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.

A Quantitative Review of Certified Burn Therapist's Involvement in the JBCR Publications and ABA Leadership.

The Burn Therapist Certification (BT-C) was introduced in 2018 to acknowledge occupational and physical therapists with specialized knowledge, skill, and experience in promotion of quality burn rehabilitation. Currently, BT-Cs make up 11.7% of therapists working in burn rehabilitation (n=39/333). The purpose of this review is to report on contributions of BT-Cs to organizational leadership of the American Burn Association (ABA) and in the generation of new knowledge through peer-reviewed publications. Despite the small percentage of burn therapists who are certified, they have a disproportionately large involvement in leadership within the ABA and burn research in the Journal of Burn Care and Rehabilitation (JBCR). From 2018-2023, BT-Cs have contributed to nearly one-half (n=26/56) of therapy authored publications in the JBCR and almost one-third (n=65/202) of accepted abstracts at the ABA annual meeting. Certified burn therapists demonstrate substantial involvement throughout the ABA including maintaining an 85% membership rate and on average serve in 53% (n=31/59) of the therapy allotted committee positions. Therapist pursuit of certification can have a profound impact on the burn community through publication, leadership, and development of care standards. Although therapists have indicated a desire to pursue certification, barriers related to a lack of association and center support have been identified. The burn community has endorsed certification as a mark of excellence for nurses and physicians. Maximizing the value of a transdisciplinary approach to burn care is also dependent on excellence from therapies. If the burn community desires improved engagement and contribution from therapies, it should support therapist certification.

Psychiatric Risk Factors and Burn Severity in Self-immolation.

Self-immolation, a form of self-harm involving setting oneself on fire, is associated with high mortality, morbidity, and healthcare burden. This study aimed to characterize potential clinical correlates and predisposing factors for self-immolation based on burn severity using TBSA percentage scoring. Additional objectives included identifying motivational elements, associated risk factors, and clinical characteristics to optimize patient care and reduce future self-immolation incidents. A retrospective review of admissions to the Arizona Burn Center from July 2015 to August 2022 identified 103 self-immolation patients for the study. Burn severity was categorized as mild to moderate (TBSA < 20%) or severe (TBSA ≥ 20%) based on TBSA. This study population had a mortality rate of 21%. Positive urine drug screens were found in 44% of subjects, and 63% having chronic substance use, with methamphetamine (37%) and alcohol (30%), being the most prevalent. Underlying psychiatric illnesses were present in 83% of patients. Suicidal intent strongly predicted severe burns (P < .001) among the 68 severe burn cases identified. In conclusion, this study emphasizes that the presence of suicidal intent among self-immolation patients significantly correlates with burn severity. These findings highlight the importance of involving psychiatric services early in patient care to improve outcomes and reduce the recurrence of self-immolation acts.

Maximizing wound coverage in full-thickness skin defects: A randomized-controlled trial of autologous skin cell suspension and widely meshed autograft versus standard autografting.

BACKGROUND: Traumatic insults, infection, and surgical procedures can leave skin defects that are not amenable to primary closure. Split-thickness skin grafting (STSG) is frequently used to achieve closure of these wounds. Although effective, STSG can be associated with donor site morbidity, compounding the burden of illness in patients undergoing soft tissue reconstruction procedures. With an expansion ratio of 1:80, autologous skin cell suspension (ASCS) has been demonstrated to significantly decrease donor skin requirements compared with traditional STSG in burn injuries. We hypothesized that the clinical performance of ASCS would be similar for soft tissue reconstruction of nonburn wounds. METHODS: A multicenter, within-patient, evaluator-blinded, randomized-controlled trial was conducted of 65 patients with acute, nonthermal, full-thickness skin defects requiring autografting. For each patient, two treatment areas were randomly assigned to concurrently receive a predefined standard-of-care meshed STSG (control) or ASCS + more widely meshed STSG (ASCS+STSG). Coprimary endpoints were noninferiority of ASCS+STSG for complete treatment area closure by Week 8, and superiority for relative reduction in donor skin area. RESULTS: At 8 weeks, complete closure was observed for 58% of control areas compared with 65% of ASCS+STSG areas (p = 0.005), establishing noninferiority of ASCS+STSG. On average, 27.4% less donor skin was required with ASCS+ STSG, establishing superiority over control (p < 0.001). Clinical healing (≥95% reepithelialization) was achieved in 87% and 85% of Control and ASCS+STSG areas, respectively, at 8 weeks. The treatment approaches had similar long-term scarring outcomes and safety profiles, with no unanticipated events and no serious ASCS device-related events. CONCLUSION: ASCS+STSG represents a clinically effective and safe solution to reduce the amount of skin required to achieve definitive closure of full-thickness defects without compromising healing, scarring, or safety outcomes. This can lead to reduced donor site morbidity and potentially decreased cost associated with patient care.Clincaltrials.gov identifier: NCT04091672. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level I.

Use of a silver-containing hydrofiber dressing for filling abscess cavity following incision and drainage in the emergency department: a randomized controlled trial.

OBJECTIVE: The objective of this study was to investigate whether the use of a silver-containing hydrofiber dressing to pack abscess cavity after incision and drainage (I & D) leads to faster wound healing and less pain. METHODS: Patients 18 years or older visiting the emergency department with cutaneous abscesses, requiring I & D, were randomly assigned to the intervention (Aquacel Ag; ConvaTec, Skillman, New Jersey) or standard care (iodoform) group between April 2008 and May 2009. Patients were followed up 48 to 72 hours and 10 to 14 days after the initial visit. Primary outcomes were the proportion of patients with greater than 30% reduction in surface area of abscess or cellulitis at first follow-up. RESULTS: Ninety-two patients were enrolled prospectively and randomly assigned to the Aquacel Ag or the iodoform groups; mean age was 38.0 (SD, 12.0) years; 49 patients were in the Aquacel Ag and 43 were in iodoform groups, respectively. There were no differences in demographic and clinical characteristics between groups. Logistic regression analysis showed that the intervention (Aquacel Ag) was independently associated with greater than 30% reduction in surface area of abscess (P = .002) but not in cellulitis at first follow-up. There was also significant decrease in pain intensity perceived by patients in the Aquacel Ag group based on the mean change in Facial Pain Scale scores between the initial visit and first follow-up. CONCLUSION: In patients with cutaneous abscesses, use of an antimicrobial hydrofiber ribbon dressing for packing was associated with faster wound healing and reduction in perceived pain in comparison with use of iodoform dressing.

Burn Center Patients at Risk for Upper Extremity Amputations.

Introduction Burn center patients present not only with burn injuries but also necrotizing infections, purpura fulminans, frostbite, toxic epidermal necrolysis, chronic wounds, and trauma. Burn surgeons are often faced with the need to amputate when limb salvage is no longer a viable option. The purpose of this study was to determine factors which predispose patients to extremity amputations. Methods: This retrospective registry review (2000-2019) compared patients who required upper extremity amputations with those who did not. Cases were pair-matched by age, sex, percent total body surface area (%TBSA), and type/location of injury to control for possible confounding variables. Results: There were 77 upper extremity amputee patients (APs) and 77 pair-matched non-amputees (NAPs) with the median age 45- and 43-years, %TBSA 21 and 10, respectively; second and third degree burn injuries were similar in the 2 groups. The AP group had longer hospitalizations (median 40 vs 15 days) P < .0001, with more intensive care unit days (median 28 vs 18 days). APs presented with significantly more cardiac, renal, and pulmonary comorbidities, acquired infections (61 [64%] vs 35 [36%]), escharotomies, and fasciotomies than the NAP, P < .0001. Mortality was similar (AP 14 [18.2%] vs NAP 9 [11.7%]), P = .26. Conclusions: Escharotomies, fasciotomies, sepsis, pneumonia, wound, and urinary tract infections contributed to prolonged hospitalizations and increased risk for upper extremity amputations in the AP group.

Introduction Les patients des centres de grands brûlés ne présentent pas seulement des lésions dues aux brûlures, mais aussi des infections nécrosantes, un purpura fulminans, des gelures, une épidermolyse bulleuse toxique, des plaies chroniques et des traumatismes. Les chirurgiens pour brûlés sont souvent confrontés au besoin d'amputer quand le sauvetage d'un membre n'est plus une option valable. L'objectif de cette étude était de déterminer les facteurs prédisposant les patients aux amputations de membres. Méthodes: Cette analyse rétrospective d'un registre (2000-2019) a comparé les patients ayant nécessité une amputation d'un membre supérieur à ceux pour lesquels l'amputation n'a pas été nécessaire. Les cas ont été appariés par âge, sexe, pourcentage de la surface corporelle totale (%SCT) et le type/emplacement des lésions pour contrôler les possibles variables confondantes. Résultats: Il y a eu 77 patients amputés (PA) du membre supérieur et 77 patients non amputés (PNA) appariés ayant, respectivement, un âge médian de 45 et 43 ans et un %SCT de 21% et 10%; les lésions par brûlures des 2e et 3e degrés étaient similaires dans les deux groupes. La durée d'hospitalisation pour le groupe PA a été plus longue que pour le groupe PNA (médiane : 40 jours contre 15 jours; P < .0001) avec un plus grand nombre de jours en unité de soins intensifs (médiane : 28 jours contre 18 jours). Les patients du groupe PA avaient plus de comorbidités cardiaques, rénales et pulmonaires et d'infections acquises (61 [64%] contre 35 [36%]), d'escarrotomies et d'aponévrotomies que les patients du groupe PNA (P <.0001). La mortalité a été semblable dans les deux groupes (PA: 14 [18.2%] contre PNA: 9 [11.7%], P = .26). Conclusion: Les incisions de décharge, les aponévrotomies, le sepsis, les pneumonies, les infections des plaies et des voies urinaires ont contribué à des hospitalisations prolongées et à une augmentation du risque d'amputation du membre supérieur dans le groupe PA.

The Battle of the Titans-Comparing Resuscitation Between Five Major Burn Centers Using the Burn Navigator.

The goal of burn resuscitation is to provide the optimal amount of fluid necessary to maintain end-organ perfusion and prevent burn shock. The objective of this analysis was to examine how the Burn Navigator (BN), a clinical decision support tool in burn resuscitation, was utilized across five major burn centers in the United States, using an observational trial of 300 adult patients. Subject demographics, burn characteristics, fluid volumes, urine output, and resuscitation-related complications were examined. Two hundred eighty-five patients were eligible for analysis. There was no difference among the centers on mean age (45.5 ± 16.8 years), body mass index (29.2 ± 6.9), median injury severity score (18 [interquartile range: 9-25]), or total body surface area (TBSA) (34 [25.8-47]). Primary crystalloid infusion volumes at 24 h differed significantly in ml/kg/TBSA (range: 3.1 ± 1.2 to 4.5 ± 1.7). Total fluids, including colloid, drip medications, and enteral fluids, differed among centers in both ml/kg (range: 132.5 ± 61.4 to 201.9 ± 109.9) and ml/kg/TBSA (3.5 ± 1.0 to 5.3 ± 2.0) at 24 h. Post-hoc adjustment using pairwise comparisons resulted in a loss of significance between most of the sites. There was a total of 156 resuscitation-related complications in 92 patients. Experienced burn centers using the BN successfully titrated resuscitation to adhere to 24 h goals. With fluid volumes near the Parkland formula prediction and a low prevalence of complications, the device can be utilized effectively in experienced centers. Further study should examine device utility in other facilities and on the battlefield.

Impact of Alcohol and Methamphetamine Use on Burn Resuscitation.

Mortality associated with burn injuries is declining with improved critical care. However, patients admitted with concurrent substance use have increased risk of complications and poor outcomes. The impact of alcohol and methamphetamine use on acute burn resuscitation has been described in single-center studies; however, has not been studied since implementation of computerized decision support for resuscitation. Patients were evaluated based presence of alcohol, with a minimum blood alcohol level of 0.10, or positive methamphetamines on urine drug screen. Fluid volumes and urine output were examined over 48 hours. A total of 296 patients were analyzed. 37 (12.5%) were positive for methamphetamine use, 50 (16.9%) were positive for alcohol use, and 209 (70.1%) with negative for both. Patients positive for methamphetamine received a mean of 5.30 ± 2.63 cc/kg/TBSA, patients positive for alcohol received a mean of 5.41 ± 2.49 cc/kg/TBSA, and patients with neither received a mean of 4.33 ± 1.79 cc/kg/TBSA. Patients with methamphetamine or alcohol use had significantly higher fluid requirements. In the first 6 hours patients with alcohol use had significantly higher urinary output (UO) in comparison to patients with methamphetamine use which had similar output to patients negative for both substances. This study demonstrated that patients with alcohol and methamphetamine use had statistically significantly greater fluid resuscitation requirements compared to patients without. The effects of alcohol as a diuretic align with previous literature. However, patients with methamphetamine lack the increased UO as a cause for their increased fluid requirements.

Higher Initial Formula for Resuscitation After Severe Burn Injury Means Higher 24-Hour Volumes.

Initial fluid infusion rates for resuscitation of burn injuries typically use formulas based on patient weight and total body surface area (TBSA) burned. However, the impact of this rate on overall resuscitation volumes and outcomes have not been extensively studied. The purpose of this study was to determine the impact of initial fluid rates on 24-hour volumes and outcomes using the Burn Navigator (BN). The BN database is composed of 300 patients with ≥20% TBSA, >40 kg that were resuscitated utilizing the BN. Four study arms were analyzed based on the initial formula-2 ml/kg/TBSA, 3 ml/kg/TBSA, 4 ml/kg/TBSA or the Rule of Ten. Total fluids infused at 24 hours after admission were compared as well as resuscitation-related outcomes. A total of 296 patients were eligible for analysis. Higher starting rates (4 ml/kg/TBSA) resulted in significantly higher volumes at 24 hours (5.2 ± 2.2 ml/kg/TBSA) than lower rates (2 ml/kg/TBSA resulted in 3.9 ± 1.4 ml/kg/TBSA). No shock was observed in the high resuscitation cohort, whereas the lowest starting rate exhibited a 12% incidence, lower than both the Rule of Ten and 3 ml/kg/TBSA arms. There was no difference in 7-day mortality across groups. Higher initial fluid rates resulted in higher 24-hour fluid volumes. The choice of 2ml/kg/TBSA as initial rate did not result in increased mortality or more complications. An initial rate of 2ml/kg/TBSA is a safe strategy.

Weighing the pediatric patient during trauma resuscitation and its concordance with estimated weight using Broselow Luten Emergency Tape.

OBJECTIVE: Obtaining an accurate weight is crucial during pediatric trauma/medical resuscitation. Currently, length-based weight estimations are used. Study objective was to assess feasibility of obtaining actual weights of children during trauma resuscitation and study its concordance with length-based estimated weight using the Broselow Pediatric Emergency Tape. METHODS: Pediatric trauma patients 0 to 14 years old presenting to a tertiary care pediatric trauma center between November 2008 and October 2009 were enrolled prospectively. Length-based weight estimation was done on patient arrival using the Broselow tape; in addition, an actual patient weight was recorded using the trauma stretcher integrated weighing scale. RESULTS: Two hundred thirty-one patients were eligible and enrolled. Weights were recorded in 145 children (63.2%). In 27 patients (18.6%) whose body length exceeded Broselow tape range, weight was measured using stretcher scale only. The remaining 118 patients (mean age, 5.0 [SE ± 0.3] years; 67% male) were used for correlation analysis. There was good correlation (Pearson correlation coefficient, r = 0.86) between estimated weight and measured weight. However, Bland-Altman analysis showed mean bias +2.6 kg (95% confidence interval [CI], 1.6-3.6 kg); lower/upper limits of agreement were -8.3 kg (CI, -10.0 to -6.6 kg) and 13.5 kg (CI, 11.7-15.2 kg). CONCLUSIONS: It is possible to obtain an actual patient weight during pediatric trauma resuscitation. Length-based estimated weight using Broselow tape underestimated weight by 2.6 kg; the mean error was greatest in the highest weight category.

Initial Results of the American Burn Association Observational Multicenter Evaluation on the Effectiveness of the Burn Navigator.

The objective of this multicenter observational study was to evaluate resuscitation volumes and outcomes of patients who underwent fluid resuscitation utilizing the Burn Navigator (BN), a resuscitation clinical decision support tool. Two analyses were performed: examination of the first 24 hours of resuscitation and the first 24 hours postburn regardless of when the resuscitation began, to account for patients who presented in a delayed fashion. Patients were classified as having followed the BN (FBN) if all hourly fluid rates were within ±20 ml of BN recommendations for that hour at least 83% of the time; otherwise, they were classified as not having followed BN (NFBN). Analysis of resuscitation volumes for FBN patients in the first 24 hours resulted in average volumes for primary crystalloid and total fluids administered of 4.07 ± 1.76 ml/kg/TBSA (151.48 ± 77.46 ml/kg) and 4.68 ± 2.06 ml/kg/TBSA (175.01 ± 92.22 ml/kg), respectively. Patients who presented in a delayed fashion revealed average volumes for primary and total fluids of 5.28 ± 2.54 ml/kg/TBSA (201.11 ± 106.53 ml/kg) and 6.35 ± 2.95 ml/kg/TBSA (244.08 ± 133.5 ml/kg), respectively. There was a significant decrease in the incidence of burn shock in the FBN group (P < .05). This study shows that the BN provides comparable resuscitation volumes of primary crystalloid fluid to the Parkland formula, recommends total fluid infusion less than the Ivy index, and was associated with a decreased incidence of burn shock. Early initiation of the BN device resulted in lower overall fluid volumes.

Evaluating Real-World National and Regional Trends in Definitive Closure in U.S. Burn Care: A Survey of U.S. Burn Centers.

To better understand trends in burn treatment patterns related to definitive closure, this study sought to benchmark real-world survey data with national data contained within the National Burn Repository version 8.0 (NBR v8.0) across key burn center practice patterns, resource utilization, and clinical outcomes. A survey, administered to a representative sample of U.S. burn surgeons, collected information across several domains: burn center characteristics, patient characteristics including number of patients and burn size and depth, aggregate number of procedures, resource use such as autograft procedure time and dressing changes, and costs. Survey findings were aggregated by key outcomes (number of procedures, costs) nationally and regionally. Aggregated burn center data were also compared to the NBR to identify trends relative to current treatment patterns. Benchmarking survey results against the NBR v8.0 demonstrated shifts in burn center patient mix, with more severe cases being seen in the inpatient setting and less severe burns moving to the outpatient setting. An overall reduction in the number of autograft procedures was observed compared to NBR v8.0, and time efficiencies improved as the intervention time per TBSA decreases as TBSA increases. Both nationally and regionally, an increase in costs was observed. The results suggest resource use estimates from NBR v8.0 may be higher than current practices, thus highlighting the importance of improved and timely NBR reporting and further research on burn center standard of care practices. This study demonstrates significant variations in burn center characteristics, practice patterns, and resource utilization, thus increasing our understanding of burn center operations and behavior.

StrataGraft skin substitute is well-tolerated and is not acutely immunogenic in patients with traumatic wounds: results from a prospective, randomized, controlled dose escalation trial.

OBJECTIVE: The goal of this study was to assess the immunogenicity and antigenicity of StrataGraft skin tissue in a randomized phase I/II clinical trial for the temporary management of full-thickness skin loss. BACKGROUND: StrataGraft skin tissue consists of a dermal equivalent containing human dermal fibroblasts and a fully stratified, biologically active epidermis derived from Near-diploid Immortalized Keratinocyte S (NIKS) cells, a pathogen-free, long-lived, consistent, human keratinocyte progenitor. METHODS: Traumatic skin wounds often require temporary allograft coverage to stabilize the wound bed until autografting is possible. StrataGraft and cadaveric allograft were placed side by side on 15 patients with full-thickness skin defects for 1 week before autografting. Allografts were removed from the wound bed and examined for allogeneic immune responses. Immunohistochemistry and indirect immunofluorescence were used to assess tissue structure and cellular composition of allografts. In vitro lymphocyte proliferation assays, chromium-release assays, and development of antibodies were used to examine allogeneic responses. RESULTS: One week after patient exposure to allografts, there were no differences in the numbers of T or B lymphocytes or Langerhans cells present in StrataGraft skin substitute compared to cadaver allograft, the standard of care. Importantly, exposure to StrataGraft skin substitute did not induce the proliferation of patient peripheral blood mononuclear cells to NIKS keratinocytes or enhance cell-mediated lysis of NIKS keratinocytes in vitro. Similarly, no evidence of antibody generation targeted to the NIKS keratinocytes was seen. CONCLUSIONS: These findings indicate that StrataGraft tissue is well-tolerated and not acutely immunogenic in patients with traumatic skin wounds. Notably, exposure to StrataGraft did not increase patient sensitivity toward or elicit immune responses against the NIKS keratinocytes. We envision that this novel skin tissue technology will be widely used to facilitate the healing of traumatic cutaneous wounds.This study was registered at www.clinicaltrials.gov (NCT00618839).

Rare Operative Intervention for Urinary and Fecal Incontinence-Associated Dermatitis.

Incontinence-associated dermatitis (IAD) is considered a cause of moisture-associated skin damage after prolonged exposure to urinary and fecal incontinence. While partial-thickness burns are often managed with topical therapies, daily dressing changes, patient positioning, hydration, nutrition, and pain management, deep partial-thickness and full-thickness burn injuries require surgical excision and, ultimately, skin grafting. The elderly and very young as well as those with medical comorbidities can develop urinary and fecal incontinence. Urinary ammonia and gastrointestinal lipolytic enzymes and proteases can produce caustic damage to weakened elderly or immature skin. In this report, 2 cases of IAD are presented as chemical burns. After a prolonged interval of urinary and fecal incontinence, an incapacitated 65-year-old male with 14% total body surface area (TBSA) partial-thickness wounds, and an 85-year-old female with 4% TBSA full-thickness wounds were admitted to the burn center and underwent operative management.

Electronic Cigarette-Related Injuries Presenting to Five Large Burn Centers, 2015-2019.

Electronic cigarettes are advertised as safer alternatives to traditional cigarettes yet cause serious injury. U.S. burn centers have witnessed a rise in both inpatient and outpatient visits to treat thermal injuries related to their use. A multicenter retrospective chart review of American Burn Association burn registry data from five large burn centers was performed from January 2015 to July 2019 to identify patients with electronic cigarette-related injuries. A total of 127 patients were identified. Most sustained less than 10% total body surface area burns (mean 3.8%). Sixty-six percent sustained second-degree burns. Most patients (78%) were injured while using their device. Eighteen percent of patients reported spontaneous device combustion. Two patients were injured while changing their device battery, and two were injured modifying their device. Three percent were injured by secondhand mechanism. Burn injury was the most common injury pattern (100%), followed by blast injury (3.93%). Flame burns were the most common (70%) type of thermal injury; however, most patients sustained a combination-type injury secondary to multiple burn mechanisms. The most injured body region was the extremities. Silver sulfadiazine was the most common agent used in the initial management of thermal injuries. Sixty-three percent of patients did not require surgery. Of the 36% requiring surgery, 43.4% required skin grafting. Multiple surgeries were uncommon. Our data recognize electronic cigarette use as a public health problem with the potential to cause thermal injury and secondary trauma. Most patients are treated on an inpatient basis although most patients treated on an outpatient basis have good outcomes.

Negative Pressure Wound Therapy With Instillation and Dwell Time for the Management of Complex Wounds: A Case Series.

INTRODUCTION: Negative pressure wound therapy (NPWT) dressings are beneficial tools for promoting granulation tissue and wound healing. An NPWT dressing with instillation and dwell time (NPWTi-d) is becoming more frequently used to provide daily, effective wound cleansing between surgical debridement procedures. Either saline or other wound solutions, such has hypochlorous acid wound solution, can be instilled in small volume aliquots to irrigate the wound periodically. OBJECTIVE: This case series describes the effective use of NPWTi-d in conjunction with hypochlorous acid (HOCl) solution in 10 patients with necrotizing soft tissue infections (NSTIs). MATERIALS AND METHODS: The hospital registry of patients between July 2018 and June 2020 was queried to identify patients older than were 18 years or older, whose wounds were managed intermittently with NPWTi-d using HOCl wound solution, regardless of wound etiology. Wound and patient demographics were reported. RESULTS: A total of 10 cases in which NPWTi-d was utilized in conjunction with HOCl were identified. Of the 10 patients, 6 were admitted for NSTIs, 2 were admitted for sacral decubitus ulcers, and 2 were admitted for burn injuries. The patients' wounds ranged from 30 cm2 to 1000 cm2, and 80% of patients ultimately underwent skin grafting for wound closure. CONCLUSIONS: This case series highlights the spectrum of wounds that can be managed with NPWTi-d dressings to yield a clean wound environment to promote healing and preparation for wound closure.

Phase I/II clinical evaluation of StrataGraft: a consistent, pathogen-free human skin substitute.

BACKGROUND: Large wounds often require temporary allograft placement to optimize the wound bed and prevent infection until permanent closure is feasible. We developed and clinically tested a second-generation living human skin substitute (StrataGraft). StrataGraft provides both a dermis and a fully-stratified, biologically-functional epidermis generated from a pathogen-free, long-lived human keratinocyte progenitor cell line, Neonatal Immortalized KeratinocyteS (NIKS). METHODS: Histology, electron microscopy, quantitative polymerase chain reaction, and bacterial growth in vitro were used to analyze human skin substitutes generated from primary human keratinocytes or NIKS cells. A phase I/II, National Institute of Health-funded, randomized, safety, and dose escalation trial was performed to assess autograft take in 15 patients 2 weeks after coverage with StrataGraft skin substitute or cryopreserved cadaver allograft. RESULTS: StrataGraft skin substitute exhibited a fully stratified epidermis with multilamellar lipid sheets and barrier function as well as robust human beta defensin-3 mRNA levels. Analysis of the primary endpoint in the clinical study revealed no differences in autograft take between wound sites pretreated with StrataGraft skin substitute or cadaver allograft. No StrataGraft-related adverse events or serious adverse events were observed. CONCLUSIONS: The major finding of this phase I/II clinical study is that performance of StrataGraft skin substitute was comparable to cadaver allograft for the temporary management of complex skin defects. StrataGraft skin substitute may also eliminate the risk for disease transmission associated with allograft tissue and offer additional protection to the wound bed through inherent antimicrobial properties. StrataGraft is a pathogen-free human skin substitute that is ideal for the management of severe skin wounds before autografting.

Burn injury outcome differences in Native Americans.

OBJECTIVE: Native Americans (NAs) have worse healthcare outcomes over some measures than non-Native Americans (non-NAs) (i.e., lower life expectancy, higher heart disease and psychiatric disease rates). Little data exists to show if there are differences in the hospital course of burned NAs versus non-NA patients. The purpose of this study is to analyze the epidemiology, clinical course, and outcomes of NA burn injury in Arizona. METHODS: We conducted a retrospective database review of all burn center burn admissions from 2000 to 2015. This initial dataset of 12,724 patients included all initial presentations for burns, non-burns, and readmissions. From this database, we extracted all patients who were new admissions for burn injuries only. This resulted in 10,521 patients of which 9555 patients were non-NA patients and 966 were NA patients. The burn center collects sixty-eight data points to populate our burn database; of these data points, we reviewed twenty-nine to assess if differences existed. RESULTS: Statistically significant differences exist between the two groups with regard to age, geographic locality at time of burn, circumstances surrounding the injury, etiology of the injury, method of transport to the regional burn center, total length of stay, Injury Severity Score on admission, total percent total body surface area burned, month of year of burn injury, hospital charges, payor source for medical costs, and the final disposition. NA burn patients were more often burned at recreational than occupational sites and while participating in non-work related activities. Burn etiologies in NA patients were more frequently due to contact and flame. NA burn patients tended to have greater hospital length of stays and greater charges, and were less likely to be discharged home. CONCLUSIONS: Our data demonstrate that NAs have a different experience with the healthcare system than non-NAs after a burn injury. The majority of these issues revolve around socioeconomic differences between the two groups.

Randomized Comparison of Hypochlorous Acid With 5% Sulfamylon Solution as Topical Therapy Following Skin Grafting.

Objective: Infections are a serious complication of thermal injury. Excision and grafting have led to a decrease in incidence, but to ensure successful skin grafting, antimicrobial irrigants are frequently utilized to prevent infection. A safe, efficacious, and cost-effective irrigant capable of preventing infections would be a valuable adjunctive therapy. The objectives of this study were to determine whether the test article was noninferior to current therapy in controlling infection and reducing postoperative pain in patients with skin graft. Methods: Patients with burns requiring skin grafting were randomized to hypochlorous acid or 5% Sulfamylon solution as topical dressings postoperatively. Inclusion criteria included thermal injury 20% or more total body surface area requiring excision and autografting, and age 18 years or more. Exclusion criteria included pregnant females, chlorine sensitivity, and electrical/chemical/cold injuries. The following outcomes were assessed: patient demographics, graft viability, infection, pain score, narcotic usage, adverse events, and cost. Results: Treatment groups were demographically equivalent. There were no differences in adverse or serious adverse events between the 2 groups. Graft viability and infection rate were equivalent between the 2 groups. In addition, pain scores and narcotic usage were similar. Hypochlorous acid was significantly less expensive than 5% Sulfamylon solution. Conclusions: Hypochlorous acid demonstrated equivalent efficacy and safety compared with 5% Sulfamylon when used as the postoperative topical dressing for skin grafts. Hypochlorous acid was more cost-effective. This pilot study was limited by its small sample size. However, hypochlorous acid shows promise as a topical wound dressing and further study with larger groups is warranted.

"Streets of Fire" revisited: contact burns.

BACKGROUND: Pavement-street contact burns are rare. This study compared recent contact burns to those published in "Pavement temperature and burns: Streets of Fire" in 1995. The hypothesis was that there were a significantly increased number of pavement-street burns, as a result of increased ambient temperatures, and that motor vehicle crash (MVC) contact burns were less severe than pavements-street burns. METHODS: This was a retrospective burn center registry study of naturally heated surface contact burns during May to September from 2016 to 2018. Statistical analyses were performed with one-way analysis of variance (ANOVA) and Maximum Likelihood chi-squared for age, percent of total burn surface area (% TBSA), treatment, hospitalization, comorbidities, hospital charges, mortality, ambient, and surface temperatures (pavement, asphalt, rocks). RESULTS: In the 1995 study, median ambient temperatures were 106 (range 100-113) °F compared to the 108 (range 86-119) °F highest noon temperature in the current study. No ambient temperature differences were recorded on days with pavement burn admissions compared to days without these admissions. There were 225 pavement, 27 MVC, 15 road rash, and 103 other contact burns. The major injuries in the pavement group were due to being "down" (unknown reason), falls, and barefoot. Compared to the others, the pavement group was older, 56+ years, p < 0.001, and had smaller burns but similar length of stay. Fifty percent of the 225 pavement group patients with full-thickness burns required skin grafts. There were 13 (6%) fatalities in the pavement group vs 1 (4%) in the MVC group, p = 0.01. Fatalities were secondary to sepsis, shock, cardiac, respiratory, or kidney complications. Compared to survivors, the non-survivors had a significantly higher % TBSA (10% vs 4%), p = 0.01, and lower Glasgow Coma Scores (10 vs 15), p = 0.002. CONCLUSION: There was a median 2 °F increase in ambient temperature since 1995. The increase in pavement burn admissions was multi-factorial: higher temperatures, population, and the number of older patients, with increased metropolis expansion, outreach, and urban heat indices. Pavement group was similar to the MVC group except for significantly older age and increased mortality. Morbidity associated with age contributed to increased mortality.