Increased mortality in women: sex differences in burn outcomes.

BACKGROUND: There is increasing evidence that sex differences may influence responses after thermal injury and affect clinical outcomes. The objective of this study was to evaluate the relationships between sex, thermal injury, body size, and inpatient mortality in burn patients. METHODS: Medical records of adults with >20% total body surface area (TBSA) burn injury admitted to two American Burn Association (ABA)-verified burn centers between 2008 and 2014 were retrospectively reviewed. Injury details and baseline characteristics, including body size as estimated by body surface area (BSA) and body mass index (BMI) were recorded, along with details of the hospital course. The primary outcome of inpatient mortality was compared between sexes. RESULTS: Out of 334 subjects, 60 were women (18%). Median TBSA was 33% (IQR 25-49) in this cohort, with 19% full thickness burns and 30% inhalation injury. Despite no significant difference in age, presence of inhalation injury, TBSA, or depth of burn, women had significantly higher rates of inpatient mortality (45 vs. 29%, P = 0.01). BSA was significantly lower in women vs. men (P < 0.001), but this difference was not more pronounced among non-survivors. There was no difference in BMI between men and women non-survivors. Although not significant (P = 0.28), women succumbed to their injuries sooner than men (day 4 vs. 10 post-injury). CONCLUSIONS: Women are less likely to survive burn injuries and die sooner than men with similar injuries. Body size does not appear to modulate this effect. Burn centers should be aware of the higher mortality risk in women with large burns.

A Multi-Center Review of Care Patterns and Outcomes in Necrotizing Soft Tissue Infections.

BACKGROUND: Surgical debridement and broad-spectrum empiric antibiotics are first-line therapy for necrotizing soft tissue infections (NSTI). The objective of this multi-center retrospective review was to evaluate antimicrobial agent initiation and duration and compare outcomes in the treatment of patients with NSTI. PATIENTS AND METHODS: This review included adults with NSTI, as indicated by International Classification of Diseases, 9th Edition, Clinical Modification codes 728.86, 608.33, or 040.0, who were admitted to three academic institutions between 1/1/09 and 5/15/14. Demographics, antibiotic practices, operative management, and clinical outcomes were compared. RESULTS: A total of 341 patients were identified at the three centers. Subjects were comparable in age (median 53 years, p = 0.14), gender (67% male, p = 0.57) and body mass index (median 31.9 (p = 0.31) between sites. No significant difference was found in time from admission to start of empiric antibiotic therapy between the three centers (median 1 d for each, p = 0.70), but duration of antibiotic therapy was significantly different (Site A = 16 d, Site B = 12 d, Site C = 9 d, medians, p < 0.001). Although total number of operations differed between sites (median of two at Sites A and B, three at Site C, p = 0.001), sites consistently operated on the day of patient arrival to their facility, and the number of debridements did not differ (median of two for all sites, p = 0.10). Mortality rate (Site A = 22%, Site B = 18%, and Site C = 9%, p = 0.02) and length of stay for survivors (Site A = 29 d, Site B = 16 d, Site C = 19 d, medians, p = 0.001) was significantly different among centers. CONCLUSIONS: Variation in antibiotic duration between centers with expertise in the care of NSTI illustrates how little is known about best care practices for patients with NSTI. Future studies should emphasize development of evidence-based practices for NSTI management to further improve the outcomes of this complex group of patients.

Nutrition in Toxic Epidermal Necrolysis: A Multicenter Review.

BACKGROUND: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe exfoliative diseases treated in burn centers due to large skin losses. Literature on SJS/TEN refers to parenteral nutrition (PN) as the preferred route of nutrition support. This study describes nutrition support interventions in SJS/TEN patients admitted to burn centers. MATERIALS AND METHODS: Seven burn centers participated in this Institutional Review Board-exempted retrospective chart review of adults with SJS/TEN admitted from 2000-2012. RESULTS: This analysis included 171 patients with SJS/TEN. Median total body surface area involvement was 35% (n = 145; interquartile range [IQR], 16%-62%). The majority required mechanical ventilation (n = 105). Based on indirect calorimetry, measured energy needs were 24.2 kcal/kg of admit weight (n = 58; IQR, 19.4-29.9). Thirty-one patients did not require enteral nutrition (EN) and started oral intake on hospital day 1 (IQR, 1-2), and 81% required EN support due to inadequate oral intake and remained on EN until day 16 (median hospital day, 16; IQR, 9-25). High-protein enteral formulas predominated. PN was rarely used (n = 12, 7%). Most patients were discharged home (57%), with 14% still requiring EN. CONCLUSIONS: Nutrition support should be considered in patients with SJS/TEN due to increased metabolic needs and an inability to meet these needs orally. Most SJS/TEN patients continued on EN and did not require escalation to PN.

Nebulized heparin for patients under mechanical ventilation: an individual patient data meta-analysis.

Pulmonary coagulopathy is a characteristic feature of lung injury including ventilator-induced lung injury. The aim of this individual patient data meta-analysis is to assess the effects of nebulized anticoagulants on outcome of ventilated intensive care unit (ICU) patients. A systematic search of PubMed (1966-2014), Scopus, EMBASE, and Web of Science was conducted to identify relevant publications. Studies evaluating nebulization of anticoagulants in ventilated patients were screened for inclusion, and corresponding authors of included studies were contacted to provide individual patient data. The primary endpoint was the number of ventilator-free days and alive at day 28. Secondary endpoints included hospital mortality, ICU- and hospital-free days at day 28, and lung injury scores at day seven. We constructed a propensity score-matched cohort for comparisons between patients treated with nebulized anticoagulants and controls. Data from five studies (one randomized controlled trial, one open label study, and three studies using historical controls) were included in the meta-analysis, compassing 286 patients. In all studies unfractionated heparin was used as anticoagulant. The number of ventilator-free days and alive at day 28 was higher in patients treated with nebulized heparin compared to patients in the control group (14 [IQR 0-23] vs. 6 [IQR 0-22]), though the difference did not reach statistical significance (P = 0.459). The number of ICU-free days and alive at day 28 was significantly higher, and the lung injury scores at day seven were significantly lower in patients treated with nebulized heparin. In the propensity score-matched analysis, there were no differences in any of the endpoints. This individual patient data meta-analysis provides no convincing evidence for benefit of heparin nebulization in intubated and ventilated ICU patients. The small patient numbers and methodological shortcomings of included studies underline the need for high-quality well-powered randomized controlled trials.

A multicenter study of preventable contact burns from glass fronted gas fireplaces.

Glass fronted gas fireplaces (GFGFs) have exterior surfaces that can reach extremely high temperatures. Burn injuries from contact with the glass front can be severe with long-term sequelae. The Consumer Product Safety Commission reported that these injuries are uncommon, whereas single-center studies indicate a much higher frequency. The purpose of this multi-institutional study was to determine the magnitude and severity of GFGF injuries in North America. Seventeen burn centers elected to participate in this retrospective chart review. Chart review identified 402 children ≤10 years of age who sustained contact burns from contact with GFGF, who were seen or admitted to the study hospitals from January 2006 to December 2010. Demographic, burn, treatment, and financial data were collected. The mean age of the study group was 16.8 ± 13.3 months. The majority suffered burns to their hands (396, 98.5%), with burns to the face being the second, much less common site (14, 3.5%). Two hundred and sixty-nine required rehabilitation therapy (66.9%). The number of GFGF injuries reported was 20 times greater than the approximately 30 injuries estimated by the Consumer Product Safety Commission's 10-year review. For the affected children, these injuries are painful, often costly and occasionally can lead to long-term sequelae. Given that less than a quarter of burn centers contributed data, the injury numbers reported herein support a need for broader safety guidelines for gas fireplaces in order to have a significant impact on future injuries.

Use of methylnaltrexone to induce laxation in acutely injured patients with burns and necrotizing soft-tissue infections.

The routine use of high-dose opioids for analgesia in patients with acute burns and soft-tissue injuries often leads to the development of opioid-induced constipation. The opioid antagonist methylnaltrexone (MLTX) reverses narcotic-related ileus without affecting systemic pain treatment. The authors' burn center developed a bowel protocol that included administration of MLTX for relief of opioid-induced constipation after other methods failed. The authors performed a retrospective review of patients with acute burns or necrotizing soft-tissue infections, who had been given subcutaneous MLTX to induce laxation. All patients who received MLTX were included and all administrations of the drug were included in the analysis. The primary outcome examined was time to laxation from drug administration. Forty-eight patients received MLTX a total of 112 times. Six patients were admitted with soft-tissue injuries and the rest suffered burns with an average TBSA of 17%. The median patient age was 41 years and the majority (75%) were men. Administration of a single dose of MLTX resulted in laxation within 4 hours in 38% of cases, and within 24 hours in 68%. Patients given MLTX received an average of 174 mg morphine equivalents daily for pain control. MLTX was given after an average of 52 hours since the last bowel movement. As this experience has evolved, it has been incorporated into an organized bowel protocol, which includes MLTX administration after other laxatives have failed. MLTX is an effective laxation agent in patients with burn and soft-tissue injuries, who have failed conventional agents.

Process evaluation of software using the international classification of external causes of injuries for collecting burn injury data at burn centers in the United States.

Detailed information on the cause of burns is necessary to construct effective prevention programs. The International Classification of External Causes of Injury (ICECI) is a data collection tool that allows comprehensive categorization of multiple facets of injury events. The objective of this study was to conduct a process evaluation of software designed to improve the ease of use of the ICECI so as to identify key additional variables useful for understanding the occurrence of burn injuries, and compare this software with existing data-collection practices conducted for burn injuries. The authors completed a process evaluation of the implementation and ease of use of the software in six U.S. burn centers. They also collected preliminary burn injury data and compared them with existing variables reported to the American Burn Association's National Burn Repository (NBR). The authors accomplished their goals of 1) creating a data-collection tool for the ICECI, which can be linked to existing operational programs of the NBR, 2) training registrars in the use of this tool, 3) establishing quality-control mechanisms for ensuring accuracy and reliability, 4) incorporating ICECI data entry into the weekly routine of the burn registrar, and 5) demonstrating the quality differences between data collected using this tool and the NBR. Using this or similar tools with the ICECI structure or key selected variables can improve the quantity and quality of data on burn injuries in the United States and elsewhere and thus can be more useful in informing prevention strategies.

Overhead lift systems reduce back injuries among burn care providers.

Extensive patient handling in burn care provides ample opportunities for staff injury. The objective of this retrospective study was to evaluate frequency of work-related back injury pre- and postinstallation of overhead lifting systems (OLS) in a burn intensive care unit. After receiving institutional review board approval, the Workers Compensation Fund of Utah released deidentified back injury claims filed from the authors' burn center between January 1, 2001 and December 31, 2012. Number of back injuries, cost to workers' compensation, and missed workdays were examined. Three distinct time periods were analyzed based on the timing of installation of OLS in the burn center. Forty-five workers were injured in the burn unit; most were female (76%) nurses (73%), with the majority having lower-back injury (71%). Thirty claims (67%) involved staff with a previous back injury. Median age was 32 years (interquartile range, 22-40) and median term of employment at the burn center before injury was 3.7 years (interquartile range, 1.6-7.7). During the intervention period, rate of staff injuries, number of missed workdays, and total number of paid claims decreased significantly. In the period since installation, only one claim has been filed, which is the lowest number of claims that any individual intensive care unit has reported in the facility. The burn unit installed five OLS at a cost of $7000 per unit. This retrospective review indicated that the installation of OLS on the burn unit was an effective tool for reducing staff injury and associated costs. Back injury was essentially eliminated when five OLS were installed.

Enoxaparin and antifactor Xa levels in pediatric acute burn patients.

Previous work from the authors' group showed a risk for inadequate enoxaparin dosing for venous thromboembolism prophylaxis in adult burn patients when traditional recommendations are used. The purpose of this study was to determine whether this also applied to pediatric burn patients. Included patients were acutely burned, aged 14 years or under, and admitted to the authors' regional burn center between October 1, 2004 and December 15, 2012. Thirty-five patients included in this analysis received enoxaparin for venous thromboembolism prophylaxis dosed initially at 0.5 mg/kg and monitored with anti-factor Xa levels (anti-Xa) between 0.2 and 0.4U/ml. Of the included patients, 80% were male with a median age of 8 years, a median TBSA of 16%, and a median length of stay of 23 days. Initially 21 patients (60%) had an undetectable anti-Xa (<0.2 U/ml). Enoxaparin doses were increased but 18 patients (51%) never achieved target anti-Xa. There were no significant differences in sex, weight, dose, depth of injury, or body mass index between those who received appropriate prophylaxis and those who were undertreated. However, median size of burn was significantly larger, median age and height were significantly lower in those who did not reach target. The low number of patients achieving target prophylactic anti-Xa in this study demonstrates the need for routine anti-Xa monitoring in pediatric burns. Additionally, pediatric patients with major burn injury may require initial dosing of enoxaparin greater than published recommendations because of altered pharmacokinetics.

Evaluation of an enoxaparin dosing calculator using burn size and weight.

Previous research has shown that inadequate antifactor Xa levels (anti-Xa) occur in burn patients and may increase the risk of venous thromboembolic events (VTE). The objective of this retrospective review was to investigate the usefulness of an enoxaparin dosing algorithm using a previously published equation. With institutional review board approval, all acute burn patients at an American Burn Association-verified regional burn center who were treated with enoxaparin for VTE prophylaxis and had at least one anti-Xa from May 1, 2011 to December 15, 2012 were included. Patients with subprophylactic anti-Xa received increased enoxaparin dose per unit protocol with the goal of obtaining a prophylactic anti-Xa (0.2-0.4 U/ml). Sixty-four patients were included in our analysis. The regression equation was used in 33 patients for initial enoxaparin dosing (Eq) whereas 31 patients received traditionally recommended prophylaxis dosing (No-Eq). Groups were comparable in sex, age, weight, inhalation injury, and burn size. Initial enoxaparin dosing in Eq was significantly more likely to reach target than in No-Eq (73 vs 32%; P = .002). No episodes of hemorrhage, thrombocytopenia, or heparin sensitivity were documented in either group. Median final enoxaparin dose required to reach prophylactic level was 40 mg every 12 hours (range, 30-80 mg). Twenty-one No-Eq patients ultimately reached target, and 11 of these final doses were equivalent to or greater than the predicted equation. Ten patients never reached prophylactic anti-Xa before enoxaparin was discontinued (nine from No-Eq). Two patients, one from each group, developed VTE complications despite appropriate anti-Xa for prophylaxis. A strong correlation was shown between weight, burn size, and enoxaparin dose (r = .68; P < .001). Use of the enoxaparin dosing algorithm significantly increased the frequency of obtaining a target initial anti-Xa. There were no bleeding complications. Enoxaparin dosing correlates to burn size and weight, making a standard dose inappropriate because patient habitus and extent of burn injury are highly variable. This simple equation improves enoxaparin dosing for acute adult burn patients.

Development and validation of a necrotizing soft-tissue infection mortality risk calculator using NSQIP.

BACKGROUND: Necrotizing soft-tissue infections (NSTI) are a group of uncommon, rapidly progressive infections requiring prompt surgical debridement and systemic support. A previous attempt to define risk factors for mortality from NSTI had multiple limitations. The objective of this study was to develop and validate a 30-day postoperative mortality risk calculator for patients with NSTI using NSQIP. STUDY DESIGN: The NSQIP Participant Use Files (2005-2010) were used as the primary data source. Patients diagnosed with NSTI were identified by ICD-9 codes. Multiple logistic regression analysis identified key preoperative variables predicting mortality. Bootstrap analysis was used to validate the model. RESULTS: In 1,392 identified NSTI cases, demographics were as follows: 42% were female, median age was 55 years (interquartile range 46 to 63 years), and median body mass index was 32 kg/m(2) (interquartile range 26 to 40 kg/m(2)). Thirty-day mortality was 13%. Seven independent variables were identified that correlated with mortality: age older than 60 years (odds ratio [OR] = 2.5; 95% CI 1.7-3.6), functional status (partially dependent: OR = 1.6; 95% CI 1.0-2.7; totally dependent: OR = 2.3; 95% CI 1.4-3.8), requiring dialysis (OR = 1.9; 95% CI 1.2-3.1), American Society of Anesthesiologists class 4 or higher (OR = 3.6; 95% CI 2.3-5.6), emergent surgery (OR = 1.6; 95% CI 1.0-2.3), septic shock (OR = 2.4; 95% CI 1.6-3.6), and low platelet count (<50K/µL: OR = 3.5; 95% CI 1.6-7.4; <150K/µL but >50K/µL: OR = 1.9; 95% CI 1.2-2.9). The receiver operating characteristic area was 0.85 (95% CI 0.82-0.87), which indicated a strong predictive model. Using bootstrap validation, the optimism-corrected receiver operating characteristic area was 0.83 (95% CI 0.81-0.86), which represents the model performance in future patients. The model was used to develop an interactive risk calculator. CONCLUSIONS: This risk calculator has excellent predictive ability for mortality in patients with NSTI. This simple interactive tool can aid physicians and patients in the decision-making process.

The impact of oxandrolone on length of stay following major burn injury: a clinical practice evaluation.

INTRODUCTION: The anabolic agent oxandrolone (OX) has been found to decrease length of stay (LOS) following 20-60% total body surface area (TBSA) burn injury. This study uses the Comprehensive Severity Index (CSI) to control for severity of illness and explores the relationship between OX and LOS in a more broadly selected sample of burn patients and a natural practice setting. METHODS: A practice-based evidence study was conducted at a single regional burn center. Maximum severity of illness (MCSIC) was measured using a burn-specific version of CSI. Data on 167 consecutive surviving patients with TBSA≥15% were analyzed using case-control matching for MCSIC, TBSA, and age. Thirty-eight patients received OX. RESULTS: Median patient age for the entire patient sample was 42.7 years. Using a 1:1 match based upon MCSIC, TBSA, then age, mean LOS for patients who received OX was 33.6 days, as opposed to 43.4 days for those who were not managed with OX (p=0.03). If patients were matched >1:1 for controls: cases, mean LOS was 40.9 days (controls) versus 31.6 days (cases). CONCLUSIONS: OX is associated with shorter LOS after controlling for MCSIC, TBSA, and age. Future comparative effectiveness studies should better define which patients derive the greatest benefits from receipt of OX during their recovery from major burn injury.

Impact of a nursing-driven sleep hygiene protocol on sleep quality.

The purpose of this study was to evaluate the impact on sleep quality of a nursing-driven sleep hygiene protocol (SHP) instituted in a single burn-trauma intensive care unit. Criteria for eligibility were adult patients admitted to the Burn Service who were not delirious, able to respond verbally, and had not received general anesthesia in the prior 24 hours. Patients were surveyed using the validated Richards-Campbell Sleep Questionnaire prior to implementation ("PRE"; May to December 2010) and following implementation ("POST"; January to August 2011) of a SHP that sought to minimize environmental stimuli and limit disruptions during the night. This analysis includes only initial survey responses from each patient. A total of 130 patients were surveyed, 81 PRE and 49 POST; 60% were burn admissions. There was no significant difference in responses to the questionnaire between burn and nonburn patients. All patients in the POST group were significantly older and more frequently endorsed taking sleep medication at home. Although not significant, POST patients reported falling asleep somewhat more quickly, but no other differences were identified between the two groups. Among patients who reported having sleep difficulties prior to admission, POST patients not only reported a significantly higher pain score than PRE patients, but also reported significant improvement in falling asleep and being able to go back to sleep. Frequency of complaints of sleep disruption was unchanged between PRE and POST patients. POST patients did complain significantly less than PRE patients about sleep disruptions by clinicians. Implementation of the SHP permitted acutely injured or ill patients in our intensive care unit to fall asleep more quickly and to experience fewer sleep disruptions. A sleep protocol may be helpful in improving sleep and overall well-being of burn center patients.

Utility of screening for diabetes in a burn center: hemoglobin A1c, Diabetes Risk Test, or simple history?

OBJECTIVE: Rates of diabetes mellitus (DM) are increasing. Early identification and treatment of hyperglycemia in the critical care setting can decrease morbidity and mortality. Many burn centers measure hemoglobin A1c (A1c). This study evaluates the prevalence of pre-existing DM and the utility of using A1c for identifying DM compared with a non-invasive risk assessment. METHODS: Adult patients admitted to our regional ABA-verified burn center from July 2008 to July 2009 had A1c levels evaluated and were asked to complete the American Diabetes Association Diabetes Risk Test (DRT). RESULTS: Forty-one patients consented to participate: 24 patients with burn (19 male) and 17 patients with non-burns (10 male). Non-burn patients had greater BMIs (BMI 32 vs. 28, p=0.093) and had a higher rate of DM prior to admission (35% vs. 17%, p=0.159) than the burn patients. These differences were not statistically significant. Most patients (23/41) were at high risk for developing DM based on the DRT. Patients with pre-existing DM were significantly more likely to have elevated A1c levels (>6.5%) compared with those without pre-existing DM (60% vs. 0%, p<0.001). Compared with history of DM, DRT had a poor positive predictive value of 36% and 50% (burn and non-burn respectively) but a 100% negative predictive value for DM for both groups. CONCLUSION: DM and obesity were more common in non-burn patients than in burn patients. A history of DM provides a simple, accurate method for identifying patients with DM. Use of A1c in the ICU provides little additional data for diagnosis of DM and does not impact patient management.

Compliance with nutrition support guidelines in acutely burned patients.

BACKGROUND: Adequate and timely provision of nutritional support is a crucial component of care of the critically ill burn patient. The goal of this study was to assess a single center's consistency with Society of Critical Care Medicine/American Society for Parenteral and Enteral Nutrition (SCCM/ASPEN) guidelines for nutritional support in critically ill patients. METHODS: Acutely burned patients >45kg in weight admitted to a regional burn center during a two-year period and who required 5 or more days of full enteral nutritional support were eligible for inclusion in this retrospective review. Specific outcomes evaluated include time from admission to feeding tube placement and enteral feeding initiation and percent of nutritional goal received within the first week of hospital stay. Descriptive statistics were used for all analyses. IRB approval was obtained. RESULTS: Thirty-seven patients were included in this retrospective review. Median age of patients was 44.9 years (IQR: 24.2-55.1), and median burn injury size was 30% (IQR: 19-47). Median time to feeding tube placement was 31.1h post admission (IQR: 23.6-50.2h), while median time to initiation of EN was 47.9h post admission (IQR: 32.4-59.9h). The median time required for patients to reach 60% of caloric goal was 3 days post-admission (IQR: 3-4.5). CONCLUSION: The median time for initiation of enteral nutrition was within the SCCM/ASPEN guidelines for initial nutrition in the critically ill patient. This project identified a 16h time lag between placement of enteral access and initiation of enteral nutrition. Development of a protocol for feeding tube placement and enteral nutrition management may optimize early nutritional support in the acutely injured burn patient.

Identification of risk factors associated with critical illness related corticosteroid insufficiency in burn patients.

The goal of this analysis was to characterize risk factors of patients who develop critical illness-related corticosteroid insufficiency (CIRCI) after acute burn injury. This is a retrospective, single-center case-control descriptive study performed at a regional burn unit at an academic medical center. Patients are adults with acute burn injury who developed CIRCI (cases) and sex-, age-, and burn size-matched controls. Cases were compared with controls based on clinical characteristics. Conditional logistic regression analysis was used to establish potential risk factors for cortisol insufficiency. CIRCI was diagnosed in 23 of 1183 patients during the period reviewed (1.9%); 159 controls were matched. CIRCI patients demonstrated significantly greater length of stay (35.1 vs 65.8 days, P ≤ .001), ventilator days (20.5 vs 33.2 days, P ≤ .001), and mortality (2.5% vs 17.4%, P ≤ .001) than controls. Patients with higher Charlson Comorbidity Index scores were more likely to develop cortisol insufficiency (odds ratio 1.58, 95% confidence interval 1.20-2.08), as were patients with inhalation injury (odds ratio 6.46, 95% confidence interval 2.01-20.72). Antibiotics and sedative/hypnotics analyzed by class were not significant. Multivariate conditional logistic regression analysis including Charlson Comorbidity Index and inhalation injury showed significant association of both dependent variables with CIRCI (pseudo-R2 = .32, P ≤ .001). Preexisting comorbidities and inhalation injury provide significant risks for development of CIRCI after acute burn injury. Acute burn patients who develop CIRCI have higher mortality, length of stay, and ventilator days than matched controls.