater number of elevated legs (p < .001). During 2LU periods, Ppeak exceeded 100 mmHg for almost half the operative duration. Pave crept steadily upwards over time and had a positive relationship with weight, regardless of leg elevation. Prolonged moderate to high pressures are exerted on the sacral and buttock areas, especially with one or both legs suspended, during burn surgery. These novel observations suggest that pressure from the operating table could contribute to HAPI development.

Burn Resuscitation Practices in North America: Results of the Acute Burn ResUscitation Multicenter Prospective Trial (ABRUPT).

OBJECTIVES: ABRUPT was a prospective, noninterventional, observational study of resuscitation practices at 21 burn centers. The primary goal was to examine burn resuscitation with albumin or crystalloids alone, to design a future prospective randomized trial. SUMMARY BACKGROUND DATA: No modern prospective study has determined whether to use colloids or crystalloids for acute burn resuscitation. METHODS: Patients ≥18 years with burns ≥ 20% total body surface area (TBSA) had hourly documentation of resuscitation parameters for 48 hours. Patients received either crystalloids alone or had albumin supplemented to crystalloid based on center protocols. RESULTS: Of 379 enrollees, two-thirds (253) were resuscitated with albumin and one-third (126) were resuscitated with crystalloid alone. Albumin patients received more total fluid than Crystalloid patients (5.2 ± 2.3 vs 3.7 ± 1.7 mL/kg/% TBSA burn/24 hours), but patients in the Albumin Group were older, had larger burns, higher admission Sequential Organ Failure Assessment (SOFA) scores, and more inhalation injury. Albumin lowered the in-to-out (I/O) ratio and was started ≤12 hours in patients with the highest initial fluid requirements, given >12 hours with intermediate requirements, and avoided in patients who responded to crystalloid alone. CONCLUSIONS: Albumin use is associated with older age, larger and deeper burns, and more severe organ dysfunction at presentation. Albumin supplementation is started when initial crystalloid rates are above expected targets and improves the I/O ratio. The fluid received in the first 24 hours was at or above the Parkland Formula estimate.

Transfusion Requirement in Burn Care Evaluation (TRIBE): A Multicenter Randomized Prospective Trial of Blood Transfusion in Major Burn Injury.

OBJECTIVE: Our objective was to compare outcomes of a restrictive to a liberal red cell transfusion strategy in 20% or more total body surface area (TBSA) burn patients. We hypothesized that the restrictive group would have less blood stream infection (BSI), organ dysfunction, and mortality. BACKGROUND: Patients with major burns have major (>1 blood volume) transfusion requirements. Studies suggest that a restrictive blood transfusion strategy is equivalent to a liberal strategy. However, major burn injury is precluded from these studies. The optimal transfusion strategy in major burn injury is thus needed but remains unknown. METHODS: This prospective randomized multicenter trial block randomized patients to a restrictive (hemoglobin 7-8 g/dL) or liberal (hemoglobin 10-11 g/dL) transfusion strategy throughout hospitalization. Data collected included demographics, infections, transfusions, and outcomes. RESULTS: Eighteen burn centers enrolled 345 patients with 20% or more TBSA burn similar in age, TBSA burn, and inhalation injury. A total of 7054 units blood were transfused. The restrictive group received fewer blood transfusions: mean 20.3 ±â€Š32.7 units, median = 8 (interquartile range: 3, 24) versus mean 31.8 ±â€Š44.3 units, median = 16 (interquartile range: 7, 40) in the liberal group (P < 0.0001, Wilcoxon rank sum). BSI incidence, organ dysfunction, ventilator days, and time to wound healing (P > 0.05) were similar. In addition, there was no 30-day mortality difference: 9.5% restrictive versus 8.5% liberal (P = 0.892, χ test). CONCLUSIONS: A restrictive transfusion strategy halved blood product utilization. Although the restrictive strategy did not decrease BSI, mortality, or organ dysfunction in major burn injury, these outcomes were no worse than the liberal strategy (Clinicaltrials.gov identifier NCT01079247).

Inhalation Injury: Pathophysiology, Diagnosis, and Treatment.

The classic determinants of mortality from severe burn injury are age, size of injury, delays of resuscitation, and the presence of inhalation injury. Of the major determinants of mortality, inhalation injury remains one of the most challenging injuries for burn care providers. Patients with inhalation injury are at increased risk for pneumonia (the leading cause of death) and multisystem organ failure. There is no consensus among leading burn care centers in the management of inhalation injury. This article outlines the current treatment algorithms and the evidence of their efficacy.

Burn Center Care of Patients with Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis.

Stevens-Johnson syndrome and toxic epidermal necrolysis are rare, life-threatening, cutaneous drug reactions. Medications are the most common cause, although an infection may be responsible. A link between genetics and certain medications has been established. Clinical diagnosis should be confirmed with biopsy. When the area of epidermal detachment approaches 30%, burn center care is advisable. An ophthalmologist should be consulted to optimize ocular care. Pharmacologic interruption has been sought but there is little consensus on the most appropriate agent and no high-quality studies have been conducted to demonstrate if any of these agents lead to improved survival.

Construction of Skin Graft Seams in Burn Patients: A Prospective Randomized Double-Blinded Study.

Prominent scars and contractures may form along the seams between adjacent skin grafts. Seams may be constructed either by approximating the graft edges (AP), or by slightly overlapping the graft edges (OV), but it is not known if one technique creates a less conspicuous seam scar. The purpose of this study was to compare seam scars between seams constructed using the AP and OV techniques. This was a prospective within-patient and within-seam controlled study in adult burn patients treated at an American Burn Association-verified burn center. At skin graft application and seam construction, study seams were divided in half. One half of the seam was made by approximating the graft edges (AP group), while the other half was made by overlapping graft edges (OV group), before identical staple or suture fixation of each half. The AP or OV technique was randomly assigned to the medial or lateral ends of transversely oriented seams or to the proximal and distal ends of longitudinally oriented seams. At 3, 6, and 12 months post surgery, a blinded rater compared the two halves of each study seam scar using the Vancouver Scar Score (VSS). Subjects were also blinded and rated each half of their study seam using a 0 (poor) to 10 (excellent) visual analogue scale. Values are shown as the median (Q1-Q3). There were 44 study seams among 19 subjects (age 51 [36-70] years, with % TBSA burn 10 [7-18], % BSA full-thickness burn 8 [6-15]). Study seams were constructed at 10 (4-15) days post burn. Study seam length was 14.5 (10.3-18.0) cm, with 25% transversely oriented and 75% longitudinally oriented, and with 35/44 seams (80%) between meshed grafts and 9/44 (20%) between sheet grafts. There were no significant differences in any of the individual domain VSS scores (height, pliability, vascularity, and pigmentation) or total VSS score between AP and OV seams at 3, 6, and 12 months. At 12 months, among the 30 study seams that were visible to the subjects, the visual analogue scale score for the AP seams was 9 (8.5-10), which did not differ significantly from the OV seams (9.5 [8.45-10], P = .821). Overlapping or approximating adjacent skin grafts at the time of seam construction does not appear to affect final seam scar quality.

Does Bronchoscopic Evaluation of Inhalation Injury Severity Predict Outcome?

Although fiber-optic bronchoscopy is essential in the diagnosis of smoke inhalation injury (INH), controversy still exists over whether or not the visualized severity of the mucosal injury predicts clinically meaningful outcomes. The purpose of this study was to assess whether the grade of mucosal INH severity was associated with various outcomes among adult burn patients. We conducted a retrospective review of all patients requiring greater than or equal to 48 hours of mechanical ventilation who were admitted between January 1, 2007 and June 1, 2014 to an adult regional American Burn Association-verified burn center. Bronchoscopy was performed on all subjects at burn center admission and grading of severity was documented using the grades 0 to 4 abbreviated injury score (AIS). Subjects with grade 1 or 2 injury formed the low-grade INH group, whereas those with grade 3 or 4 injury formed the high-grade INH group. Values are shown as the median (first to third quartiles). A P value less than .05 was considered significant. The study population consisted of 160 subjects (age, 48 [35-60] years; %TBSA burn, 28 [19-39.9]; % full thickness burn, 12.8 [0-30]; and 61% with INH). There were no significant differences in age, %TBSA burn, or % full thickness burn between subjects with different individual INH severity grades. Oxygenation on the day of injury worsened significantly as the severity of INH increased, but otherwise there were no significant differences in 24 and 48-hour fluid requirements, duration of ventilation, ventilator free days, incidence of acute respiratory distress syndrome, or mortality between subjects with different individual grades of INH severity. Subjects with high-grade INH showed statistically insignificant trends toward larger 48-hour fluid volumes (P = .07), poorer oxygenation over the first 3 post burn days (P = .055), longer duration of ventilation (P = .08), and fewer ventilator free days (P = .047) than low-grade INH. High-grade and low-grade INH subjects did not differ significantly in the incidence of acute respiratory distress syndrome or mortality. The individual grades of the 0 to 4 AIS INH severity grading scale were not particularly robust in the prediction of various outcomes among a population of adult burn patients. However, clinically relevant trends toward worsened oxygenation over postburn days 0 to 3, longer duration of mechanical ventilation, and reduced ventilator-free days in association with more severe INH were identified when subjects were broadly stratified into low-grade (grades 1and 2) INH and high-grade (grades 3 and 4) INH. This suggests that there may clinically meaningful differences between patients with less and more severe INH, and that further refinement of the grades 0 to 4 AIS INH severity should be subjected to additional investigation.

Enteral nutrition: what the dietitian prescribes is not what the burn patient gets!

Enteral nutrition (EN) is commonly interrupted in burn patients for many reasons, which leads to discrepancies between prescribed and actual EN delivery. The magnitude and origin of these discrepancies have never been well documented among burn patients. The purpose of this study was to examine differences between prescribed and actual EN delivery and to identify the specific causes of EN interruption and to quantify these. Retrospective review of patients treated between June 6, 2009 and June 6, 2012 at an adult regional American Burn Association-verified burn center who had ≥10% TBSA burns and who were prescribed EN for at least 24 hours. On postburn days (PBD) 0 to 14 the daily volume of EN prescribed by the dietitian was compared with the actual volume received by the patient. The cause and duration of interruptions to EN delivery were recorded. A total of 90 subjects, [mean (± SD) age 47 ± 18 years, 32% female, median %TBSA burn size 28, median %TBSA full-thickness burn size 11, and a 54% incidence of inhalation injury], were studied. EN was initiated at a median of 9.5 hours after burn center admission. Received calories were significantly less than prescribed calories on every study day. The median daily caloric deficit ranged between 172 and 930 kcal. The median percent of prescribed calories received each day ranged from 19% on PBD 0 to 91% on PBD 14. The mean (± SD) total duration of EN interruption was 8.9 ± 3.0 hours per day. Gradually increasing the feed rate to reach the prescribed EN goal rate ("ramping-in") was the most common cause of a discrepancy between prescribed and actual EN delivery, accounting for 35% of total discrepancy time. Interruptions for surgery accounted for 24% of total discrepancy time. Other causes of discrepancies were physician- or nurse-directed interruptions (16% of time), planned extubation (7%), feed intolerance (11%), tube malfunction (2%), bedside procedures (2%), and dressing changes (3%).Enterally fed burn patients received significantly less nutrition than prescribed. Some of the causes for discrepancies between prescribed and received EN are unavoidable, but many are not, suggesting the need for careful review and possible alteration of existing EN practices.

Common postburn deformities and their management.

This article describes a practical, clinically based approach to classification of postburn deformities. Burn scar contractures are of either the broad diffuse type or linear band-like type. The former generally respond well to release and insertion of a skin graft or substitute, whereas the latter are generally repaired using a simple or modified Z-plasty or a transpositional flap technique. The pulsed dye laser is a promising technique used to reduce scar thickness and redness. Postburn deformities of the face, upper and lower extremities, and trunk are discussed, in addition to novel techniques for vascularized composite allotransplantation of the face.

Albumin supplementation for hypoalbuminemia following burns: unnecessary and costly!

Following fluid resuscitation, patients with major burns frequently develop prolonged hypoalbuminemia. It is not known whether this should be corrected by albumin supplementation. The purpose of this study was to determine whether there are any benefits associated with albumin supplementation to correct hypoalbuminemia in burned adults. We conducted a retrospective comparison of patients with burns ≥ 20% TBSA admitted to an adult regional American Burn Association-verified burn center, from May 1, 2009, to September 30, 2010, where we did not routinely supplement albumin (control group), with patients admitted from October 1, 2010, to May 30, 2011, where we had instituted a protocol in which 5% human albumin was provided to maintain serum albumin levels >20 g/L (albumin group). Comparisons were made from postburn (PB) day 2 to day 30 inclusive. There were no significant differences between control (n = 26) and albumin (n = 17) in age (48 ± 15 vs 45 ± 21 years; P = .56), burn size (33 ± 13 vs 34 ± 13 %TBSA; P = .831), or full thickness burn size (19 ± 19 vs 23 ± 19 %TBSA; P = .581). Inhalation injury was significantly more frequent in the albumin group than in controls (71% vs 31%; P = .01). The groups did not differ significantly in need for admission escharotomy, admission Sequential Organ Failure Assessment (SOFA) score, number of surgical procedures/first 30 days, or 24 and 48 hours fluid resuscitation volume requirements. The overall mean daily serum albumin level from PB day 2 to 30 in the albumin group (26.9 ± 3.0 g/L) was significantly greater than in controls (21.9 ± 4.4 g/L; P < .001). There were no significant differences between the groups in daily SOFA score/first 30 days, peak SOFA score, ΔSOFA, hospital length of stay, time to wound healing, duration of mechanical ventilation, or 30-day and in-hospital mortality. The cost of routinely supplementing 5% albumin between PB day 2 to 30 in the albumin group was more than four times that for the controls where we did not routinely provide albumin (Can $65.50 vs Can $16.57 per patient per day). We conclude that routine supplementation of 5% human albumin to maintain a serum albumin level ≥ 20 g/L in burn patients is expensive and provides no benefit.

Anesthesia and intraoperative high-frequency oscillatory ventilation during burn surgery.

High-frequency oscillatory ventilation (HFOV) is a mainstay in the ventilatory management of severe acute respiratory distress syndrome in our burn center. Many patients require burn surgery while on HFOV, potentially necessitating the use of HFOV during general anesthesia in the operating room. The purpose of this study was to describe the technique of providing and maintaining intraoperative HFOV. This is a retrospective analysis of the hospital and anesthesia records of all adult burn patients who went to the operating room on HFOV at our regional burn center between October 22, 1999, and April 30, 2009. There were 57 procedures performed on 36 patients who were receiving HFOV for severe acute respiratory distress syndrome available for analysis (age 45 ± 16 years, %TBSA burn 43 ± 14, % full-thickness burn 32 ± 19, and 69% with inhalation injury). Intraoperative HFOV settings were mean airway pressure 33 ± 4 cm H2O, frequency 5 ± 1 Hz, and FiO2 0.7 ± 0.2. There were no significant changes in oxygenation as measured by the PaO2/FiO2 ratio and the oxygenation index, but there was a transient but significant increase in PaCO2 intraoperatively. Existing continuous infusions of midazolam, opioids, and neuromuscular blockers were continued during surgery and were augmented by a variety of parenteral agents, including propofol, fentanyl, and ketamine during surgery. Prone positioning was required in 16 of 57 procedures. Subanalysis of the prone cases showed no significant changes in the PaO2/FiO2 ratio or oxygenation index but again showed a significant but temporary increase in intraoperative PaCO2. HFOV was aborted for conventional mechanical ventilation in three cases due to respiratory deterioration (2 cases) and hemodynamic instability (1 case). There were no intraoperative deaths. In-hospital mortality was 33%. Intraoperative HFOV was feasible and safe in the overwhelming majority of cases, and aside from an inconsequential period of intraoperative hypercapnia, this was not associated with any hemodynamic instability or compromise in oxygenation.

Fluid resuscitation of the thermally injured patient.

Increased capillary permeability and reduced plasma colloid osmotic pressure following burn injury result in hypovolemia and development of edema in the burn and nonburn tissues. Replenishment of the intravascular deficit with crystalloid fluid has been the mainstay of resuscitation for the better part of four decades. A progressive but as yet unexplained trend toward provision of resuscitation volumes well in excess of those predicted by the Parkland formula, associated with numerous edema-related complications, has been repeatedly observed recently. Correction of this phenomenon, called fluid creep, will likely revolve around several strategies, which may include tighter control of titration, re-emergence of colloids and hypertonic salt solutions, and possibly the use of adjunctive markers of resuscitation other than urinary output.

Oscillation after inhalation: high frequency oscillatory ventilation in burn patients with the acute respiratory distress syndrome and co-existing smoke inhalation injury.

The purpose of this study was to evaluate the effectiveness of, and complications associated with High Frequency Oscillatory Ventilation (HFOV) in burn patients with the Acute Respiratory Distress Syndrome (ARDS) who have had a smoke inhalation injury, and to compare with those without an inhalation injury. Burn patients with progressive oxygenation failure from ARDS while on conventional mechanical ventilation were placed on HFOV as a "rescue" ventilation modality. There were 19 patients with burn + inhalation injury and 30 patients with burn only. Burned patients with ARDS but without inhalation injury had significant temporal improvement in the oxygenation index from 27 +/- 8 on conventional mechanical ventilation to 17 +/- 6 within 48 hours of initiating HFOV. However, burned patients with ARDS and smoke inhalation injury did not achieve significant or even eventual improvements in oxygenation index with HFOV. There was also a trend towards higher rates of early HFOV failure and severe hypercapnia while on HFOV among the patients with inhalation injury. Delivery of nebulized bronchodilators, heparin and n-acetyl cysteine, normally mainstays of smoke inhalation therapy, was impossible during HFOV. The presence of a smoke inhalation injury appears to impair the response to HFOV when this ventilation modality is instituted for ARDS-related oxygenation failure. Severe hypercapnia tended to be more frequent during HFOV among patients with smoke inhalation. These findings, combined with the difficulties in delivery of nebulized medications during HFOV suggest that HFOV may not be the optimal "rescue" ventilation modality in cases of ARDS if there has been an inhalation injury.

Improved survival following thermal injury in adult patients treated at a regional burn center.

Since January 1999, changes in the management of acute burn patients at a regional adult burn center included no hydrotherapy, blood sparing surgical techniques, a restrictive blood transfusion strategy, newer protective modes of mechanical ventilation, aggressive surgical wound excision, temporary wound closure with allograft skin, employment of advanced critical care trained nurses, and an increased number of dedicated full-time fellowship-trained burn surgeons. The purpose of this study was to determine the composite effect of these modifications on burn patients' survival. A retrospective hospital chart review was conducted among adult burn patients admitted during a 10-year period (1996-2005). Patients were stratified in two time periods: PAST (1996-1998) and RECENT (1999-2005). RECENT patients were selected by matching age, gender, total body surface area burn, full thickness burn, and presence of inhalation injury with PAST patients. All values are mean +/- SD. Student's t-test and chi2 analysis were performed accordingly with a P < .05 considered significant. Of 1569 acute burn patients admitted between 1996 and 2005, 96 (6%) were excluded because they received comfort measures only. Of the remaining 1473 patients, 684 patients (PAST = 342, RECENT = 342) were selected by the matching criteria. More RECENT patients required mechanical ventilation (25% vs 17%, P = .011), with a trend toward more prolonged duration (9 vs 11.5 days, P = .175), more escharotomies (9.6% vs 5.6%, P = .036), more operations (1.1 vs 0.8, P = .003), and more temporary allograft skin (10% vs 2%, P < .001) than did PAST patients. RECENT patients had lower mortality than did PAST patients (2.3% vs 5.6%, P = .048), specifically patients aged 60 or older (5.4% vs 25.5%, P = .004), patients with TBSA lower than 20% (1% vs 3.9%, P = .031), patients on mechanical ventilation (9.3% vs 27.6%, P = .006), and patients who had surgery (2.6% vs 7.3%, P = .032). The significant decrease in burn patient's mortality was likely due to the composite effects of improvements in clinical care between the two time periods.

Immunopathogenesis of hypersensitivity syndrome reactions to sulfonamides.

Cytokines play a role in the immunopathological and molecular mechanisms of sulfonamide-induced hypersensitivity reactions (HSRs). The objective of this study was to analyze the reliability and correlation between the clinical symptoms observed in affected patients (n = 86) because of a sulfonamide-induced HSR and their lymphocyte toxicity assay (LTA) values. Another goal was to determine the cytokine secretion in the patient's sera and their expression in the peripheral blood mononuclear cells (PBMCs) and to explore whether a correlation exists among positive LTA score, cytokine levels, and HSR occurrence. The final goal is to determine whether these measures could be used to predict the likelihood of a patient to experience an HSR during sulfonamide treatment. Such a predictive ability would be valuable to the clinician to know whether the patient would tolerate sulfonamides or whether an alternative antibiotic should be prescribed. The LTA showed a good correlation with the clinical involvement of patients with hypersensitivity syndromes. In addition, the pro-inflammatory cytokines presented significant differences in patients that had rash, fever, and organ involvement than in control patients or any of the other patient groups. Expression of tumor necrosis factor alpha (TNF-alpha) is significantly higher in patients presenting rash, fever, and organ involvement versus all other groups. It is concluded that a positive LTA is a predictor for sulfonamide-induced true HSR. In addition, T-helper cell 1 cytokines [TNF-alpha, interleukins (ILs) 1 and 2] as well as the chemokine regulated upon activation, normal T-cell expressed and secreted (RANTES) control the pathogenesis of sulfonamide-induced HSR and may be used in early diagnosis of the syndrome.

The burned hand: optimizing long-term outcomes with a standardized approach to acute and subacute care.

Deep partial- and full-thickness burns to the hands are common and the source of significant potential morbidity for the patient. This article emphasizes that when these burns are managed by an experienced team of burn surgeons, rehabilitation therapists, and nurses, using a standardized protocol, good long-term functional outcomes may be reliably obtained in most cases. The details of the author's standardized protocol, as well as late outcomes achieved using this approach, are discussed.