An Introduction to Burn Care: The Sequel.

GENERAL PURPOSE: To review burn care, with an emphasis on burn-specific issues and treatment. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Select the appropriate treatment guidelines for patients who have burn injuries.2. Identify common complications of major burns.3. Choose the recommended pharmacologic approaches to burn care.

Care of burns, particularly those that are deep and/or extensive, requires a very specific approach from a multidisciplinary team of different types of experts. In contrast to many chronic lesions, large burns are also immediately life-threatening and have significant systemic effects that require specialized treatment as well. This article provides a high-level overview of burn care with an emphasis on these burn-specific issues and treatment.

A Retrospective Health Economic Analysis of a Stable Hypochlorous Acid Preserved Wound Cleanser Versus 0.9% Saline Solution as Instillation for Negative-Pressure Wound Therapy in Severe and Infected Wounds.

Introduction Negative-pressure wound therapy (NPWT) with instillation and dwell time is an accepted adjunct therapy for infected wounds. A study was conducted to assess whether the use of hypochlorous acid preserved wound cleanser (HAPWOC) (Vashe, Urgo Medical North America, Fort Worth, TX, USA) as the irrigant would reduce the cost of care in comparison to 0.9% saline (NaCl). Method A comparative, observational, retrospective analysis assessed 27 serious and infected wounds in 24 patients. The lesions were of different and complex etiologies, including necrotizing fasciitis and stage IV diabetic foot ulcers. NPWT was used as part of the overall multimodal treatment regimen. The only variance in the treatment protocol was the use of saline (N=8) or HAPWOC (N=19) as the irrigant. Results When compared to NaCl, wounds treated with HAPWOC trended toward fewer operating room (OR) visits versus NaCl (3.3 versus 4.1) and a shorter length of hospital stay (LOS) (24.3 days versus 37.9 days). The Orlando Health Transparency guide shows the cost of OR debridement as $2,525. Thus, debridement for HAPWOC-treated wounds ($8,332) costs $2,020 (24%) less than for NaCl-treated wounds ($10,352). Using the 2016 Kaiser Health data (average daily hospital cost, excludingall interventions: $2,052), the cost of HAPWOC and NaCl instill translates to $49,864 and $77,771, respectively, a difference of $27,906 (56%) more for NaCl treatment. The Agency for Healthcare Research and Quality (AHRQ) 2012 data indicate an average daily cost of hospital stay, including all interventions, of $10,400. Thus, HAPWOC treatment cost translates to $252,720 versus NaCl-related costs of $394,160; in these calculations, using NaCl costs $141.440 (+56%) more per patient than HAPWOC. Conclusion The use of NPWT with HAPWOC versus NaCl as instillation in NPWT reduces the number of visits to the operating room and LOS. This has a significant impact on lowering the cost of care when HAPWOC is used.

Neodermis Formation in Full Thickness Wounds Using an Esterified Hyaluronic Acid Matrix.

The role of the dermis is essential for the proper orchestration of all phases of the normal wound healing process. Wounds with seriously damaged or even absent dermis consistently show seriously impaired wound healing and/or long-term complications such as hypertrophic scarring. Replacing a damaged dermis requires a dermal matrix that is compatible with, or even stimulates, the process of wound healing. Hyaluronic acid (HA), in an esterified form, is among the many matrices that are available. HA has been used in a number of indications, such as ulcers (ie, diabetic foot ulcers and venous leg ulcers), trauma, including burns, and for the repair of contractures and hypertrophic scars. The shorter healing time and the decrease of recurring hypertrophy demonstrate the efficiency of HA-derived matrices. Biopsies, taken up to 12 months post-reconstruction show a neodermis that histologically is largely comparable to normal skin, which probably is a function of HA playing such a pivotal role in normal, unwounded skin, as well as in the process of healing.

Necrotizing Fasciitis: An Overview and 2 Illustrative Cases.

Necrotizing fasciitis is the generic term for a series of progressive gangrenous infections of the skin and subcutaneous tissues. Typically, necrotizing fasciitis start with an, often small, infected lesion with atypical symptoms, which then quickly develops into a rapidly spreading, massive infection. The primary therapy is excision of all necrotic tissue in combination with treatment of systemic symptoms such as shock. The defects resulting from rigorous excision are often very large. Once they are clean, they require closure with an autograft. This article reviews the symptoms and treatment of necrotizing fasciitis. In addition, it illustrates, with 2 cases, how a hyaluronic-based extracellular matrix can be used to "fill in" with neodermis for the lost dermis and can create a wound bed most suitable for grafting.

Managing Wounds with Exposed Bone and Tendon with an Esterified Hyaluronic Acid Matrix (eHAM): A Literature Review and Personal Experience.

The loss of extracellular matrix in combination with the exposure of structures such as bone and tendon pose a major challenge; the development of granulation tissue and subsequent reepithelialization over these structures is extremely slow and often may not happen at all. Replacement of the matrix has been shown to significantly increase the chances of healing since, with revascularization of the matrix, a wound bed is created that may either heal by secondary intention or via the application of a skin graft. A literature search on an esterified hyaluronic acid-based matrix (eHAM) returned five articles on the treatment of wounds with tendon and bone loss in which the eHAM was used. The etiologies of the wounds described varied among the articles, as did treatment modalities. However, all of them received proper debridement of necrosis with subsequent (although not always immediately) application of the eHAM. A very high percentage of all wounds reached the different primary endpoints in the studies, which were complete reepithelialization, complete coverage with granulation tissue and/or 10% coverage of the original wound size with epithelium, the latter being a strong indicator of the wound continuing to heal. The individual authors concluded that the esterified hyaluronic acid matrix (eHAM) is a valuable tool to assist in the complete healing of difficult to heal wounds.

Failure to Reposition After Sliding Down in Bed Increases Pressure at the Sacrum and Heels.

UNLABELLED: The head of the bed (HOB) for a patient is often elevated since it improves comfort and facilitates respiratory functions. However, elevating the HOB essentially causes the patient support surface to turn into a ramp, forcing the patient's body to slide down. As the patient slides down, weight pressing on the pelvis, the coccyx, and the ischial tuberosities increases, resulting in associated increases in interface pressures. METHODS: In an institutional review board-approved study, pressure distribution was measured on volunteers at 4 discrete body positions sliding down in bed on 3 commonly used support surfaces. RESULTS: This study showed the total contact area of the patients decreased as they slid down, resulting in increased pressure, particularly on the sacral area and the heels. The study also confirmed that these pressure increases are persistent and occurred on all of the support surfaces tested. CONCLUSION: These increases in pressure likely contribute to the development of pressure ulcers.

Real-world Experience With a Decellularized Dehydrated Human Amniotic Membrane Allograft.

UNLABELLED: While randomized controlled trials (RCTs) are designed to evaluate efficacy and/or safety under controlled conditions, use of strict inclusion/ exclusion criteria are noted to exclude more than 50% of wound populations. Applicability of RCT outcomes to performance expectations in real-world wound populations raises questions about generalizing their results. The primary aim of this decellularized, dehydrated human amniotic membrane (DDHAM) Use Registry Study was to gain experience and observe outcomes with use of a DDHAM in uninfected, full-thickness, or partial-thickness wounds that, in the investigators' opinions, would benefit from such treatment. METHODS: Investigators were instructed to provide usual care regarding visit and application frequencies, concomitant therapies, and change in wound-care regimens. The only exclusions were patients with actively infected wounds or known hypersensitivity to DDHAM. Fifteen sites with practicing wound care clinicians of various specialties participated in this review, enrolling chronic wounds including venous, diabetic, pressure, collagen vascular, and arterial ulcers-all of various severities, durations, sizes, and previous treatments. Twenty-eight ulcers studied had failed 32 previous treatments with advanced biologic therapies. A total of 244 wounds were observed in this study, however, this review is limited to the 179 chronic wounds in 165 patients that were enrolled at 15 of the 19 participating centers. The 4 centers that enrolled acute wounds only were excluded. RESULTS: Results from the analysis of this very heterogeneous population demonstrated that during the usual course of an average of 8 weeks of wound management, patients experienced factors that significantly affected wound closure. These factors included wound infections, noncompliance with prescribed treatments (eg, compression, off-loading, and wound care), re-injury of the wound, and systemic comorbidities. Nearly 50% of chronic wounds (including those that failed previous therapy with advanced biologics) with an average baseline area of 3.1 cm2 achieved complete closure within a median of 6.3 weeks without product-related adverse experiences. CONCLUSION: Despite the challenges of uncontrolled factors that affect healing, this registry study demonstrated the safety and clinical benefit of DDHAM to support wound closure across a variety of chronic wound types and patient conditions in real-world environments.

Results of a retrospective comparative study: material cost for managing a series of large wounds in subjects with serious morbidity with a hydrokinetic fiber dressing or negative pressure wound therapy.

UNLABELLED: This retrospective observational study analyzed lesions with regard to healing trends and cost of materials. MATERIALS AND METHODS: The observed lesions were mostly postsurgical or stage IV pressure ulcers in patients with serious morbidity. The wounds were treated with a hydrokinetic fiber dressing (sorbion Sachet S, sorbion Gmbh & Co, a BSN medical company, Senden, Germany) (n = 26) or negative pressure wound therapy (NPWT) (n = 16). RESULTS: Primary healing trends (ie, reduction of wound size, change from necrosis to granulation tissue, and change from granulation tissue to epithelium) and secondary healing trends (ie, periwound conditions) were similar for wounds treated with the hydrokinetic dressing when compared to wounds treated with NPWT. Cost of materials was substantially lower for wounds treated with the hydrokinetic fiber dressing compared to the NPWT, with cost reductions of $1,640 (348%) to $2,242 (1794%) per wound, depending on the criteria used for the analysis. CONCLUSION: In this set of wounds, the hydrokinetic fiber dressing was shown to lead to similar healing results while providing substantial reductions of the cost of materials. For the types of wounds presented in this observational study, the hydrokinetic fiber dressing seems to be an effective substitution for negative pressure wound therapy.

Porcine xenografts vs. (cryopreserved) allografts in the management of partial thickness burns: is there a clinical difference?

Porcine xenografts and cryopreserved allografts are used for the management of partial thickness burns and both biological materials have strong advocates with regard to clinical performance, the possibility of disease transfer from donor to recipient and other clinical aspects. A literature analysis was performed in an attempt to investigate whether true (statistically significant) differences exist on clinical performance and on other determinants for use. Comparing the results of this study with a similar, previously published study performed on possible differences amongst different types of allograft in the management of partial thickness burns, both allografts and porcine xenograft seem to perform equally well clinically with regard to healing related outcomes. In addition, the risk of disease transfer, in real life, was shown to be minimal. Consequently, clinical aspects being equal, other aspects such as price and availability should be used to decide which material to use for the management of partial thickness burns.

Adhesion prevention in an intraperitoneal wound model: performance of two resorbable hemostats in a controlled study in rabbits.

Adhesions, particularly in the abdominal and pelvic cavities, represent a significant clinical problem. Among other complications, they are considered the most common cause of intestinal obstructions in the Western world. The purpose of this study was to evaluate two commercially available hemostats for their ability to prevent adhesion formation in an abdominal wound model. The hemostats, a microfibrillar collagen-based composite and microporous polysaccharide spheres were used in a rabbit abdominal model. In the model the cecum was abraded and a peritoneal defect was created on the abdominal sidewall. The test materials were applied over the defects. Clinical and histological results were compared with control (no application of any hemostat at the defect site) on postoperative day 14. The results showed a significant reduction in the incidence, extent and severity of adhesions for both surgical hemostat materials compared with control. The microfibrillar collagen-based composite showed a total absence of adhesions and a high level of reperitonealization. This preclinical study suggests that the use of surgical hemostats may help to reduce or eliminate adhesions and may promote reperitonealization.

Preservation methods of allografts and their (lack of) influence on clinical results in partial thickness burns.

Allografts, cadaver skin and amnion membrane are considered the golden standard in the management of partial thickness burns. However, debate on whether the tissue needs to be viable is on-going, since many believe that viable grafts result in better healing. The objective of this literature survey was to analyse the evidence on the method of preservation of allografts (cadaver skin or amnion membrane, glycerol, cryopreservation, lyophilisation) having a clinical impact on the healing of partial thickness burns. The survey focussed on preservation techniques and clinical outcomes (reepithelialisation) in partial thickness burns, as well as on differences in viability, immunogenicity and antimicrobial properties of the preservation methods. Most studies on allograft treatment of partial thickness burns are observational, with only one study of a (historical) comparative nature. A true meta-analysis was not performed and the results of this survey are observational in nature as well: they indicate that there is no evidence that viability of the graft influences healing outcomes. Thus, instead of viability, other aspects, such as intrinsic antimicrobial safety of the preservation method and cost should be the primary criteria for the choice of preservation method to be used for allografts.

Evaluation of Vashe Wound Therapy in the clinical management of patients with chronic wounds.

OBJECTIVE: To analyze if Vashe Wound Therapy (PuriCore, Malvern, Pennsylvania) is a valuable contribution to standard protocols of wound care. DESIGN: Open, noncomparative study. SETTING: Outpatient clinic. PATIENTS: Thirty-one patients, primarily with venous or mixed venous/arterial leg ulcers. INTERVENTIONS: Vashe Wound Therapy (hypochlorous acid, produced on site and on demand) was used as an adjunct to a standard wound care protocol. MAIN OUTCOME MEASURES: Wound healing, reduction of pain, and odor. MAIN RESULTS: At the end of the study, 86% of all lesions healed, and the average size of reduction in nonhealed wounds was 47%. Odor was present at the beginning of enrollment in 21 patients and was rated 4.58 on the visual analog scale. In all patients, the odor score at end of treatment was zero. Seventy-seven percent of all patients reported a positive pain score at the beginning of participation in the evaluation (average pain score, 4.7). At the end of the study, no patient experienced pain. CONCLUSION: Vashe Wound Therapy is a valuable contribution to standard protocols of wound care.

 wounds and ulcers: back to the old nomenclature .

Currently, most skin lesions are called wounds and primarily are divided into acute and chronic, the difference being the time period during which they have been in existence and/or their tendency to heal properly or not. Etiology is not taken into account when applying the definitions of chronic versus acute. The traditional definition of wounds and ulcers was based primarily on etiology, where a wound (now called an acute or surgical wound) was said to be caused by violence (eg, an outside force such as a bullet, a surgical incision) and an ulcer, presently called a chronic "wound," was defined as being caused by some kind of internal etiology (eg, venous hypertension with its secondary consequences to skin integrity). Based on the differences in etiology and physiology, morbidity and mortality, therapeutic options and requirements, and other aspects of different types of skin lesions, this author proposes to reinstitute the "old" nomenclature.

Results of an internet survey on the treatment of partial thickness burns, full thickness burns, and donor sites.

The objective of this study was to analyze which materials and methods are used for the management of partial and full thickness burns, as well as donor sites. An Internet survey was used to poll directors of burn centers around the world on their preferences for local treatment of different types of burns and donor sites. Results were tabulated and expressed as a percentage of the total number of answers for a given indication. Although many new wound care materials have been launched in the last decade, few of these actually are used widely. The most commonly used materials for partial thickness burns and donor sites are still silver sulphadiazine 1% cream, other antimicrobial ointments and creams and impregnated gauze type dressings. Of the newly available treatment modalities, only two silver dressings were chosen frequently as a primary option for the management of partial thickness burns and donor sites. For full thickness burns, the primary choice is excision and grafting. The diversity of dressings and techniques indicated as preferred in this survey, including many that are known to have side effects, indicates that there is no consensus on topical treatment of partial thickness burns and donor sites. Many respondents prefer "tried and true" materials over newer dressings, particularly if the latter have not been tested in a clinical trial.