Virtual Reality as Pain Relief in Burn Care: A Pilot Randomized Controlled Trial on the Effectiveness on Pain During Multiple Dressing Changes.

This pilot Randomized Controlled Trial (RCT) aimed to investigate the effectiveness of Virtual Reality (VR)-distraction on pain during multiple Wound Dressing Changes (WDCs). Furthermore, associations between demographic, clinical, and psychological factors and pain during WDC were determined. Participants were randomized to either the VR-condition or Care As Usual (CAU)-condition. Both groups received standard wound care and pain medication. The VR-group additionally received VR-distraction. The primary outcome measure was pain intensity (VAT 0-10). Secondary outcome measures were pain medication (Fentanyl spray and/or Piritramide) and satisfaction with WDC (VAT 0-10). Only 38 patients (VR-group: n = 21; CAU-group: n = 17) of the 128 intended patients were included during the study period due to several limitations (strict exclusion criteria and restrictions of the VR-equipment). No significant differences were found between both groups on pain intensity and medication. Both groups were also equally satisfied with WDC. Age showed a significant negative correlation with pain during WDC. In view of the small sample size, this study has restricted power and should be considered a pilot. Nevertheless, a RCT with between-subjects design across multiple WDCs was feasible and, given the speed of VR-developments, we expect larger, better powered RCTs to be possible in the near future, for which our experiences and recommendations are relevant.

Hydrosurgical and conventional debridement of burns: randomized clinical trial.

BACKGROUND: Tangential excision of burned tissue followed by skin grafting is the cornerstone of burn surgery. Hydrosurgery has become popular for tangential excision, with the hypothesis that enhanced preservation of vital dermal tissue reduces scarring. The aim of this trial was to compare scar quality after hydrosurgical versus conventional debridement before split-skin grafting. METHODS: A double-blind randomized within-patient multicentre controlled trial was conducted in patients with burns that required split-skin grafting. One wound area was randomized to hydrosurgical debridement and the other to Weck knife debridement. The primary outcome was scar quality at 12 months, assessed with the observer part of the Patient and Observer Scar Assessment Scale (POSAS). Secondary outcomes included complications, scar quality, colour, pliability, and histological dermal preservation. RESULTS: Some 137 patients were randomized. At 12 months, scars of the hydrosurgical debrided wounds had a lower POSAS observer total item score (mean 2.42 (95 per cent c.i. 2.26 to 2.59) versus 2.54 (95 per cent c.i. 2.36 to 2.72; P = 0.023)) and overall opinion score (mean 3.08 (95 per cent c.i. 2.88 to 3.28) versus 3.30 (95 per cent c.i. 3.09-3.51); P = 0.006). Patient-reported scar quality and pliability measurements were significantly better for the hydrosurgically debrided wounds. Complication rates did not differ between both treatments. Histologically, significantly more dermis was preserved with hydrosurgery (P < 0.001). CONCLUSION: One year after surgery scar quality and pliability was better for hydrosurgically debrided burns, probably owing to enhanced histological preservation of dermis. REGISTRATION NUMBER: Trial NL6085 (NTR6232 (http://www.trialregister.nl)).

Burns in the elderly: a nationwide study on management and clinical outcomes.

BACKGROUND: In modern-day burn care, advanced age remains an important predictor for mortality among burn victims. In this study, we compared the complete treatment trajectory (including pre-hospital and surgical treatment) and the outcomes between an elderly burn population and a younger adult burn population. METHODS: In this nationwide study, data from the Dutch Burn Repository were used. This is a uniform national registration for Dutch specialized burn care. All adult patients that were admitted to one of the three Dutch burn centres from the period 2009 to 2015 were included in the analysis. Burn patients were considered as elderly when ≥65 years of age, and were then further subdivided into three age categories: 65-74, 75-85 and 85+ years. Younger adults in the age category 18-64 years were used as the reference group.Surgical management was studied comprehensively and included timing of surgery, the number of procedures and details on the surgical technique, especially the technique used for debridement and the grafting technique that was applied.For the comparison of clinical outcome, the following parameters were included: mortality, wound infections, length of stay/TBSA (total body surface area) burned, discharge disposition and secondary reconstructions. RESULTS: During the study period, 3155 adult patients were included (elderly, n = 505). Burn severity, reflected by the median TBSA, varied between 3.2-4.0% and was comparable, but aetiology and pre-hospital care were different between elderly and the younger adult reference group.Surgical treatment was initiated significantly faster in elderly burn patients (p < 0.001). Less selective techniques for surgical debridement were used in the elderly burns patients (hydrosurgery, 42.0% vs 23.5-22.6%), and on the other hand more avulsion (5.3% vs 7.3-17.6%) and primary wound closure (6.7% vs 24.5%). The most frequently used grafting technique was meshed skin grafts (79.2-88.6%); this was not related to age.Mortality increased rapidly with a higher age and showed a high peak in the 85+ category (23.8%). Furthermore, considerable differences were found in hospital discharge disposition between the elderly and the reference group. CONCLUSIONS: In conclusion, elderly burn patients who require specialized burn care are vulnerable and medically challenging. Differences in aetiology, comorbidity, physiology and the management prior to admission possibly affect the initial surgical management and result in significantly worse outcomes in elderly. Elderly patients need optimal, timely and specialized burn care to enhance survival after burn injuries.

Long-term scar quality after hydrosurgical versus conventional debridement of deep dermal burns (HyCon trial): study protocol for a randomized controlled trial.

BACKGROUND: Deep dermal burns require tangential excision of non-viable tissue and skin grafting to improve wound healing and burn-scar quality. Tangential excision is conventionally performed with a knife, but during the last decade hydrosurgery has become popular as a new tool for tangential excision. Hydrosurgery is generally thought to be a more precise and controlled manner of burn debridement leading to preservation of viable tissue and, therefore, better scar quality. Although scar quality is considered to be one of the most important outcomes in burn surgery today, no randomized controlled study has compared the effect of these two common treatment modalities with scar quality as a primary outcome. The aim of this study is, therefore, to compare long-term scar quality after hydrosurgical versus conventional tangential excision in deep dermal burns. METHODS/DESIGN: A multicenter, randomized, intra-patient, controlled trial will be conducted in the Dutch burn centers of Rotterdam, Beverwijk, and Groningen. All patients with deep dermal burns that require excision and grafting are eligible. Exclusion criteria are: a burn wound < 50 cm2, total body surface area (TBSA) burned > 30%, full-thickness burns, chemical or electrical burns, infected wounds (clinical symptoms in combination with positive wound swabs), insufficient knowledge of the Dutch or English language, patients that are unlikely to comply with requirements of the study protocol and follow-up, and patients who are (temporarily) incompetent because of sedation and/or intubation. A total of 137 patients will be included. Comparable wound areas A and B will be appointed, randomized and either excised conventionally with a knife or with the hydrosurgery system. The primary outcome is scar quality measured by the observer score of the Patient and Observer Scar Assessment Scale (POSAS); a subjective scar-assessment instrument, consisting of two separate six-item scales (observer and patient) that are both scored on a 10-point rating scale. DISCUSSION: This study will contribute to the optimal surgical treatment of patients with deep dermal burn wounds. TRIAL REGISTRATION: Dutch Trial Register, NTR6232 . Registered on 23 January 2017.

Epidemiology and Outcome of Patients With Burns Treated With Cerium Nitrate Silversulfadiazine.

In this study, the outcome of treatment with Flammacerium in burn patients is studied. The retrospective study involved patients with acute burns admitted to the Burn Centre of Martini Hospital, Groningen, The Netherlands, between 2009 and 2014. The outcome parameters were mortality, complications (noninfectious and infectious), need of surgery, and length of stay. The group of patients consisted of 853 patients, of which 554 were male (64.9%). There were 23 patients with a total burn size of 40% TBSA or more (2.7%). In total, 13 of the 853 patients (1.5%) died, and none of them were children (<16 years). The overall mortality in the group of patient with burns >40% TBSA was 30.4%. In the elderly group (>70 years), the mortality rate was 6.3%. Treatment with Flammacerium is applicable in all thermal burn patients. Especially children, elderly patients, and patients with severe burns can benefit from a more conservative treatment with Flammacerium whereby the first operation can be postponed until the patient is stabilized and in which the wounds can be covered directly with skin transplants.

Skin stretching for primary closure of acute burn wounds.

BACKGROUND: In burn care, a well-acknowledged problem is the suboptimal scar outcome from skin grafted burn wounds. With the aim of improving this, we focused on a new technique: excision of the burn wound followed by primary closure, thereby using a skin-stretching device to stretch the adjacent healthy skin. The short- and long-term effect of Skin Stretch was compared to split skin grafting (SSG) in a randomized controlled trial. METHODS: Patients with burn wounds were randomized for SSG or primary wound closure using Skin Stretch. Follow-up was performed at 3 and 12 months postoperatively. The scar surface area was calculated and the scar quality was assessed, using subjective and objective measurement methods. RESULTS: No significant differences between the SSG and the Skin Stretch group were found for scar surface area. In the Skin Stretch group, a significant reduction of the surface area from 65.4cm(2) (13.6-129.1) to 13.4cm(2) (3.0-36.6) was found at 3 months (p=0.028) and at 12 months postoperatively (65.4cm(2) (13.6-129.1) to 33.0cm(2) (8.9-63.7), p=0.046, Wilcoxon signed ranks test). CONCLUSIONS: Skin Stretch for primary closure of acute burn wounds is a suitable technique and can be considered for specific circumscript full-thickness burn wounds. However, future research should be performed to provide additional scientific evidence.

Increased B-type natriuretic peptide and decreased proteinuria might reflect decreased capillary leakage and is associated with a better outcome in patients with severe burns.

INTRODUCTION: It is difficult to adjust fluid balance adequately in patients with severe burns due to various physical changes. B-type natriuretic peptide (BNP) is emerging as a potential marker of hydration state. Proteinuria is used as a predictor of outcome in severe illness and might correlate to systemic capillary leakage. This study investigates whether combining BNP and proteinuria can be used as a guide for individualized resuscitation and as a predictor of outcome in patients with severe burns. METHODS: From 2006 to 2009, 38 consecutive patients (age 47 ± 15 years, 74% male) with severe burns were included and followed for 20 days. All had normal kidney function at admission. BNP and proteinuria were routinely measured. Ordered and actually administered fluid resuscitation volumes were recorded. The Sequential Organ Failure Assessment (SOFA) score was used as the measure of outcome. RESULTS: BNP increased during follow-up, reaching a plateau level at Day 3. Based on median BNP levels at Day 3, patients were divided into those with low BNP and those with high BNP levels. Both groups had comparable initial SOFA scores. Patients with high BNP received less fluid from Days 3 to 10. Furthermore, patients with a high BNP at Day 3 had less morbidity, reflected by lower SOFA scores on the following days. To minimize effects of biological variability, proteinuria on Days 1 and 2 was averaged. By dividing the patients based on median BNP at Day 3 and median proteinuria, patients with high BNP and low proteinuria had significantly lower SOFA scores during the entire follow-up period compared to those patients with low BNP and high proteinuria. CONCLUSIONS: Patients with higher BNP levels received less fluid. This might be explained by a lower capillary leakage in these patients, resulting in more intravascular fluid and consequently an increase in BNP. In combination with low proteinuria, possibly reflecting minimal systemic capillary leakage, a high BNP level was associated with a better outcome. BNP and proteinuria have prognostic potential in severely burned patients and may be used to adjust individual resuscitation.