National Institute on Drug Abuse Clinical Trials Network Meeting Report: Managing Patients Exposed to Xylazine-Adulterated Opioids in Emergency, Hospital and Addiction Care Settings.

Used as a veterinary sedative and not approved for human use, xylazine has been increasingly linked with opioid overdose deaths in the United States. A growing number of people have been exposed to xylazine in the illicit opioid supply (especially fentanyl) or in other drugs, particularly in some areas of the Northeast. Xylazine is an α-2 adrenergic agonist that decreases sympathetic nervous system activity. When combined with fentanyl or heroin, it is purported to extend the duration of the opioid's sedative effect and to cause dependence and an associated withdrawal syndrome; however, data to support these concerns are limited. Despite the escalating frequency of detection of xylazine in people with nonfatal and fatal opioid overdose, direct links to these outcomes have not been identified. Because the strongest causal link is to fentanyl coexposure, ventilatory support and naloxone remain the cornerstones of overdose management. Xylazine is also associated with severe tissue injury, including skin ulcers and tissue loss, but little is known about the underlying mechanisms. Nonetheless, strategies for prevention and treatment are emerging. The significance and clinical effects of xylazine as an adulterant is focused on 4 domains that merit further evaluation: fentanyl-xylazine overdose, xylazine dependence and withdrawal, xylazine-associated dermal manifestations, and xylazine surveillance and detection in clinical and nonclinical settings. This report reflects the Proceedings of the National Institute on Drug Abuse Center for the Clinical Trials Network convening of clinical and scientific experts, federal staff, and other stakeholders to describe emerging best practices for treating people exposed to xylazine-adulterated opioids. Participants identified scientific gaps and opportunities for research to inform clinical practice in emergency departments, hospitals, and addiction medicine settings.

Evaluating the Effects of Food Deserts and Food Swamps in an Urban Burn Patient Population.

Poverty is a known risk factor for burn injury and is associated with residency in food deserts and food swamps. Our aim was to determine the prevalence of residency in food deserts and food swamps and to investigate the relationship between food environment, comorbidities, and wound healing in burn patients. We performed a retrospective chart review of all burn patients age ≥ 18 seen in the emergency department or admitted to the burn service at an ABA-verified urban academic center between January 2016 and January 2022. Patient GeoIDs were used to classify residency in food deserts and food swamps and comorbidities and demographics were recorded. A subset of patients with less than 20% total body surface area burns who underwent single-operation split-thickness skin grafting was identified for wound healing analysis. A total of 3,063 patients were included, with 206 in the heal-time analysis. 2,490 (81.3%) lived in food swamps and 96 (3.1%) lived in food deserts. Diabetes, hypertension, and tobacco smoking were more prevalent in food swamps than food deserts or good access areas. While there was no significant effect of food environment on wound healing, diabetes was associated with longer heal times. Most burn patients reside in food swamps, which are associated with a higher prevalence of hypertension, diabetes, and smoking. Food environment was not significantly associated with wound healing. Not having diabetes was associated with a shorter time to wound healing.

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.

Analysis of real-world length of stay data and costs associated with use of autologous skin cell suspension for the treatment of small burns in U.S. centers.

BACKGROUND: Autologous skin cell suspension (ASCS) is a treatment for acute thermal burn injuries associated with significantly lower donor skin requirements than conventional split-thickness skin grafts (STSG). Projections using the BEACON model suggest that among patients with small burns (total body surface area [TBSA]<20 %), use of ASCS± STSG leads to a shorter length of stay (LOS) in hospital and cost savings compared with use of STSG alone. This study evaluated whether data from real-world clinical practice corroborate these findings. MATERIALS AND METHODS: Electronic medical record data were collected from January 2019 through August 2020 from 500 healthcare facilities in the United States. Adult patients receiving inpatient treatment with ASCS± STSG for small burns were identified and matched to patients receiving STSG using baseline characteristics. LOS was assumed to cost $7554/day and to account for 70 % of overall costs. Mean LOS and costs were calculated for the ASCS± STSG and STSG cohorts. RESULTS: A total of 151 ASCS± STSG and 2243 STSG cases were identified; 63.0 % of patients were male and the average age was 44.2 years. Sixty-three matches were made between cohorts. LOS was 18.5 days with ASCS± STSG and 20.6 days with STSG (difference: 2.1 days [10.2 %]). This difference led to bed cost savings of $15,587.62 per ASCS± STSG patient. Overall cost savings with ASCS± STSG were $22,268.03 per patient. CONCLUSIONS: Analysis of real-world data shows that treatment of small burn injuries with ASCS± STSG provides reduced LOS and substantial cost savings compared with STSG, supporting the validity of the BEACON model projections.

Length of Stay and Costs with Autologous Skin Cell Suspension Versus Split-Thickness Skin Grafts: Burn Care Data from US Centers.

INTRODUCTION: Autologous skin cell suspension (ASCS) significantly reduces donor skin requirements versus conventional split-thickness skin grafts (STSG) for thermal burn treatment. In analyses using the Burn-medical counter measure Effectiveness Assessment Cost Outcomes Nexus (BEACON) model, ASCS was associated with shorter hospital length of stay (LOS) and cost savings versus STSG. This study hypothesized that daily practice data from the USA would support these findings. METHODS: Electronic medical record data from 500 healthcare facilities (January 2019-August 2020) were used to match adult patients who received inpatient burn treatment with ASCS (± STSG) to patients treated with STSG alone on the basis of sex, age, percent total body surface area (TBSA), and comorbidities. Based on BEACON analyses, LOS was assumed to represent 70% of total costs and used as a proxy to assess the data. Mean LOS, costs, and the incremental revenue associated with inpatient capacity changes were calculated. RESULTS: A total of 151 ASCS and 2443 STSG patients were identified: 63.0% were male and average age was 44.5 years. Eight-one matches were made between cohorts. LOS was 21.7 days with ASCS and 25.0 days with STSG alone (difference 3.3 days [13.2%]). LOS was lower with ASCS than STSG in four of five TBSA intervals. The LOS difference led to hospital bed cost savings of $25,864 per ASCS patient; overall cost savings were $36,949 per patient. Similar cost savings were observed in TBSA groupings < 20% and ≥ 20%. The reduced LOS with ASCS translated into an increased capacity of 2.2 inpatients/bed annually, which increased hospital revenue by $92,283/burn unit bed annually. CONCLUSIONS: Real-world data show that ASCS (± STSG) is associated with reduced LOS and cost savings versus STSG alone across all burn sizes, supporting the validity of the BEACON analyses. ASCS use may also increase patient capacity and throughput, leading to increased hospital revenue.

Autologous skin cell suspension (ASCS) is a treatment for thermal skin burn injuries that can be used alone or in combination with split-thickness skin grafts (STSG), the conventional standard of care. Projections using the Burn-medical counter measure Effectiveness Assessment Cost Outcomes Nexus (BEACON) model indicate that ASCS leads to shorter hospital length of stay (LOS) and overall cost savings compared with STSG alone. These model findings are supported by benchmarking study data from a limited sample of US burn centers. The current study aimed to understand whether the BEACON projections are supported by daily clinical practice data from US healthcare facilities. Using electronic medical record data, we matched patients who received ASCS ± STSG from January 2019 to August 2020 to those receiving STSG alone on the basis of demographic and clinical factors. Data analysis showed that hospital LOS was shorter (3.3 days) with ASCS ± STSG than STSG alone, a difference associated with a hospital bed cost savings of $25,864 per ASCS patient. Overall cost savings, which included nursing time and other costs, were $36,949 per patient. Analysis of patients with burns comprising total body surface areas less than 20% or at least 20% showed cost savings in both groups. The reduced LOS with ASCS also translated into the ability to treat 2.2 more patients per hospital bed per year, which was projected to increase hospital earnings. These real-world findings support those of modeling analyses, indicating that use of ASCS ± STSG is associated with meaningful clinical and economic benefits compared with use of STSG alone.

Assessment of Outreach by a Regional Burn Center: Could Referral Criteria Revision Help with Utilization of Resources?

The objectives of this study were to identify trends in preburn center care, assess needs for outreach and education efforts, and evaluate resource utilization with regard to referral criteria. We hypothesized that many transferred patients were discharged home after brief hospitalizations and without need for operation. Retrospective chart review was performed for all adult and pediatric transfers to our regional burn center from July 2012 to July 2014. Details of initial management including TBSA estimation, fluid resuscitation, and intubation status were recorded. Mode of transport, burn center length of stay, need for operation, and in-hospital mortality were analyzed. In two years, our burn center received 1004 referrals from other hospitals including 713 inpatient transfers. Within this group, 621 were included in the study. Among transferred patients, 476 (77%) had burns less than 10% TBSA, 69 (11%) had burns between 10-20% TBSA, and 76 (12%) had burns greater than 20% TBSA. Referring providers did not document TBSA for 261 (42%) of patients. Among patients with less than 10% TBSA burns, 196 (41%) received fluid boluses. Among patients with TBSA < 10%, 196 (41%) were sent home from the emergency department or discharged within 24 hours, and an additional 144 (30%) were discharged within 48 hours. Overall, 187 (30%) patients required an operation. In-hospital mortality rates were 1.5% for patients who arrived by ground transport, 14.9% for rotor wing transport, and 18.2% for fixed wing transport. Future education efforts should emphasize the importance of calculating TBSA to guide need for fluid resuscitation and restricting fluid boluses to patients that are hypotensive. Clarifying the American Burn Association burn center referral criteria to distinguish between immediate transfer vs outpatient referral may improve patient care and resource utilization.

A survey of the use of propranolol in burn centers: Who, what, when, why.

INTRODUCTION: Many burn centers utilize propranolol in both adult and pediatric burn patients to attenuate the hypermetabolic response related to thermal injury despite the relative paucity of data in adults compared to children. The purpose of this study was to identify practice patterns related to propranolol, for which groups it is being used, length of use, and the intended benefit. METHODS: A 17 question survey regarding the use of propranolol was distributed to burn centers listed in the ABA website with a link to provide anonymous responses. RESULTS: A 31% response rate was achieved. Results demonstrated 60.5% use propranolol while 39.5% do not. Use in both adult and pediatric patients was reported in 82% of centers. The majority of centers (60.8%) initiate propranolol in patients with >20% TBSA burns. The drug is continued while inpatient for most adults (43%) with only 10% continuing treatment up to 6 months vs. rates of 17.6% long term outpatient use in pediatric patients. Drug dosing ranged from 10 to 40mg in adults and 0.1mg/kg to 5mg/kg in pediatric patients dosed twice daily to four times daily with 25% and 40% titrating the dose to a reduced heart rate respectively. Propranolol was felt to improve outcomes in 56% of responses while 39% were "unsure". CONCLUSION: The majority of centers use propranolol for both adult and pediatric patients despise the lack of randomized studies in adult populations. A wide variation of practice patterns highlights the need for further study in regard to patient outcomes, duration of therapy, and dosing to drive consensus guidelines.

Propylthiouracil-Associated Leukocytoclastic Necrotizing Cutaneous Vasculitis: A Case Report and Review of the Literature.

The purpose of this case report and review of the literature is to provide an exploration of the clinical symptoms, diagnosis, prevention, and management of propylthiouracil (PTU)-associated vasculitis in the intensive care setting. A PubMed search of the available literature was conducted using the MeSH search terms "propylthiouracil" and "vasculitis." The literature search returned 121 articles. Twenty-five were excluded because they were not in English. Fifty-nine case reports or case studies describing PTU-associated vasculitis were included. Data extracted from each case study included patient age, sex, autoimmune markers, laboratory tests, length of time on PTU, treatment for vasculitis, and patient outcomes. The authors reviewed 128 cases of PTU-associated vasculitis. The majority were women (8.8:1 F:M ratio), and the most common presenting symptoms were rash (51.6%), fever (46.9%), and arthralgia (43.8%). In addition to discontinuing PTU, the most common treatment was steroids (71.9%). Eight patients (6.3%) progressed to end-stage renal disease; two (1.6%) required intubation for respiratory failure; and five (3.9%) died of various organ systems failure related to vasculitis development. A high index of suspicion for vasculitis should be maintained, especially when presented with skin manifestations in the presence of PTU therapy. Screening with myeloperoxidase-antinuclear cytoplasmic antibodies is most sensitive. Positive screening should prompt a thorough clinical investigation. In cases of severe skin manifestations, the focus should be on aggressive wound care. Our case report is unique, not only in the size and extent of cutaneous involvement, but also as the first description of mortality secondary to cutaneous manifestations.

The Physiologic Basis of Burn Shock and the Need for Aggressive Fluid Resuscitation.

Burn trauma in the current age of medical care still portends a 3% to 8% mortality. Of patients who die from their burn injuries, 58% of deaths occur in the first 72 hours after injury, indicating death from the initial burn shock is still a major cause of burn mortality. Significant thermal injury incites an inflammatory response, which distinguishes burns from other trauma. This article focuses on the current understanding of the pathophysiology of burn shock, the inflammatory response, and the direction of research and targeted therapies to improve resuscitation, morbidity, and mortality.

The Fire Challenge: A Case Report and Analysis of Self-Inflicted Flame Injury Posted on Social Media.

With the advent of social media platforms such as Facebook and YouTube, online dissemination of exhibitionist videos has gained popularity. One recent disturbing trend is the "fire challenge" wherein a participant douses his or herself in a household accelerant such as isopropyl alcohol or acetone, sets him or herself ablaze, and attempts to extinguish the flames before serious burns are incurred. As expected, participants in the "fire challenge" often accidentally suffer serious burns. A 17-year-old white male was recently treated at our burn center after participating in the "fire challenge." He suffered 15% TBSA full and partial thickness burns requiring split thickness skin grafting to his abdomen. He reported lighting himself on fire because he had seen this stunt performed on the internet. A search for "fire challenge" and similar terms was conducted on YouTube (www.youtube.com). Gender and ethnicity of each participant were documented. Burn size, burn depth, and age of video participant were estimated by two attending burn surgeons evaluating YouTube videos. Results were reported with descriptive statistics. The search yielded thousands of hits, mostly home videos, compilations of stunts, and commentaries. After omitting duplicate and irrelevant videos, 50 videos were selected for the study. Of these, 13 videos included postburn footage demonstrating burn wounds of various location, size, and severity. Of these burns, the median TBSA burned was 4 ± 2.7% with a maximum size of 10%. Superficial and partial thickness burns were sustained on the torso (10/13, 77%), face (4/13, 31%), and extremities (2/13, 15%). Full thickness burns were seen in 2/13 videos. Some burn wounds were obscured by dressings. Of the 50 videos reviewed, 45/50 participants (90%) were male and 32/50 (64%) were African American with 29/50 participants (58%) estimated to be under age 20. The "fire challenge" is a popular social media phenomenon, but it can result in severe injury as seen with the patient at our institution. The lure of a challenge and potential for a shocking video to "go viral" might entice people to mimic this risky behavior. This study shows a disturbing trend, but undoubtedly only reflects a small portion of actual participants. A disproportionate number of videos featured young African American males, making this a target population for education and prevention efforts. Our patient's TBSA exceeded the maximum found on YouTube, suggesting that less severe burns may be posted online while larger burns are not, diminishing perceived risk and encouraging this behavior.

Surgeon-Performed Hemodynamic Transesophageal Echocardiography in the Burn Intensive Care Unit.

The use of transesophageal echocardiography (TEE) for resuscitation after burn injury has been reported in small case studies. Conventional TEE is invasive and often requires a subspecialist with a high level of training. The authors report a series of surgeon-performed hemodynamic TEE with an indwelling, less bulky, user-friendly probe. Records of patients treated in a regional burn center who underwent hemodynamic TEE between October 1, 2012 and May 30, 2014 were reviewed. The clinical course of each patient was recorded. All bedside interpretations were retrospectively reviewed for accuracy by a cardiac anesthesiologist. Eleven patients were included in the study. Median age was 68.5 years (interquartile range, 49.5-79.5). Median burn size was 37% TBSA (interquartile range: 16.3-53%). Seven patients were male, and four suffered inhalation injury. The operator's interpretation matched that of the echocardiography technician and cardiac anesthesiologist in all instances. No complications occurred from probe placement. Four patients underwent hemodynamic TEE to determine volume status during resuscitation. Changes in volume status on echocardiography preceded the eventual changes in urine output and vital signs for one patient. Hemodynamic TEE diagnosed cardiogenic shock and was used to titrate inotropes and vasopressors in seven elderly patients. Hemodynamic TEE is a useful adjunct to manage the burn patient who deviates off the expected course, especially if there is a question of cardiac function or volume status. It is less invasive and can be accurately performed by surgical intensivists when transthoracic echo windows are limited. The role of echocardiography in optimizing routine burn resuscitations needs to be further studied.

The use of porcine xenografts in patients with toxic epidermal necrolysis.

INTRODUCTION: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) can be challenging to treat due to pain with wound care and ongoing fluid loss. The purpose of this study is to determine the role of porcine xenograft as a modality for wound coverage. MATERIAL AND METHODS: A retrospective review from 2006 to 2014 was performed at a regional burn center on all patients admitted with the diagnosis of SJS (<10% TBSA involvement), SJS/TEN overlap (10-30% TBSA involvement), and TEN (>30% TBSA involvement). Patients who received porcine xenograft had physiologic and biochemical parameters compared in the 24h before and after graft placement. In addition, xenograft patients were compared to historical controls that received traditional wound care which included silver impregnated dressings. Outcomes and variables collected included intravenous fluid given, urine output, pain scores (1-10), pain medication for wound care, biochemical markers, skin infections, hospital length of stay, and mortality. RESULTS: Eight patients had placement of a porcine xenograft. Median age was 50 years (IQR 41, 66) and 2 were male. Median % TBSA affected was 76 (IQR 64, 80). The median amount of fluid (ml/kg/day/%TBSA) administered decreased from 1.45 (IQR 1.03, 1.78) to 0.9 (IQR 0.65, 1.08) after xenograft placement (p=0.02). The median amount of intravenous fluid (ml/kg/day/%TBSA) administered in the treatment group and historical control group was 0.9 (IQR 0.65, 1.08) and 0.8 (IQR 0.7, 1.47) respectively (p=0.72). The median amount of urine output (ml/kg/day) in the treatment group and historical control group was 34.2 (IQR 22, 44.38) and 22 (IQR 11.25, 38.13) respectively (p=0.17). Pain scores significantly decreased from 5.5 (IQR 2.5, 8.25) pre-xenograft to 2.8 (IQR 0.75, 4) post-xenograft placement (p=0.03). There was a significant difference in pain scores between the treatment group and historical control group, 2.8 (IQR 0.75, 4) and 6 (IQR 5, 8) respectively (p=0.02). Each study patient underwent moderate sedation for wound care prior to xenograft placement and one study patient required one moderate sedation for wound care after xenograft placement. One patient in the xenograft placement group was diagnosed with a cutaneous infection compared to 4 patients in the historical control group (p=0.63). The mortality was 12.5% in each group. CONCLUSIONS: Placement of a porcine xenograft in patients with SJS, SJS/TEN overlap, or TEN is associated with a significant reduction in intravenous fluid use, pain scores, and pain medication. Further study with larger sample sizes is warranted to evaluate for statistically significant differences in outcomes after porcine xenograft placement for SJS, SJS/TEN overlap or TEN.

Optimizing feedback from a designated level 1 trauma/burn center to referring hospitals.

BACKGROUND: The American College of Surgeons Committee on Trauma (ACS-COT) is dedicated to improving the quality of care for severely injured patients. The ACS-COT charges designated centers with providing feedback to referring hospitals. There are no guidelines or recommendations as to what should be included in the feedback or how it should be used. STUDY DESIGN: The objectives of this study were to evaluate current feedback efforts regarding patients transferred to Harborview Medical Center (HMC), a regional level 1 trauma and burn center, to better understand how the feedback is used, and to evaluate what types of feedback are most useful to the referring hospitals. An analysis of U-link (password-protected access to patient's electronic medical record) and other forms of feedback was performed. A survey was sent to 82 Washington State hospitals in the regionalized trauma system to evaluate the current feedback process and its utility. RESULTS: During 1 year, HMC admitted 5,988 trauma and 763 burn patients; 54.8% of trauma and 66.5% of burn admissions were transferred from referring hospitals. Currently, 90 different referring hospitals have acquired a U-link account to follow their patients. Discharge summaries were the primary source of information used. When hospitals were asked how this information is used, education (100%), systems analysis (98.5%), and quality assurance (92%) were most common. CONCLUSIONS: There is significant interest on the part of referring hospitals to receive feedback from a designated level 1 trauma/burn center to improve quality of care. A system like U-link can allow secure access to review patient charts for quality improvement and feedback purposes, in a manner that is efficient for the referring and receiving hospitals.

Line of duty firefighter fatalities: an evolving trend over time.

Between 1990 and 2012, 2775 firefighters were killed in the line of duty. Myocardial infarction (MI) was responsible for approximately 40% of these mortalities, followed by mechanical trauma, asphyxiation, and burns. Protective gear, safety awareness, medical care, and the age of the workforce have evolved since 1990, possibly affecting the nature of mortality during this 22-year time period. The purpose of this study is to determine whether the causes of firefighter mortality have changed over time to allow a targeted focus in prevention efforts. The U.S. Fire Administration fatality database was queried for all-cause on-duty mortality between 1990 to 2000 and 2002 to 2012. The year 2001 was excluded due to inability to eliminate the 347 deaths that occurred on September 11. Data collected included age range at the time of fatality (exact age not included in report), type of duty (on-scene fire, responding, training, and returning), incident type (structure fire, motor vehicle crash, etc), and nature of fatality (MI, trauma, asphyxiation, cerebrovascular accident [CVA], and burns). Data were compared between the two time periods with a χ test. Between 1990 and 2000, 1140 firefighters sustained a fatal injury while on duty, and 1174 were killed during 2002 to 2012. MI has increased from 43% to 46.5% of deaths (P = .012) between the 2 decades. CVA has increased from 1.6% to 3.7% of deaths (P = .002). Asphyxiation has decreased from 12.1% to 7.9% (P = .003) and burns have decreased from 7.7% to 3.9% (P = .0004). Electrocution is down from 1.8% to 0.5% (P = .004). Death from trauma was unchanged (27.8 to 29.6%, P = .12). The percentage of fatalities of firefighters over age 40 years has increased from 52% to 65% (P = .0001). Fatality by sex was constant at 3% female. Fatalities during training have increased from 7.3% to 11.2% of deaths (P = .00001). The nature of firefighter mortality has evolved over time. In the current decade, line-of-duty mortality is more likely to occur during training. Mortality from burns, asphyxiation, and electrocution has decreased; but death from MI and CVA has increased, particularly in older firefighters. Outreach and education should be targeted toward vehicle safety, welfare during training, and cardiovascular disease prevention in the firefighter population.

Differences in resuscitation in morbidly obese burn patients may contribute to high mortality.

The rising number of obese patients poses new challenges for burn care. These may include adjustments in calculations of burn size, resuscitation, ventilator wean, nutritional goals as well as challenges in mobilization. The authors have focused this observational study on resuscitation in the obese patient population in the first 48 hours after burn injury. Previous trauma studies suggest a prolonged time to reach end points of resuscitation in the obese compared to nonobese injured patients. The authors hypothesize that obese patients have worse outcomes after thermal injury and that differences in the response to resuscitation contribute to this disparity. The authors retrospectively analyzed data prospectively collected in a multicenter trial to compare resuscitation and outcomes in patients stratified by National Institutes of Health/World Health Organization body mass index (BMI) classification (BMI: normal weight, 18.5-24.9; overweight, 25-29.9, obese, 30-39.9; morbidly obese, ≥40). Because of the distribution of body habitus in the obese, total burn size was recalculated for all patients by using the method proposed by Neaman and compared with Lund-Browder estimates. The authors analyzed patients by BMI class for fluids administered and end points of resuscitation at 24 and 48 hours. Multivariate analysis was used to compare morbidity and mortality across BMI groups. The authors identified 296 adult patients with a mean TBSA of 41%. Patient and injury characteristics were similar across BMI categories. No significant differences were observed in burn size calculations by using Neaman vs Lund-Browder formulas. Although resuscitation volumes exceeded the predicted formula in all BMI categories, higher BMI was associated with less fluid administered per actual body weight (P = .001). Base deficit on admission was highest in the morbidly obese group at 24 and 48 hours. Furthermore, the morbidly obese patients did not correct their metabolic acidosis to the extent of their lower BMI counterparts (P values .04 and .03). Complications and morbidities across BMI groups were similar, although examination of organ failure scores indicated more severe organ dysfunction in the morbidly obese group. Compared with being normal weight, being morbidly obese was an independent risk factor for death (odds ratio = 10.1; confidence interval, 1.94-52.5; P = .006). Morbidly obese patients with severe burns tend to receive closer to predicted fluid resuscitation volumes for their actual weight. However, this patient group has persistent metabolic acidosis during the resuscitation phase and is at risk of developing more severe multiple organ failure. These factors may contribute to higher mortality risk in the morbidly obese burn patient.