Comfort care in burns: the Burn Modified Liverpool Care Pathway (BM-LCP).

INTRODUCTION: Despite advances in burn care some injuries remain non survivable. Good end of life care for these patients is arguably as important as life prolonging care. The Liverpool Care Pathway is a useful tool for providing good quality end of life care. It has previously been modified for the acute setting. We modified it further specifically for use in burn care in 2007 and would like to share our experience of using it. METHODS: A retrospective case series of deaths occurring between 01/01/08 and 31/12/09 is presented and adherence to the Burn Modified Liverpool Care Pathway (BM-LCP) is assessed. RESULTS: There were 22 deaths over the study period with a mean TBSA of 55%. Mean Acute Burn Severity Index score (ABSI) 12.5. A decision of futility was made in 14 cases, 11 of these were started on the BM-LCP. 7 were started on the pathway at the time of admission. Mean time from decision to start the pathway to death 11 h (range 3-48). There were no variances from the pathway. CONCLUSION: The BM-LCP appears to be an appropriate tool for assisting in end of life care in burns and when used appears to improve end of life care. We recommend its use and would encourage others to implement its use.

The use of the Cortrak Enteral Access System™ for post-pyloric (PP) feeding tube placement in a Burns Intensive Care Unit.

INTRODUCTION: 50% of critically ill patients fail to reach caloric targets with NG feeding. PP feeding may enhance caloric intake. PP feeding can be continued throughout theatre in patients with a secure airway. Blind PP tube placement is difficult. CEAS has been developed to assist tube placement and eliminate check X-rays of tube position. METHOD: All BITU patients with CEAS PP feeding tube placement were identified. Notes and X-rays were reviewed. Tube position, calorie deficit and time off feed were recorded. RESULTS: 44 tubes were placed in 21 patients using CEAS. 84% were PP, 16% NG. Position correlated to X-ray findings in 86%. In 16% position was NG on CEAS but was PP on X-ray. 10 patients required both CXR and AXR to confirm position, the remainder required CXR only. Time off feed varied from 0-24 h (mean 7.4 h). Calorie deficit ranged from 0-2465 kCal (mean 858 kCal). Average wait for X-ray was 3.4h. If X-ray wait was eliminated calorie deficit would be reduced by 45% to 393 kCal. CONCLUSION: The Cortrak system is safe and effective on BITU. It reduces calorie deficit, reduces X-ray exposure and is cost effective. We recommend its use on BITU.

Burns related to sunbed use.

The quest for a year round tan has led to an increase in the use of artificial tanning devices, namely sunbeds. There has been much debate in the press recently regarding the dangers of sunbed use and calls for tighter regulation of the industry, particularly the licensing of unmanned tanning salons. The dangers of sunbed use have long been recognised and the body of evidence linking sunbed use to skin malignancy is growing, in fact this month the Lancet published a review from the International Agency for Research on Cancer classifying UV emitting tanning devices as carcinogenic to humans. At the Welsh Centre for Burns and Plastic Surgery we noticed a rise in the number of patients presenting with burns related to sunbed use and present our data surrounding this injury over the last 6 years.

Do cosmetic surgeons consider estrogen-containing drugs to be of significant risk in the development of thromboembolism?

BACKGROUND: Well-documented evidence shows that estrogen increases the risk of deep vein thrombosis (DVT), and that the effects of DVT are compounded by the stress of surgery and an anesthetic. METHODS: This study sought to determine the current views and practice of plastic surgeons regarding combined oral contraceptive and surgery. In the United Kingdom, 285 consultant plastic surgeons were identified, and postal questionnaires were distributed to each surgeon. RESULTS: Of 286 postal questionnaires distributed to consultant plastic surgeons, 53% were returned and analyzed. Most of the surgeons considered combined oral contraceptive and surgery to be a risk factor for DVT, although only 54% discontinued it before surgery. Approximately 50% believed hormone-replacement therapy (HRT) is a risk, but fewer than a one-fourth of surgeons stopped its use before surgery. There was a range of distribution for the length of time HRT was discontinued for surgery. The majority of consultants discontinue HRT use for 5 to 6 weeks before surgery and until full ambulation after surgery. Data retrieved were used to compare documented evidence relating to combined oral contraceptive and surgery and its association with DVT. CONCLUSION: This survey shows that the management of patients taking estrogen-containing medication before plastic surgery varies, and guidelines regarding this should be sought.

Multiple malignant melanomas in association with neurofibromatosis type 1.

We present a case of multiple primary malignant melanomata occurring over a six year period in a 63-year-old Caucasian man with neurofibromatosis type 1. There is doubt regarding a definite association between these two diseases despite a number of case reports and clear, potential pathological mechanisms. This case not only strengthens support for an association but also highlights the great difficulties that arise in the management of cutaneous melanomata in patients with neurofibromatosis.

Colloid or crystalloid for resuscitation of major burns.

There is continuing debate over the merits of colloid versus crystalloids for the resuscitation of major burns. This article reviews fluids used in burn resuscitation and discusses potential advantages and disadvantages of colloid and crystalloid.

A comparison of laser Doppler imaging with other measurement techniques to assess burn depth.

Evaluation of burn depth is crucial in supporting treatment decisions, yet none of the commonly used methods offer clinicians the desired level of accuracy. This article reviews the literature to determine the advantages of laser Doppler imaging.