Burns in the Elderly.

Burns in the elderly are a significant cause of morbidity and mortality. Frailty is an important indicator of patient health and physiologic reserve. Comorbidities and typical age-related changes significantly impact the outcomes of elderly burn patients and decisions made during their burn care. It is essential to have early and thorough discussions about the goals of care and rehabilitation plans. Physiologic changes that occur from aging cause slower wound healing and may make operative treatment more challenging, although techniques such as autographing, skin substitutes, and flaps may all play a role in treating this patient population.

Acute kidney injury in patients with burns.

Burn injury is associated with a high risk of acute kidney injury (AKI) with a prevalence of AKI among patients with burns of 9-50%. Despite an improvement in burn injury survival in the past decade, AKI in patients with burns is associated with an extremely poor short-term and long-term prognosis, with a mortality of >80% among those with severe AKI. Factors that contribute to the development of AKI in patients with burns include haemodynamic alterations, burn-induced systemic inflammation and apoptosis, haemolysis, rhabdomyolysis, smoke inhalation injury, drug nephrotoxicity and sepsis. Early and late AKI after burn injury differ in their aetiologies and outcomes. Sepsis is the main driver of late AKI in patients with burns and late AKI has been associated with higher mortality than early AKI. Prevention of early AKI involves correction of hypovolaemia and avoidance of nephrotoxic drugs (for example, hydroxocobalamin), whereas prevention of late AKI involves prevention and early recognition of sepsis as well as avoidance of nephrotoxins. Treatment of AKI in patients with burns remains supportive, including prevention of fluid overload, treatment of electrolyte disturbance and use of kidney replacement therapy when indicated.

Burn Patient Metabolism and Nutrition.

Following severe burns, patients have unique metabolic derangements that make adequate nutritional support imperative for their survival and recovery. Patients with burns have persistent and prolonged hypermetabolic states that lead to increased catabolism following injury. During rehabilitation, catabolism leads to increased muscle wasting and cachexia. Failure to adequately meet the patient's increased nutritional requirements can lead to poor wound healing, increased infections, and overall organ dysfunction. Because of these risks, adequate assessment and provision of nutritional needs are imperative to care for these patients.

Rapid development of squamous cell carcinoma at a split-thickness skin graft donor site.

The development of a Marjolin ulcer at the site of a split-thickness skin graft donor site is exceptionally rare. Here we describe the rapid development of squamous cell carcinoma at a split-thickness skin graft donor site in the setting of severe burn. We present a case of a 52-year-old male with no past medical history who presented with a 24% total body surface area burn caused by a flash flame. Four months after his initial excision and grafting, he presented for revision of a burn scar with an additional complaint of a rapidly developing skin lesion at his donor site, which arose over 2 weeks. The lesion was excised en bloc and found to be invasive squamous cell carcinoma. There are 5 previous cases of squamous cell carcinoma development at the site of split-thickness skin harvest in the setting of severe burn. While the typical Marjolin ulcer has a latency period of up to 30 years, lesions that arise in split-thickness skin graft donor sites appear to have a rapid onset of weeks to months. Squamous cell carcinoma at the site of split-thickness skin grafting is an uncommon but important sequelae of burn care.

Fungal brain abscess in a severely burned patient.

Burn patients are particularly susceptible to atypical and opportunistic infections. Here we report an unusual case of a 40-year-old previously healthy man with a 74% TBSA burn injury who developed a presumed Fusarium brain abscess. This patient had a complicated infectious course including ESBL E. coli and Elizabethkingia bacteremia and pneumonia, MRSA ventilator-associated pneumonia, Mycobacterium abscessus bacteremia, and Fusarium fungemia. After diagnosis with a fungal abscess on magnetic resonance imaging of the brain, the patient was treated with aspiration and appropriate antifungal therapies. The patient was eventually transitioned to comfort care and died on hospital day 167. This is the first published report of a Fusarium-related brain abscess since it was first reported in a case report of a burned child in 1974.

The Fuel Gauge: A Simple Tool for Assessing General Surgery Resident Well-Being.

OBJECTIVE: Resident well-being is an increasingly relevant issue in medical education; however, there is no consensus on how to best measure well-being. The "fuel gauge," is a simple, easy-to-use tool developed to measure resident well-being and previously applied in an Internal Medicine Residency Program at our institution. The current study sought to evaluate its acceptability and usefulness in a surgery program. DESIGN: Weekly fuel gauge data was retrospectively collected from August 2017 through December 2018 along with resident Postgraduate Year designations. SETTING: This study was conducted at a single, large general surgery residency program that rotates through a variety of hospitals, including a University hospital, a large county hospital, a Veterans Affairs hospital, and a freestanding Children's hospital. PARTICIPANTS: Categorical general surgery residents at every level of training as well as preliminary interns and off service intern rotators from urology, oral and maxillofacial surgery, and otolaryngology were eligible for the study. Fuel gauge submissions which did not denote a score were excluded from analysis. RESULTS: Out of 130 residents, 103 (79.2%) completed at least 1 fuel gauge assessment with a weekly mean response rate of 41.5%. Low scores were submitted by 39.8% of resident participants. Narrative feedback was provided in 6.2% of submissions with increased length associated with decreased fuel gauge score. CONCLUSIONS: The fuel gauge was well accepted by a large general surgery program with no decline in participation rates over the study period. The tool provided residents with a direct line of communication with their program's administration, and a feasible way for the program director's office to monitor and identify residents who were struggling with regard to their well-being.

Muscle Homeostasis Is Disrupted in Burned Adults.

Severe burn leads to substantial skeletal muscle wasting that is associated with adverse outcomes and protracted recovery. The purpose of our study was to investigate muscle tissue homeostasis in response to severe burn. Muscle biopsies from the right m. lateralis were obtained from 10 adult burn patients at the time of their first operation. Patients were grouped by burn size (total body surface area of <30% vs ≥30%). Muscle fiber size and factors of cell death and muscle regeneration were examined. Muscle cell cross-sectional area was significantly smaller in the large-burn group (2174.3 ± 183.8 µm2 vs 3687.0 ± 527.2 µm2, P = .04). The expression of ubiquitin E3 ligase MuRF1 and cell death downstream effector caspace 3 was increased in the large-burn group (P < .05). No significant difference was seen between groups in expression of the myogenic factors Pax7, MyoD, or myogenin. Interestingly, Pax7 and proliferating cell nuclear antigen (PCNA) expression in muscle tissue were significantly correlated to injury severity only in the smaller-burn group (P < .05). In conclusion, muscle atrophy after burn is driven by apoptotic activation without an equal response of satellite cell activation, differentiation, and fusion.

Administration of Tumescence in Pediatric Burn Patients Causes Significant Hypertension.

The effects of injecting tumescence containing phenylephrine in pediatric burn patients are unknown, but anecdotally our clinicians note a high incidence of hypertension requiring treatment. This study sought to determine whether tumescence with phenylephrine was associated with hypertension requiring treatment in our pediatric burn patients. This was a retrospective cohort study of pediatric burn patients who underwent tangential excision with split-thickness autografting, excision alone, or autografting alone from 2013 to 2017. Records were reviewed for hypertensive episodes, defined as ≥2 consecutive blood pressure readings that were >2 SD above normal. Published intraoperative age- and sex-adjusted standards were used to define reference values. Parametric and nonparametric tests were used when appropriate. In total, 258 operations were evaluated. Mean patient age was 7.6 ± 5.2 years, and 64.7% were male. Patients were predominately white (69.8%). Overall, there was a 62.8% incidence of hypertension. On univariate logistic regression analysis, duration of operation, estimated blood loss, treated TBSA, and weight-adjusted volume of tumescence were significant predictors of intraoperative hypertension (P < .01). On multivariate analysis, weight-adjusted volume of tumescence alone was significantly associated with the presence of hypertension with an odds ratio of 2.0 (95% confidence interval: 1.33-3.04). Of the 162 operations which exhibited at least one episode of significant hypertension, 128 cases (79%) were treated. Intraoperative administration of phenylephrine-containing tumescence in pediatric burn patients is associated with clinically significant hypertension requiring treatment. This practice should be conducted with caution in pediatric burn operations until its clinical implications are defined.

Analysis of operating room efficiency between a hospital-owned ambulatory surgical center and hospital outpatient department.

BACKGROUND: Ambulatory surgery centers (ASCs) are frequently utilized; however some ambulatory procedures may be performed in hospital outpatient departments (HOPs). Our aim was to compare operating room efficiency between our ASC and HOP. METHODS: We reviewed outpatient general surgery procedures performed at our ASC and HOP. Total case time was divided into five components: ancillary time, procedure time, exit time, turnover time, and nonoperative time. RESULTS: Overall, 220 procedures were included (114 ASC, 106 HOP). Expressed in minutes, the mean turnover time (29.8 ±â€¯9.6 vs. 24.5 ±â€¯12.7; p < 0.01), ancillary time (32.2 ±â€¯7.0 vs. 22.2 ±â€¯4.5; p < 0.01), procedure time (77.4 ±â€¯44.9 vs. 56.2 ±â€¯23.0 p < 0.01), exit time (11.8 ±â€¯4.4 vs. 8.5 ±â€¯4.3; p < 0.01), and nonoperative time (62.9 ±â€¯21.9 vs. 48.7 ±â€¯15.0; p < 0.01) were longer at the HOP than at the ASC. CONCLUSION: ASC outpatient procedures are more efficient than those performed at our HOP. A system evaluation of our HOP operating room efficiency is necessary.

Treating Hypertrophic Burn Scar With 2940-nm Er:YAG Laser Fractional Ablation Improves Scar Characteristics as Measured by Noninvasive Technology.

Their group previously demonstrated high-patient satisfaction for the treatment of hypertrophic burn scar (HBS) with the erbium: yttrium aluminum garnet (Er:YAG) laser, but this and other literature supporting the practice suffer from a common weakness of a reliance on subjective assessments by patients or providers. Herein, they sought to prospectively study the effects of Er:YAG fractional ablation on HBS using noninvasive, objective technologies to measure outcomes. Patients with HBS had identical regions of scar designated for treatment by the Er:YAG laser (TREAT) or to be left untreated (CONTROL). They prospectively collected scar measurements of TREAT and CONTROL regions preoperatively, 3 weeks, and 3 months after Er:YAG treatment. Scar measurements included viscoelastometry, transepidermal water loss, optical coherent tomography, and high-frequency ultrasound. Outcomes were measured for the aggregate difference between the TREAT group vs the CONTROL group, as well as within each group in isolation. Seventeen patients were seen preoperatively, followed by n = 15 at 3 weeks and n = 11 at 3 months. A mixed-model repeated measures analysis showed no significant effect of fractional ablation when comparing the overall TREAT group measurements with those of the CONTROL group. However, when considered as within-group measurements, TREAT scars showed significant improvement in viscoelastic deformity (P = .03), elastic deformity (P = .004), skin roughness (P = .05), and wrinkle depth (P = .04) after fractional ablation, whereas CONTROL scars showed no such within-group changes. HBS treated by the Er:YAG laser showed objective improvements, whereas no such changes were seen within the untreated scars over the same time frame.

Assessment of general surgery resident study habits and use of the TrueLearn question bank for American Board of Surgery In-Training exam preparation.

BACKGROUND: Little information exists on the value of online question banks in preparing residents for the American Board of Surgery In-Training Examination (ABSITE). METHODS: We reviewed surgical residents' use of an online question bank (TrueLearn) and compared it to their ABSITE performance. RESULTS: The 2016-2017 records of 44 PGY 2-5 general surgery residents were examined. The total number of TrueLearn questions answered significantly correlated (p < 0.05) with correct answers and percentile rank on the 2017 ABSITE. If a resident was to complete the entire online TL question bank consisting of 1000 questions, the overall percentage correct and overall percentile on the ABSITE is estimated to increase by 3% and 20%, respectively. CONCLUSIONS: The use of the TrueLearn question bank is associated with an improved percentage of ABSITE questions answered correctly and improved PGY percentile scores.

Prospective Analysis of Operating Room and Discharge Delays in a Burn Center.

Delays to the operating room (OR) or discharge (DC) lead to longer lengths of stay and increased costs. Surprisingly, little work has been done to quantify the number and cost of delays for inpatients to the OR, and to DC to outpatient status. They reviewed their burn admissions to determine how often a patient experiences delays in healthcare delivery. Data for all burn admissions were prospectively collected from 2014 to 2016. A quality improvement filter was created to define acceptable parameters for patient throughput. Every hospital day was labeled as 1) No delay, 2) Operation, 3) Delay to the OR, or 4) Delay to DC. They had 1633 admissions: 432 ICU admissions (26%) and 1201 floor admissions (74%). Six hundred fifteen patients (37.7%) received an operation. Patients with delays included 331 with OR delays (20.3%) and 503 with DC delays (30.8%). Average delay days included (Mean ± SD): OR delay days = 4.7 ± 6.2 and DC delay days = 4.1 ± 4.4. Total number of hospital days was 13,009, divided into 1616 OR delay days (12%) and 2096 DC delay days (16%). Significant OR delays were due to patient unstable for OR (n = 387 [24%]), OR space availability (n = 662 [41%]), indeterminate wound depth (n = 437 [27%]), and donor site availability (n = 83 [5%]). Significant DC delays were due to medical goals not reached (n = 388 [19%]), pain control and wound care (n = 694 [33%]), PT/OT clearance (n = 168 [8.0%]), and DC placement delays (n = 754 [36%]). Costs for OR and DC delays ranged between US$1,000,000 and US$5,000,000. Costs of increasing OR capacity and/or additional social work ancillary staff can be justified through millions of dollars of savings annually.

Acute Kidney Injury After Burn: A Cohort Study From the Parkland Burn Intensive Care Unit.

Acute kidney injury (AKI) is a common and morbid complication in patients with severe burn. The reported incidence of AKI and mortality in this population varies widely due to inconsistent and changing definitions. They aimed to examine the incidence, severity, and hospital mortality of patients with AKI after burn using consensus criteria. This is a retrospective cohort study of adults with thermal injury admitted to the Parkland burn intensive care unit (ICU) from 2008 to 2015. One thousand forty adult patients with burn were admitted to the burn ICU. AKI was defined by KDIGO serum creatinine criteria. Primary outcome includes hospital death and secondary outcome includes length of mechanical ventilation, ICU, and hospital stay. All available serum creatinine measurements were used to determine the occurrence of AKI during the hospitalization. All relevant clinical data were collected. The median total body surface area (TBSA) of burn was 16% (IQR: 6%-29%). AKI occurred in 601 patients (58%; AKI stage 1, 60%; stage 2, 19.8%; stage 3, 10.5%; and stage 3 requiring renal replacement therapy [3-RRT], 9.7%). Patients with AKI had larger TBSA burn (median 20.5% vs 11.0%; P < .001) and more mechanical ventilation and hospitalization days than patients without AKI. The hospital death rate was higher in those with AKI vs those without AKI (19.7% vs 3.9%; P < .001) and increased by each AKI severity stage (P trend < .001). AKI severity was independently associated with hospital mortality in the small burn group (for TBSA ≤ 10%: stage 1 adjusted OR 9.3; 95% CI, 2.6-33.0; stage 2-3 OR, 35.0; 95% CI, 9.0-136.8; stage 3-RRT OR, 30.7; 95% CI, 4.2-226.4) and medium burn group (TBSA 10%-40%: stage 2-3 OR, 6.5; 95% CI, 1.9-22.1; stage 3-RRT OR, 35.1; 95% CI, 8.2-150.3). AKI was not independently associated with hospital death in the large burn group (TBSA > 40%). Urine output data were unavailable. AKI occurs frequently in patients after burn. Presence of and increasing severity of AKI are associated with increased hospital mortality. AKI appears to be independently and strongly associated with mortality in patients with TBSA ≤ 40%. Further investigation to develop risk-stratification tools tailoring this susceptible population is direly needed.

Prospective validation of the Parkland Grading Scale for Cholecystitis.

BACKGROUND: The Parkland Grading Scale for Cholecystitis (PGS) was developed as an intraoperative grading scale to stratify gallbladder (GB) disease severity during laparoscopic cholecystectomy (LC). We aimed to prospectively validate this scale as a measure of LC outcomes. METHODS: Eleven surgeons took pictures of and prospectively graded the initial view of 317 GBs using PGS while performing LC (LIVE) between 9/2016 and 3/2017. Three independent surgeon raters retrospectively graded these saved GB images (STORED). The Intraclass Correlation Coefficient (ICC) statistic assessed rater reliability. Fisher's Exact, Jonckheere-Terpstra, or ANOVA tested association between peri-operative data and gallbladder grade. RESULTS: ICC between LIVE and STORED PGS grades demonstrated excellent reliability (ICC = 0.8210). Diagnosis of acute cholecystitis, difficulty of surgery, incidence of partial and open cholecystectomy rates, pre-op WBC, length of operation, and bile leak rates all significantly increased with increasing grade. CONCLUSIONS: PGS is a highly reliable, simple, operative based scale that can accurately predict outcomes after LC. TABLE OF CONTENTS SUMMARY: The Parkland Grading Scale for Cholecystitis was found to be a reliable and accurate predictor of laparoscopic cholecystectomy outcomes. Diagnosis of acute cholecystitis, surgical difficulty, incidence of partial and open cholecystectomy rates, pre-op WBC, operation length, and bile leak rates all significantly increased with increasing grade.

A comparison of cholecystitis grading scales.

BACKGROUND: Previously, our group developed the Parkland grading scale for cholecystitis (PGS) to stratify gallbladder (GB) disease severity that can be determined immediately when performing laparoscopic cholecystectomy (LC). In prior studies, PGS demonstrated excellent interrater reliability and was internally validated as an accurate measure of LC outcomes. Here, we compare PGS against a more complex cholecystitis severity score developed by the national trauma society, American Association for the Surgery of Trauma (AAST), which requires clinical, operative, imaging, and pathologic inputs, as a predictor of LC outcomes. METHODS: Eleven acute care surgeons prospectively graded 179 GBs using PGS and filled out a postoperative questionnaire regarding the difficulty of the surgery. Three independent raters retrospectively graded these GBs using PGS from images stored in the electronic medical record. Three additional surgeons then assigned separate AAST scores to each GB. The intraclass correlation coefficient statistic assessed rater reliability for both PGS and AAST. The PGS score and the median AAST score became predictors in separate linear, logistic, and negative binomial regression models to estimate perioperative outcomes. RESULTS: The average intraclass correlation coefficient of PGS and AAST was 0.8647 and 0.8341, respectively. Parkland grading scale for cholecystitis was found to be a superior predictor of increasing operative difficulty (R, 0.566 vs. 0.202), case length (R, 0.217 vs. 0.037), open conversion rates (area under the curve, 0.904 vs. 0.757), and complication rates (area under the curve, 0.7039 vs. 0.6474) defined as retained stone, small-bowel obstruction, wound infection, or postoperative biliary leak. Parkland grading scale for cholecystitis performed similar to AAST in predicting partial cholecystectomy, readmission, bile leak rates, and length of stay. CONCLUSION: Both PGS and AAST are accurate predictors of LC outcomes. Parkland grading scale for cholecystitis was found to be a superior predictor of subjective operative difficulty, case length, open conversion rates, and complication rates. Parkland grading scale for cholecystitis has the advantage of being a simpler, operative-based scale which can be scored at a single point in time. LEVEL OF EVIDENCE: Single institution, retrospective review, level IV.

Prospective validation of the safety of a laparoscopic cholecystectomy training paradigm featuring incremental autonomy.

BACKGROUND: Surgical training is under scrutiny for the effect increased resident autonomy may have on patient outcomes. We hypothesize that as laparoscopic cholecystectomy (LC) difficulty increases, there will be increased involvement by senior residents and attending physicians with no differences in complications. METHODS: Ten acute care surgeons were asked to fill out a postoperative questionnaire regarding surgical difficulty after every LC between 11/9/2016 and 3/30/2017. Either the Jonckheere-Terpstra test, Mantel-Haenzel chi square test, or ANOVA was used to test for the association between perioperative data and surgical difficulty. RESULTS: A total of 190 LCs were analyzed. PGY level, percent of surgery time with attending surgeon involvement, partial cholecystectomy rate, and length of operation all significantly rose with increasing level of difficulty (p < 0.001) with no significant differences in 60-day emergency room bounce-backs, readmission, or complication rates. CONCLUSIONS: We found that as LC difficulty increases, so does attending surgeon and/or senior resident involvement, without increased morbidity.

Weight changes and patterns of weight measurements in hospitalized burn patients: a contemporary analysis.

BACKGROUND: Severe burn is associated with significant changes in body weight due to resuscitation volumes, fluid shifts, a hypermetabolic state, prolonged bed rest, and caloric intake. Our goal was to quantify and describe trends in weight change in patients with burns of all severities under modern treatment conditions and to identify the time points at which these changes occur. METHODS: An institutional review board-approved chart review was conducted of acute burn patients treated at an American Burn Association-verified regional burn center from February 2016 to November 2016. Patients were then divided into three groups based on percent of total burn surface area (%TBSA) burn: 1-19%, 20-39%, and ≥ 40%. Weight was expressed as percent change of weight from baseline. Regression analysis was conducted on percent weight changes for each TBSA group. RESULTS: We identified 197 burn patients with a length of stay (LOS) of ≥ 7 days. Of the study cohort, 149 had TBSA burn of 1-19%, 27 had TBSA burn of 20-39%, and 21 had TBSA burn of ≥ 40%. All groups had a majority of White male, non-Hispanic patients with mean ages between 40 and 42 years. Burn patients with > 20% TBSA burn had a median increase in weight above baseline of approximately 5 to 8% likely due to resuscitation fluids within the first week of hospitalization. Weight loss below baseline often did not exceed 10% and was more pronounced as LOS increased, mostly in patients with > 20% TBSA burn. Whereas patients with 1-19% TBSA burn on average returned to baseline weight at last measurement, patients with 20-39% TBSA and ≥ 40% TBSA burn continued a decline in weight at 4 weeks (r 2 = 0.57 and 0.55, respectively) on the same trajectory. CONCLUSIONS: Burn patients with > 20% TBSA burn had an increase in weight above baseline of up to 8%, likely due to resuscitation fluids within the first week of hospitalization. Weight loss below baseline often did not exceed 10% and was more pronounced as LOS increased, mostly in patients with > 20% TBSA burn. Therefore, our patients on average, lost body weight to a lesser extent than the maximum mean loss of 22% of pre-burn weight reported prior to modern treatment conditions.

Trauma and emergency general surgery patients should be extubated with an open abdomen.

BACKGROUND: Open abdomen (OA) and temporary abdominal closure (TAC) are common techniques to manage several surgical problems in trauma and emergency general surgery (EGS). Patients with an OA are subjected to prolonged mechanical ventilation. This can lead to increased rates of ventilator-associated pneumonia (VAP). We hypothesized that patients who were extubated with an OA would have a decrease in ventilator hours and as a result would have a lower rate of VAP without an increase in extubation failures. METHODS: A retrospective review was performed of all trauma and EGS patients managed at our institution with OA and TAC from January 2014 to February 2016. Patients were divided into cohorts consisting of those who were successfully extubated with an OA and those who were not. The number of extubation events and ventilator-free hours were calculated for each patient. Adverse events such as the need for reintubation with an OA and VAP were collected. RESULTS: Fifty-two patients (20 trauma, 32 EGS) were managed with an OA and TAC during the study period. Twenty-five patients (6 trauma, 19 EGS) had at least one extubation event with an OA. Median extubation events per patient was 3 (interquartile range, 1-5). The median ventilator-free hours for patients who were extubated was 101 hours (interquartile range, 39.42-260.46). Patients that were never extubated with an OA had higher rates of VAP (30.8% vs. 3.8%, p = 0.01). CONCLUSION: This study provides much needed data regarding the feasibility of extubation in trauma and EGS patients managed with an OA and TAC. Benefits of early extubation may include lower VAP rates in this population. Plans for reexploration hinder the decision to extubate in these patients. LEVEL OF EVIDENCE: Therapeutic study, level IV.