Interventions for postburn pruritus.

BACKGROUND: Postburn pruritus (itch) is a common and distressing symptom experienced on healing or healed burn or donor site wounds. Topical, systemic, and physical treatments are available to control postburn pruritus; however, it remains unclear how effective these are. OBJECTIVES: To assess the effects of interventions for treating postburn pruritus in any care setting. SEARCH METHODS: In September 2022, we searched the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE (including In-Process & Other Non-Indexed Citations), Ovid Embase, and EBSCO CINAHL Plus. We also searched clinical trials registries and scanned references of relevant publications to identify eligible trials. There were no restrictions with respect to language, publication date, or study setting. SELECTION CRITERIA: Randomised controlled trials (RCTs) that enrolled people with postburn pruritus to compare an intervention for postburn pruritus with any other intervention, placebo or sham intervention, or no intervention. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane. We used GRADE to assess the certainty of the evidence. MAIN RESULTS: We included 25 RCTs assessing 21 interventions with 1166 randomised participants. These 21 interventions can be grouped into six categories: neuromodulatory agents (such as doxepin, gabapentin, pregabalin, ondansetron), topical therapies (such as CQ-01 hydrogel, silicone gel, enalapril ointment, Provase moisturiser, beeswax and herbal oil cream), physical modalities (such as massage therapy, therapeutic touch, extracorporeal shock wave therapy, enhanced education about silicone gel sheeting), laser scar revision (pulsed dye laser, pulsed high-intensity laser, fractional CO2 laser), electrical stimulation (transcutaneous electrical nerve stimulation, transcranial direct current stimulation), and other therapies (cetirizine/cimetidine combination, lemon balm tea). Most RCTs were conducted at academic hospitals and were at a high risk of performance, attrition, and detection bias. While 24 out of 25 included studies reported change in burn-related pruritus, secondary outcomes such as cost-effectiveness, pain, patient perception, wound healing, and participant health-related quality of life were not reported or were reported incompletely. Neuromodulatory agents versus antihistamines or placebo There is low-certainty evidence that doxepin cream may reduce burn-related pruritus compared with oral antihistamine (mean difference (MD) -2.60 on a 0 to 10 visual analogue scale (VAS), 95% confidence interval (CI) -3.79 to -1.42; 2 studies, 49 participants). A change of 2 points represents a minimal clinically important difference (MCID). Due to very low-certainty evidence, it is uncertain whether doxepin cream impacts the incidence of somnolence as an adverse event compared to oral antihistamine (risk ratio (RR) 0.64, 95% CI 0.32 to 1.25; 1 study, 24 participants). No data were reported on pain in the included study. There is low-certainty evidence that gabapentin may reduce burn-related pruritus compared with cetirizine (MD -2.40 VAS, 95% CI -4.14 to -0.66; 1 study, 40 participants). A change of 2 points represents a MCID. There is low-certainty evidence that gabapentin reduces the incidence of somnolence compared to cetirizine (RR 0.02, 95% CI 0.00 to 0.38; 1 study, 40 participants). No data were reported on pain in the included study. There is low-certainty evidence that pregabalin may result in a reduction in burn-related pruritus intensity compared with cetirizine with pheniramine maleate (MD -0.80 VAS, 95% CI -1.24 to -0.36; 1 study, 40 participants). A change of 2 points represents a MCID. There is low-certainty evidence that pregabalin reduces the incidence of somnolence compared to cetirizine (RR 0.04, 95% CI 0.00 to 0.69; 1 study, 40 participants). No data were reported on pain in the included study. There is moderate-certainty evidence that ondansetron probably results in a reduction in burn-related pruritus intensity compared with diphenhydramine (MD -0.76 on a 0 to 10 numeric analogue scale (NAS), 95% CI -1.50 to -0.02; 1 study, 38 participants). A change of 2 points represents a MCID. No data were reported on pain and adverse events in the included study. Topical therapies versus relevant comparators There is moderate-certainty evidence that enalapril ointment probably decreases mean burn-related pruritus compared with placebo control (MD -0.70 on a 0 to 4 scoring table for itching, 95% CI -1.04 to -0.36; 1 study, 60 participants). No data were reported on pain and adverse events in the included study. Physical modalities versus relevant comparators Compared with standard care, there is low-certainty evidence that massage may reduce burn-related pruritus (standardised mean difference (SMD) -0.86, 95% CI -1.45 to -0.27; 2 studies, 166 participants) and pain (SMD -1.32, 95% CI -1.66 to -0.98). These SMDs equate to a 4.60-point reduction in pruritus and a 3.74-point reduction in pain on a 10-point VAS. A change of 2 VAS points in itch represents a MCID. No data were reported on adverse events in the included studies. There is low-certainty evidence that extracorporeal shock wave therapy (ESWT) may reduce burn-related pruritus compared with sham stimulation (SMD -1.20, 95% CI -1.65 to -0.75; 2 studies, 91 participants). This equates to a 5.93-point reduction in pruritus on a 22-point 12-item Pruritus Severity Scale. There is low-certainty evidence that ESWT may reduce pain compared with sham stimulation (MD 2.96 on a 0 to 25 pressure pain threshold (PPT), 95% CI 1.76 to 4.16; 1 study, 45 participants). No data were reported on adverse events in the included studies. Laser scar revision versus untreated or placebo controls There is moderate-certainty evidence that pulsed high-intensity laser probably results in a reduction in burn-related pruritus intensity compared with placebo laser (MD -0.51 on a 0 to 1 Itch Severity Scale (ISS), 95% CI -0.64 to -0.38; 1 study, 49 participants). There is moderate-certainty evidence that pulsed high-intensity laser probably reduces pain compared with placebo laser (MD -3.23 VAS, 95% CI -5.41 to -1.05; 1 study, 49 participants). No data were reported on adverse events in the included studies. AUTHORS' CONCLUSIONS: There is moderate to low-certainty evidence on the effects of 21 interventions. Most studies were small and at a high risk of bias related to blinding and incomplete outcome data. Where there is moderate-certainty evidence, practitioners should consider the applicability of the evidence for their patients.

It all doesn't always have to go: abdominal wall reconstruction involving selective synthetic mesh explantation with biologic mesh salvage.

The comparative performance of synthetic and biologic meshes in complex and contaminated abdominal wall repairs remains controversial. Though biologic meshes are generally favoured in contaminated fields, this practice is based on limited data. Standard dictum regarding infected mesh is to either explant it early or pursue aggressive conservation measures depending on mesh position and composition. Explantation is typically morbid, leaving the patient with recurrent hernias and few reconstructive options. We report a case in which a hernia repaired with synthetic mesh recurred and was reconstructed with underlay biologic mesh. Delayed wound hematoma occurred after initiating anticoagulation for late postoperative pulmonary embolism, which became chronically infected. After multiple failed attempts at medical and interventional salvage of the mesh infection, the patient underwent selective explantation of synthetic mesh with conservation of the underlying biological mesh. She recovered completely without recurrent abdominal wall failure at long-term follow-up. We suggest the "salvageable" characteristics of biologic meshes may allow conservation, rather than explantation, in select cases of infection.

Single Digit Index Finger Amputation-To Replant or Not?

Background: Single index finger replantation is often listed as a contraindication due to its hindrance of hand function when replanted. Recent studies demonstrate comparable subjective and global functional outcomes for index flexor zone II finger replants versus revision amputations. We therefore sought to identify current opinions of plastic surgery trainees and staff treating single index finger zone II amputations including influential patient and injury characteristics. Methods: With the approval of the Canadian Society of Plastic Surgery, a 17-question survey was sent via email to all listed members on 3 separate occasions. Participation was voluntary and survey responses were compiled and analyzed using SPSS statistical software. Results: Survey response rate was 38.5%. When asked whether the surgeon would replant a single index digit, flexor zone II, sharp amputation, 55.3% of respondents chose "yes," while 44.7% responded "no." Staff (51.5%) were less likely to replant a single index digit amputation. Likelihood of replant dropped substantially in crush (12.4%) and avulsion (17.1%) injury. Smoking was the most likely patient characteristic to change a surgeon's decision (61.9%). Poor range of motion (77.5%) and patient satisfaction (72.5%) were the most frequently listed reasons not to replant. Conclusion: Among Canadian plastic surgeons, there exists disagreement in how single index flexor zone II amputations should be managed. In review of the literature, these notions and previous teaching around replants highlight many inherent surgeon biases with regard to the merit and value of single digit replantation.

Contexte: La réimplantation isolée de l'index est souvent considérée comme une contre-indication compte tenu de la gêne causée au fonctionnement de la main une fois réimplanté. Des études récentes démontrent des résultats fonctionnels, subjectifs et globaux, comparables pour les réimplantations digitales du fléchisseur de l'index en zone II comparativement aux amputations de révision. Nous avons donc cherché à identifier l'avis actuel des stagiaires et du personnel de chirurgie plastique traitant des amputations isolées en zone II, incluant les caractéristiques de la blessure et l'influence des patients. Méthodes: Une enquête comportant dix-sept questions a été envoyée à trois reprises avec l'approbation de la Société canadienne de chirurgie plastique aux adresses de courriel de tous les membres listés. La participation était volontaire et les réponses à l'enquête ont été compilées et analysées au moyen du logiciel statistique SPSS. Résultats: Le taux de réponse à l'enquête a été de 38,5 %. À la question de savoir si le chirurgien réimplanterait un index isolé, fléchisseur zone II, après amputation nette, 55,3 % des répondants ont choisi « oui ¼ et 44,7 % ont répondu « non ¼. Le personnel (51,5 %) était moins susceptible de réimplanter un index après amputation isolée. La probabilité de réimplantation diminuait nettement en cas de lésion par écrasement (12,4 %) et arrachement (17,1 %). Le tabagisme était la caractéristique du patient le plus susceptible de modifier la décision d'un chirurgien (61,9 %). Une mauvaise amplitude de mouvement (77,5 %) et satisfaction du patient (72,5 %) ont été les raisons citées le plus souvent pour ne pas réimplanter. Conclusion: Il existe, parmi les chirurgiens plasticiens canadiens, un désaccord sur la manière dont les amputations isolées d'un index (fléchisseur zone II) doivent être gérées. La revue des publications montre que ces notions et l'enseignement antérieur concernant les réimplantations soulignent les multiples biais inhérents aux chirurgiens pour ce qui concerne l'intérêt et la valeur de la réimplantation d'un seul doigt.

Attitudes of Canadian Plastic Surgeons on Temporal Artery Biopsy in Giant Cell Arteritis Management.

Temporal artery biopsies (TAB) rarely impact management of patients with suspected giant cell arteritis and carry complications. We sought plastic surgeons' perspectives on this procedure's risks and benefits. METHODS: An email survey was designed, piloted, and refined to elicit Canadian Society of Plastic Surgeons (CSPS) members about TAB's diagnostic contribution, complications, usefulness as a resident education tool, and surgeons' insight into emerging diagnostic modalities like ultrasound. Text comments were sought at each question. A reminder was emailed one week later. Data was compared and analyzed using the chi-squared test and student t-test. RESULTS: An estimated 83 responses were received from 435 surgeons (19%). Of the surgeons, 20% voiced uncertainty regarding TAB indications; 40% were unsure if TAB results changed steroid duration and dose; 83% did not see patients postoperatively. Surgeons recalled 29 cases of hematoma and three facial nerve injuries from TAB. In total, 80% felt TAB was a valuable learning opportunity for residents, although residents were involved in only 21% of cases; 65% of surgeons supported a changeover to ultrasound as primary diagnostic modality. Analysis of text comments revealed a sense of futility from TAB and disdain toward being mere technicians. Several participants wished for stakeholders to collaborate and potentially endorse noninvasive diagnostic modalities. CONCLUSIONS: This survey demonstrated varying attitudes to TAB. Generally, plastic surgeons were uncertain of TAB's contribution to treatment, tended not to follow-up on results or patients, and recognized a number of complications. Conversations are desired regarding switching from scalpel to probe to evaluate the temporal artery.

Predatory publishing solicitation: a review of a single surgeon's inbox and implications for information technology resources at an organizational level.

Over a 6-month period, roughly one-third of emails received in a single surgeon's email inbox were predatory in nature (i.e., soliciting material for nonexistent journals or conferences). While existing databases (e.g., Beall's list and The CalTech Library list of questionable conferences) catalogue many fraudulent senders, the list is ever-expanding. The overall cost to health care organizations in terms of wasted bandwidth and financial diversion is extensive, as is confusion for trainees and colleagues. For the sake of fiscal responsibility and the maintenance of scholarly standards, it is incumbent upon organizational information technology departments to continually refine strategies to reduce this adverse impact.

The Whole Glove Tourniquet Technique Revisited With Video Instruction.

This article revisits the whole glove tourniquet technique with video instruction. The whole glove tourniquet is a digital device that can be used to improve patient safety during hand surgery procedures performed under local anesthesia. Major benefits include of using this device are lower risk of the tourniquet being inadvertently left on the finger after completion of the procedure and improved sterile field in patients with heavily soiled extremities. The procedure is simple to use and does not require any specialized equipment, making it ideal for a wide variety of economic environments.

Invasive Candida albicans fungal infection requiring explantation of a noncrosslinked porcine derived biologic mesh: a rare but catastrophic complication in abdominal wall reconstruction.

SUMMARY: Biologic mesh is preferred over synthetic mesh for complex and contaminated abdominal wall repairs; however, there are very little data on the risks and complications associated with its use. We report the case of a 67-year-old man with failed synthetic mesh repair for recurrent ventral hernia, who subsequently required an abdominal wall reconstruction (AWR), including the intraperitoneal sublay of noncrosslinked biologic mesh. His postoperative course was complicated with catastrophic sepsis and sustained hemodynamic instability, responding only to mesh explantation. The biologic mesh was subsequently noted to be histologically infected with invasive Candida albicans. Although noncrosslinked biologic mesh is a valuable adjunct to AWR, it is not infection-resistant. Although it is rare, infection of any foreign tissue, including biologic mesh, can occur in the setting of complex ventral abdominal wall repairs. Clinicians should be watchful for such infections in complex repairs as they may require biologic mesh explantation for clinical recovery.

Adult Human Dermal Progenitor Cell Transplantation Modulates the Functional Outcome of Split-Thickness Skin Xenografts.

Following full-thickness skin injuries, epithelialization of the wound is essential. The standard of care to achieve this wound "closure" in patients is autologous split-thickness skin grafting (STSG). However, patients living with STSGs report significant chronic impairments leading to functional deficiencies such as itch, altered sensation, fragility, hypertrophic scarring, and contractures. These features are attributable to the absence of functional dermis combined with the formation of disorganized fibrotic extracellular matrix. Recent work has demonstrated the existence of dermal progenitor cells (DPCs) residing within hair follicles that function to continuously regenerate mesenchymal tissue. The present work examines whether cultured DPCs could regenerate dermis within an STSG and improve overall graft function. Adult human DPCs were transplanted into a full-thickness skin wound in immune-compromised mice and closed with a human STSG. At 3 months, human DPCs (hDPCs) had successfully integrated into the xenograft and differentiated into various regionally specified phenotypes, improving both viscoelastic properties of the graft and mitigating pruritus.

A Review of Perforator Flaps for Burn Scar Contractures of Joints.

OBJECTIVE: Perforator flaps are one possible surgical treatment for burn scar contractures; however, a review of evidence on this topic is lacking. METHODS: MEDLINE was searched for articles related to perforator flaps for burn contractures. Following title and abstract screen, full texts were searched to identify articles describing perforator flaps for burn scar joint contractures. Data were extracted and summarized descriptively. Only articles that contained ≥10 patients with burn scar contracture were considered. RESULTS: Two hundred forty-eight articles were identified, of which 17 met criteria for review. Of these, 16 were low-quality case series, while 1 was an open randomized controlled trial. In total, perforator flaps were performed on 339 patients (age range: 3-75 years), with the most common contracture locations being cervical (n = 218) and knee (n = 41). Nine of the 17 articles described a rehabilitation strategy. In general, functional outcomes were excellent, with the majority of patients experiencing return of normal joint range of motion and no recontracture. Compared to full-thickness skin grafts, perforator flaps showed greater improvements in joint range of motion. Cosmetically, perforator flaps were shown to have good color match with surrounding tissue, good contour around anatomical landmarks, and improved overall patient appearance. The most common complications were marginal flap necrosis (n = 26 patients) and venous congestion (n = 17 patients). CONCLUSIONS: Preliminary evidence from low-quality case series and 1 high-quality trial suggests perforator flaps may be successful for resurfacing released burn scar contractures; however, there is a need for additional trials comparing perforator flaps to other approaches.

OBJECTIF: Les lambeaux perforateurs font partie des traitements chirurgicaux des contractures des cicatrices de brûlure, mais il n'y a pas d'analyse des données probantes sur le sujet. MÉTHODOLOGIE: Les chercheurs ont effectué une recherche dans MEDLINE pour extraire les articles liés aux lambeaux perforateurs pour les contractures causées par des brûlures. Après un filtrage en fonction des titres et des résumés, ils ont fouillé les textes intégraux et retenu les articles décrivant les lambeaux perforateurs pour corriger les contractures causées par des cicatrices de brûlure. Ils ont extrait les données et procédé à un résumé descriptif. Ils n'ont évalué que les articles portant sur au moins dix patients ayant des contractures causées par des cicatrices de brûlure. RÉSULTATS: Les chercheurs ont extrait 248 articles, dont 17 respectaient les critères d'analyse. De ce nombre, 16 étaient des séries de cas de faible qualité et un, un essai aléatoire et contrôlé ouvert. Au total, 339 patients (de trois à 75 ans) ont reçu des lambeaux perforateurs, et les contractures étaient surtout situées dans la région du cou (n = 218) et du genou (n = 41). Neuf des 17 articles décrivaient une stratégie de réadaptation. En général, les résultats fonctionnels étaient excellents, car la majorité des patients retrouvaient une amplitude de mouvements normale et n'avaient plus de contractures. Par rapport aux greffes cutanées pleine épaisseur, les lambeaux perforateurs assuraient une plus grande amélioration de l'amplitude du mouvement articulaire. Sur le plan esthétique, les lambeaux perforateurs assuraient un bel appariement de couleur par rapport aux tissus avoisinants, un beau contour des repères anatomiques et une amélioration globale de l'apparence. Les principales complications étaient une nécrose du lambeau marginal (n = 26 patients) et une congestion veineuse (n = 17 patients). CONCLUSIONS: D'après les données probantes préliminaires de séries de cas de faible qualité et d'un essai de haute qualité, les lambeaux perforateurs peuvent être utiles pour le resurfaçage de contractures causées par des cicatrices de brûlure. D'autres études devront être réalisées pour comparer les lambeaux perforateurs à d'autres approches.

Epidemiological analysis of pediatric burns in the Dominican Republic reveals a demographic profile at significant risk for electrical burns.

OBJECTIVE: Pediatric burns are preventable with legislative and infrastructural changes. Although retrospective audits of many low- and middle-income countries have aided preventative efforts, the epidemiological status of burns in the Caribbean is not known. This study characterizes pediatric burns in the Dominican Republic (DR) and compares these to age-matched North American records captured by the National Burn Repository. METHODS: A retrospective audit of 1600 patients admitted to the Unidad de Niños Quemados Dra. Thelma Rosario Hospital, the island's only major pediatric burn center, between January 2010 to March 2017 was performed. Epidemiological variables analyzed included age, gender, burn mechanism, year, month, city, admission duration, nationality, mortality, and %TBSA. RESULTS: Pediatric burn patients in the DR sustained larger burns (8.2% vs. 6.5% TBSA) and spent more days in the hospital (10 vs. 6 days). Females were overrepresented (M:F=1:1.5) and mortality amongst admitted patients was 4-fold higher (2.8% vs. 0.7%). Electrical burns were significantly overrepresented in DR (21%) compared to age-matched North American patients (2%). Although electrical burns were smaller (4% TBSA), compared to scald (14% TBSA), and flame (19% TBSA), these burns preferred hands and had a high mortality rate (3%). No significant seasonality in burn mechanisms were observed. Finally, we report geographical and age group differences in the distribution of burn mechanisms and highlight particularly vulnerable subpopulations. CONCLUSION: This investigation identifies a demographical profile where electrical burns account for a significant percentage of the burn population. This provides a basis for concentrating preventative efforts in vulnerable populations.

The development of a treatment pathway for dermal regenerative matrix (DRM).

The process of standardising burn care and creating protocols within burn centres has, at its core, evidence-based practice principles combined with the clinical experiences of burn care specialists. Although protocols and pathways have been created for certain topics of burn care, they tend to be tailored to the local individual needs of each burn centre, which is a limiting factor for consideration of larger/nationwide approaches. In order to continue to improve the short and long term outcomes after burn injuries, such as increasing the survival rate, reduction in the incidence of sepsis and organ failure, and improving wound healing and scarring, more generalised care pathways combining the recommendations of a nationwide working group of burn care specialists should be created around the topics of interest to ultimately improve patients' outcomes. We describe the steps put in place in Canada to design and adopt a nationwide protocol from a single burn centre on the topic of wound healing and dermal substitutes as the initial exemplary process. This report summarizes the Canadian experience for this type of initiative, which can be used as framework for developing additional guidelines/protocols in other relevant burn care related topics in Canada or other countries.

Burns from illegal cannabis oil manufacturing: a case series.

BACKGROUND: The increasing consideration of cannabis legalization in Canada and the United States has motivated physicians to assess its prospective impact on the health care system. Health care providers in the burns community are concerned about injuries sustained as a result of the illegal manufacturing of cannabis oil because it involves highly flammable reagents. METHODS: We report a retrospective case series of patients with cannabis oil burns (identified by evidence of combustion during cannabis oil manufacturing) treated from April 2012 to March 2014 at the Foothills Medical Centre in Calgary, Alberta, Canada. We compare the characteristics of these patients with those of patients admitted over the same period with any burns. RESULTS: We found that 12 (out of 161 patients) admitted over the review period sustained burns from cannabis oil manufacturing. Compared with patients in the total burn group, patients with cannabis oil burns were younger (75% and 48% were younger than 41 years in the group with cannabis oil burns and the total burn group, respectively), were more likely to be male (83% in the group with cannabis oil burns v. 74% in the total burn group) and sustained burns over a larger percentage of their total body surface area (24% v. 9%). Patients with cannabis oil burns also required extensive surgical management (skin grafting in 75% of cases) and spent a substantial amount of time (mean 32 d) in the burn unit. INTERPRETATION: Burns from illegal cannabis oil manufacturing are large, require extensive management and involve younger patients than burns in general. Given that the frequency of cannabis oil burns may increase in Canada after legalization, Canadian burn centres are encouraged to monitor and report on cases with this injury mechanism.

Burn clinical trials: A systematic review of registration and publications.

BACKGROUND: Randomized controlled clinical trials (CTs) are gold standard tools for assessing interventions. Although burn CTs have improved care, their status, publication frequency, and publication quality are not known. OBJECTIVES: (1) Characterize burn CTs by analyzing location, completion status, temporal trend, and funding sources. (2) Assess quality of trial reporting. DATA SOURCES: CT records were obtained from ClinicalTrials.gov and WHO's CT Registry (searched May 2017). Publications were obtained from PubMed, Google Scholar, OVID MEDLINE, and ClinicalTrials.gov (searched June 2017). PUBLICATION APPRAISAL: 23-item rubric adapted from CONSORT and ICH E3 guidelines. RESULTS: 738 burn CTs were identified globally, of which majority were publically-funded (77%), ongoing (52%), and assessed behavioral, pharmacological, device-based, dietary-based, and biological/procedural interventions. Amongst the ended trials, 69 (28%) published their findings. Significantly fewer industry-funded trials published findings (14% vs 33% publically-funded). Quality of reporting was suboptimal, and most underreported categories were trial phase, severity, and sample size estimation. LIMITATIONS: Incomplete, outdated, and non-registered CTs which are difficult to track. CONCLUSIONS: Burn trials are proliferating in number, location, and interventions assessed. Only a small proportion are published and quality of reporting is suboptimal. IMPLICATIONS OF KEY FINDINGS: Burn researchers should aim to register and report on all clinical trials regardless of outcome. Superior a priori design can reduce precocious termination and mandatory reporting of data fields can improve quality of reporting. Systematic review registration number: CRD42017068549.

Treating pain on skin graft donor sites: Review and clinical recommendations.

Split-thickness skin grafting is the most common reconstructive procedure in managing burn injuries. Harvesting split-thickness skin creates a new partial thickness wound referred to as the donor site. Pain at the donor site is reported to be one of the most distressing symptoms during the early postoperative period. Here, we (a) identify strategies for managing donor site pain, (b) assess the quality of individual studies, and (c) formulate evidence-based recommendations based on the amount and consistency of evidence. Our analysis revealed five distinct approaches to minimize donor site pain. These include: continuous subcutaneous local anesthetic infusion (three studies), subcutaneous anesthetic injection (five studies), topical agents (six studies), nonpharmacological interventions (three studies), and wound dressings (18 studies). Available randomized control trials typically evaluated pain on standardized scales (i.e. Visual Analog Scale, Numerical Rating Scale), and compared the experimental group with standard care. Recommended treatments include: (a) subcutaneous anesthetic injection of adrenaline-lidocaine; (b) ice application; (c) topical agents, such as lidocaine and bupivacaine; and (d) hydrocolloid- and polyurethane-based wound dressings accompanied with fibrin sealant. Methodologically sound randomized control trials examining the efficacy of modified tumescent solution, ropivacaine, plasma therapy, noncontact ultrasound, and morphine gels are lacking and should be a priority for future research.

Charts versus Discharge ICD-10 Coding for Sternal Wound Infection Following Coronary Artery Bypass Grafting.

BACKGROUND: Sternal wound infection (SWI) in patients undergoing coronary artery bypass grafting (CABG) can carry a significant risk of morbidity and mortality. The objective of this work is to describe the methods used to identify cases of SWI in an administrative database and to demonstrate the effectiveness of using an International Classification of Diseases, Tenth Revision (ICD-10) coding algorithm for this purpose. METHODS: ICD-10 codes were used to identify cases of SWI within one year of CABG between April 2002 and November 2009. We randomly chose 200 charts for detailed chart review (100 from each of the groups coded as having SWI and not having SWI) to determine the utility of the ICD-10 coding algorithm. RESULTS: There were 2,820 patients undergoing CABG. Of these, 264 (9.4 percent) were coded as having SWI. Thirty-eight cases of SWI were identified by chart review. The ICD-10 coding algorithm of T81.3 or T81.4 was able to identify incident SWI with a positive predictive value of 35 percent and a negative predictive value of 97 percent. The agreement between the ICD-10 coding algorithm and presence of SWI remained fair, with an overall kappa coefficient of 0.32 (95 percent confidence interval, 0.22-0.43). The effectiveness of identifying deep SWI cases is also presented. CONCLUSIONS: This article describes an effective algorithm for identifying a cohort of patients with SWI following open sternotomy in large databases using ICD-10 coding. In addition, alternative search strategies are presented to suit researchers' needs.

The economic and logistical burden of care for severe work-related injuries in a level 1 tertiary care trauma referral center.

BACKGROUND: Work-related injuries (WRIs) represent a significant economic and logistical burden to healthcare systems. METHODS: All patients with severe WRIs (Injury Severity Score [ISS] ≥ 12) (1995 to 2013) were compared with patients with non-WRIs using standard methodology (P < .05). RESULTS: A total of 1,270 (8.5%) trauma admissions were for severe WRIs (mean age = 45 years, male:female ratio = 2.8:1, mean ISS = 22.7). Compared with patients with non-WRIs, WRI patients were younger, male, and had fewer comorbidities. Despite equivalent ISS, WRIs had a longer intensive care unit length of stay, length of mechanical ventilation, and number of surgical/operative procedures. Fewer patients with WRIs died in hospital and more were discharged home without support services. The acute care economic burden of WRIs was higher (because of intensive care unit and operating theatre, and physician compensation) (all analyses, P < .05). CONCLUSION: Patients with WRIs were younger, less comorbid, male, and had significantly higher utilization of acute care resources despite a similar ISS.

Trends in postcoronary artery bypass graft sternal wound dehiscence in a provincial population.

BACKGROUND: It appears that the medical profile of patients undergoing coronary artery bypass graft (CABG) surgery has changed. The impact of this demographic shift on CABG outcomes, such as sternal wound dehiscence, is unclear. OBJECTIVES: To quantify the incidence and trends of sternal wound dehiscence, quantify the demographic shift of those undergoing CABG and identify patient factors predictive of disease. METHODS: A prospective analysis was performed on a historical cohort of consecutive patients who underwent CABG (without valve replacement) in Alberta between April 1, 2002 and November 30, 2009. The incidence and trends of sternal wound dehiscence were determined. In addition, the trend of the mean Charlson index score and European System for Cardiac Operative Risk Evaluation (EuroSCORE) (capturing patient comorbidities) was analyzed. Univariable analysis and multivariable models were performed to determine factors predictive of wound dehiscence. RESULTS: A total of 5815 patients underwent CABG during the study period. The incidence proportion of sternal wound dehiscence in Alberta was 1.86% and the incidence rate was 1.98 cases per 100 person-years. Although both the EuroSCORE and Charlson scores significantly increased over the study period, the incidence of sternal wound dehiscence did not change significantly. Factors predictive of sternal wound dehiscence were diabetes (OR 2.97 [95% CI 1.73 to 5.10]), obesity (OR 1.55 [95% CI 1.05 to 2.27]) and female sex (OR 1.90 [95% CI 1.26 to 2.87]). CONCLUSIONS: The incidence proportion of sternal wound dehiscence in Alberta was comparable with the incidence previously published in the literature. While patients undergoing CABG had worsening medical profiles, the incidence of sternal wound dehiscence did not appear to be increasing significantly.

HISTORIQUE: Il semble que le profil médical des patients qui subisent un pontage aortocoronarien (PAC) a changé. On ne connaît pas les effets de ce changement démographique sur les résultats des PAC, tels que la déhiscence sternale. OBJECTIF: Quantifier l'incidence et les tendances de déhiscence sternale, quantifier le changement démographique des personnes qui subissent un PAC et cerner les facteurs liés aux patients qui sont prédictifs de maladie. MÉTHODOLOGIE: Les chercheurs ont effectué une analyse prospective auprès d'une cohorte historique de patients consécutifs qui avaient subi un PAC (sans remplacement valvulaire) en Alberta entre le 1er avril 2002 et le 30 novembre 2009. Ils ont déterminé l'incidence et les tendances des déhiscences sternales. Ils ont analysé la tendance de l'indice moyen de Charlson et de l'EuroSCORE (European System for Cardiac Operative Risk Evaluation) (qui saisit les comorbidités des patients). Ils ont utilisé des analyses univariables et des modèles multivariables pour déterminer les facteurs prédictifs d'une déhiscence de la plaie. RÉSULTATS: Au total, 5 815 patients ont subi un PAC pendant la période de l'étude. La proportion de déhiscence sternale en Alberta était de 1,86 % et le taux d'incidence, de 1,98 cas sur 100 personnes-année. Même si l'EuroSCORE et l'indice de Charlson ont augmenté considérablement pendant la période de l'étude, l'incidence de déhiscence sternale n'a pas changé de manière significative. Le diabète (RC 2,97 [95 % IC 1,73 à 5,10]), l'obésité (RC 1,55 [95 % IC 1,05 à 2,27]) et le sexe féminin (RC 1,90 [95 % IC 1,26 à 2,87]) étaient les facteurs prédictifs de déhiscence sternale. CONCLUSIONS: La proportion de déhiscence sternale en Alberta était comparable à celle publiée par le passé. Le profil médical des patients qui subissent un PAC s'aggravait, mais l'incidence de déhiscence sternale ne semblait pas augmenter de manière significative.

A necessary evil? Intra-abdominal hypertension complicating burn patient resuscitation.

OBJECTIVE: Severe burns are devastating injuries that result in considerable systemic inflammation and often require resuscitation with large volumes of fluid. The result of massive resuscitation is often raised intra-abdominal pressures leading to Intra-abdominal hypertension (IAH) and the secondary abdominal compartment syndrome. The objective of this study is to conduct (1) a 10 year retrospective study to investigate epidemiological factors contributing to burn injuries in Alberta, (2) to characterize fluid management and incidence of IAH and ACS and (3) to review fluid resuscitation with a goal to identify optimal strategies for fluid resuscitation. DESIGN: A comprehensive 10-year retrospective review of burn injuries from 1999. OUTCOME MEASURES: Age, sex, date, mechanism of injury, location of incident, on scene vitals and GCS, type of transport to hospital and routing, ISS, presenting vitals and GCS, diagnoses, procedures, complications, hospital LOS, ICU LOS, and events surrounding the injury. RESULTS: One hundred and seventy five patients (79.4% M, 20.6% F) were identified as having traumatic burn injuries with a mean ISS score of 21.8 (±8.3). The mean age was 41.6 (±17.5) (range 14-94) years. Nearly half (49.7%) of patients suffered their injuries at home, 17.7% were related to industrial incidents and 14.3% were MVC related. One hundred and ten patients required ICU admission. ICU LOS 18.5 (±8.8) days. Hospital LOS 38.0 (±37.8) days. The mean extent of burn injury was 31.4 (±20.9) % TBSA. Nearly half of the patients suffered inhalational injuries (mild 12.5%, moderate 13.7%, severe 9.1%). Thirty-nine (22.2%) of patients died from their injuries. Routine IAP monitoring began in September, 2005 with 15 of 28 patients having at least two IAP measurements. The mean IAP was 16.5 (±5.7) cm H2O (range: 1-40) with an average of 58 (±97) IAP measurements per patient. Those patients with IAP monitoring had an average TBSA of 35.0 (±16.0)%, ISS of 47.5 (±7.5). The mean 48 hr fluid balance was 25.6 (±11.1)L exceeding predicted Parkland formula estimates by 86 (±32)%. CONCLUSIONS: Further evaluation of IAP monitoring is needed to further characterize IAP and fluid resuscitation in patients with burn injuries.

Use of cyanide antidotes in burn patients with suspected inhalation injuries in North America: a cross-sectional survey.

This study aimed to assess the use of cyanide antidotes and the determine the opinion on empiric administration of hydroxocobalamin in North American burn patients with suspected smoke inhalation injuries. An online cross-sectional survey was sent to directors of 90 major burn centers in North America, which were listed on the American Burn Association Web site. A multiple-choice format was used to determine the percentage of patients tested for cyanide poisoning on admission, the current administration of a cyanide antidote based solely on clinical suspicion of poisoning, and the antidote used. To ascertain views on immediate administration of hydroxocobalamin before confirmation of cyanide poisoning an option was included to expand the response in written format. Twenty-nine of 90 burn directors (32%) completed the survey. For the population of interest, the majority of burn centers (59%) do not test for cyanide poisoning on admission and do not administer an antidote based solely on clinical suspicion of cyanide poisoning (58%). The most commonly available antidote is hydroxocobalamin (50%), followed by the cyanide antidote kit (29%). The opinion regarding instant administration of hydroxocobalamin when inhalation injury is suspected is mixed: 31% support its empiric use, 17% do not, and the remaining 52% have varying degrees of confidence in its utility. In North America, most patients burnt in closed-space fires with inhalation injuries are neither tested for cyanide poisoning in a timely manner nor empirically treated with a cyanide antidote. Although studies have shown the safety and efficacy of empiric and immediate administration of hydroxocobalamin, most centers are not willing to do so.