Iris Faraklas

Outcomes from treatment of necrotizing soft-tissue infections: results from the National Surgical Quality Improvement Program database.

BACKGROUND Necrotizing soft-tissue infections (NSTIs) are a group of uncommon, rapidly progressive, potentially fatal disorders. The National Surgical Quality Improvement Program (NSQIP) Registry was used to determine current data on the incidence, treatment, and outcomes of NSTIs. METHODS There were 688 NSTI cases identified for years 2005 to 2008. Ten control patients for each NSTI patient were also selected. Demographic, laboratory, and outcome data were collected to compare both groups. RESULTS Evidence of systemic inflammatory response syndrome (SIRS), sepsis, or septic shock occurred in 83% of NSTI cases. Mortality was 12% for NSTI patients versus 2% for controls. Regression analysis showed that age, emergent surgery, transfer from an outside hospital, sepsis, and several comorbid diseases correlated with mortality but not sex or diabetes. Direct admission was associated with reduced mortality. CONCLUSIONS NSTIs are seen regularly in academic centers, and their incidence may be increasing. Despite a high incidence of comorbid conditions and frequent presentation with sepsis, mortality is lower than previously reported, reflecting ongoing progress in the treatment of these disorders at NSQIP hospitals.

Colloid administration normalizes resuscitation ratio and ameliorates "fluid creep".

Although colloid was a component of the original Parkland formula, it has been omitted from standard Parkland resuscitation for over 30 years. However, some burn centers use colloid as “rescue” therapy for patients who exhibit progressively increasing crystalloid requirements, a phenomenon termed “fluid creep.” We reviewed our experience with this procedure. With Institutional Review Board approval, we reviewed all adult patients with ≥20%TBSA burns admitted from January 1, 2005, through December 31, 2007, who completed formal resuscitation. Patients were resuscitated using the Parkland formula, adjusted to maintain urine output of 30 to 50 ml/hr. Patients who required greater amounts of fluid than expected were given a combination of 5% albumin and lactated Ringers until fluid requirements normalized. Results were expressed as an hourly ratio (I/O ratio) of fluid infusion (ml/kg/%TBSA/hr) to urine output (ml/kg/hr). Predicted values for this ratio vary for individual patients but are usually less than 0.5 to 1.0. Fifty-two patients were reviewed, of whom 26 completed resuscitation using crystalloid alone, and the remaining 26 required albumin supplementation (AR). The groups were comparable in age, gender, weight, mortality, and time between injury and admission. AR patients had larger total and full-thickness burns and more inhalation injuries. Patients managed with crystalloid alone maintained mean resuscitation ratios from 0.13 to 0.40, whereas AR patients demonstrated progressively increasing ratios to a maximum mean of 1.97, until albumin was started. Administration of albumin produced a dramatic and precipitous return of ratios to within predicted ranges throughout the remainder of resuscitation. No patient developed abdominal compartment syndrome. Measuring hourly I/O ratios is an effective means of expressing and tracking fluid requirements. The addition of colloid to Parkland resuscitation rapidly reduces hourly fluid requirements, restores normal resuscitation ratios, and ameliorates fluid creep. This practice can be applied selectively as needed using predetermined algorithms.

Peripherally inserted central venous catheters and central venous catheters in burn patients: a comparative review.

Central venous catheters (CVCs) are traditionally used for central venous access in the intensive care unit setting. Use of peripherally inserted central catheters (PICCs) now often extends into the intensive care unit. The goal of this review is to compare the use and safety of PICCs vs CVCs in burn patients. This institutional review board-approved cohort review included all burn patients at a single center who received one or more PICCs during a 2-year period. Primary outcome was number of days each line remained in place. Secondary outcomes were catheter-related bloodstream infection (CR-BSI) and thrombotic and technical complications. Thirty-one burn patients had 37 PICCs during the study period. Patients and controls were comparable in terms of age, TBSA burn injury, and ventilator days. The median length of time that each PICC remained in was 8.8 vs 9.3 days for CVCs (P = .77). The CR-BSI rate for PICCs was 0 per 1000 line days, whereas for CVCs, it was 6.6 per 1000 line days (P = .13). No thrombotic complications were attributed to CVCs; one PICC-associated right upper extremity deep vein thrombosis was identified (2.8% rate). No technical complications were identified in either group. The longevity and complications of PICCs in burn patients differs little from CVCs. CVCs may have a higher rate of CR-BSI in burn patients than PICCs. Although PICCs are not adequate for the fluid volumes typically required during burn shock resuscitation, they can provide a safe and effective alternative for central access in the ongoing care of the burn patient.

Enoxaparin and antifactor Xa levels in acute burn patients

Altered pharmacokinetics in critically ill patients have been shown to result in inadequate enoxaparin dosing for venous thromboembolism (VTE) prophylaxis. In the burn unit, routine monitoring of antifactor Xa levels was implemented to ensure adequate VTE prophylaxis. The purpose of this study was to examine the appropriateness of enoxaparin dosing for VTE prophylaxis in this specialized patient population. The authors reviewed patients with acute burn injury from June 1, 2009, to October 20, 2009, who had enoxaparin therapy monitored with antifactor Xa levels. Data collection occurred prospectively. Thirty-eight patients received enoxaparin subcutaneously for prophylaxis of VTE and had antifactor Xa levels measured. Thirty (79%) patients had initial antifactor Xa levels less than 0.2 U/ml. Enoxaparin dosages were subsequently increased as needed to achieve antifactor Xa levels of 0.2 to 0.4 U/ml. Eight of 38 patients never achieved goal antifactor Xa level before enoxaparin was discontinued. The median final dose required to achieve an antifactor Xa level within therapeutic range was 50 mg every 12 hours (range 30–70 mg). In linear regression, final enoxaparin dose correlated with TBSA. Two patients had clinically significant thromboembolic events. There were no documented episodes of significant hemorrhage, thrombocytopenia, or heparin-associated allergy. The low antifactor Xa levels observed in this study demonstrate that standard dosing of enoxaparin for VTE prophylaxis is inadequate for patients with acute burns. In these patients, both a higher initial enoxaparin dose and routine monitoring of antifactor Xa levels are recommended.

Colloid normalizes resuscitation ratio in pediatric burns.

Fluid resuscitation of burned children is challenging because of their small size and intolerance to over- or underresuscitation. Our American Burn Association-verified regional burn center has used colloid “rescue” as part of our pediatric resuscitation protocol. With Institutional Review Board approval, the authors reviewed children with ≥15% TBSA burns admitted from January 1, 2004, to May 1, 2009. Resuscitation was based on the Parkland formula, which was adjusted to maintain urine output. Patients requiring progressive increases in crystalloid were placed on a colloid protocol. Results were expressed as an hourly resuscitation ratio (I/O ratio) of fluid infusion (ml/kg/%TBSA/hr) to urine output (ml/kg/hr). We reviewed 53 patients; 29 completed resuscitation using crystalloid alone (lactated Ringers solution [LR]), and 24 received colloid supplementation albumin (ALB). Groups were comparable in age, gender, weight, and time from injury to admission. ALB patients had more inhalation injuries and larger total and full-thickness burns. LR patients maintained a median I/O of 0.17 (range, 0.08–0.31), whereas ALB patients demonstrated escalating ratios until the institution of albumin produced a precipitous return of I/O comparable with that of the LR group. Hospital stay was lower for LR patients than ALB patients (0.59 vs 1.06 days/%TBSA, P = .033). Twelve patients required extremity or torso escharotomy, but this did not differ between groups. There were no decompressive laparotomies. The median resuscitation volume for ALB group was greater than LR group (9.7 vs 6.2 ml/kg/%TBSA, P = .004). Measuring hourly I/O is a helpful means of evaluating fluid demands during burn shock resuscitation. The addition of colloid restores normal I/O in pediatric patients.

Synopsis of the 2013 annual report of the national burn repository.

Most burn centers maintain some record or registry of the patients they treat. These registries typically include information on the clinical characteristics of the patients and their injuries, the care and treatment they received, and the clinical outcome. These records document the burn center’s work and experience. They can be used to estimate the resources—supplies, personnel, space—required to provide care. They can be reviewed by the clinicians working there to discern imperfections in their systems of providing care and to identify opportunities to improve the structure, processes, and outcomes of those systems. They may also, in part, describe the characteristics of burn injury in the community served by the burn center. More than 40 years ago, burn clinicians envisioned the creation of a larger database of burn-injured patients. Such a database would be composed of data from several individual facility registries. It could provide a much broader view of burn injury and burn care in a larger geopolitical region than a single community. It could serve as the basis for burn research, burn prevention, public health, health planning, and advocacy at a regional, state, and even national level. This database then would benefit victims of burn injury, providers of burn care, state and national policy makers, and the public. Such a database was started at the University of Michigan in the early 1970s. It included a handful of burn centers. Over the years, that database was transferred to other entities, and in 2001, the American Burn Association (ABA) assumed responsibility for it, almost three decades after it was begun. By then, it had become national in scope and was known as the National Burn Repository (NBR). An NBR Committee was formed by the ABA, and it began preparing annual summaries of the database in 2006. These reports summarized cases treated by contributing centers during a 10-year period. They were made available not only to members of the ABA but also to the public. Two of these reports were summarized for publication in this Journal,1,2 the most recent of which was a summary of the 2007 annual report published in 2008. As the result of efforts of both the NBR Committee and the Burn Registry Committee of the ABA to improve the quality of the data in the NBR in the intervening years, the annual NBR report prepared in 2013 was based on data that were of a much higher quality than those that existed before. The purpose of this current article is to summarize and review highlights from that 2013 NBR Report.

Enoxaparin dose adjustment is associated with low incidence of venous thromboembolic events in acute burn patients

BACKGROUND Inadequate antifactor Xa levels have been documented in critically ill patients given prophylactic enoxaparin and may result in increased risk of venous thromboembolic (VTE) events. The objective of this study was to examine the impact of dose adjustment of enoxaparin and associated incidence of VTE in acute burn patients. METHODS All acute burn patients who were treated with prophylactic enoxaparin on a burn/trauma intensive care unit were prospectively followed. Patients with subtherapeutic antifactor Xa levels had enoxaparin doses increased as per unit protocol with the goal of obtaining a therapeutic antifactor Xa level. RESULTS Eighty-four acute burn patients who were treated with enoxaparin had at least one appropriately obtained antifactor Xa level between June 2009 and October 2010. Initial antifactor Xa levels in 64 patients (76.2%) were below 0.2 U/mL, resulting in increased enoxaparin dose. Fifteen patients never achieved the target antifactor Xa level before enoxaparin was discontinued. Median final enoxaparin dose required to achieve therapeutic antifactor Xa levels was 40 mg every 12 hours (range, 20-70 mg). Using linear regression, final enoxaparin dose correlated with burn size (%total body surface area) and weight. No episodes of hemorrhage, thrombocytopenia, or heparin sensitivity were documented. Two patients (2.4%) had VTE complications despite adequate prophylaxis. CONCLUSIONS Frequent occurrence of low antifactor Xa levels observed in this study demonstrated the inadequacy of standard dosing of enoxaparin for VTE prophylaxis in many patients with acute burns. Enoxaparin dose adjustment was associated with a low incidence of VTE events and no bleeding complications.

Use of dexmedetomidine for sedation in critically ill mechanically ventilated pediatric burn patients.

Dexmedetomidine has previously been used only for short-term, procedural sedation in children. The purpose of this review was to describe the dosing, safety, and efficacy of dexmedetomidine for sustained sedation in intubated pediatric burn patients. The authors reviewed acutely burned children treated between 2005 and 2008 who were intubated during their course of care and who received dexmedetomidine for sedation. Patients served as their own controls using the time periods when they received sedatives other than dexmedetomidine. Eleven patients with 17 dexmedetomidine treatment courses were identified. The median patient age was 7 years (range 1.6–17 years), and median burn size was 30.5% TBSA (range 6–59%). Patients were ventilated for a median of 9 days (range 4–46 days). The median initial dose of dexmedetomidine was 0.39 &mgr;g/kg/hr (range 0.10–1.16 &mgr;g/kg/hr), with a median infusion dose of 0.57 &mgr;g/kg/hr (range 0.11–1.17 &mgr;g/kg/hr) and median treatment duration of 40 hours (range 1–356 hours). None of the patients received dexmedetomidine loading dose. Patients achieved more appropriate Riker scores while treated with dexmedetomidine than while being treated with other sedatives (3.8 vs 3.3, P = .003). The incidence of hypotension and/or bradycardia while on dexmedetomidine was not greater than when it was not being used. Clinically significant rebound hypertension and tachycardia were absent on discontinuation of dexmedetomidine. No unplanned extubations were observed. Median length of hospital stay was 49 days (range 7–118 days). Dexmedetomidine seems to be safe and effective for sedation of pediatric burn patients on mechanical ventilation with close cardiovascular monitoring.

The evolution of resource utilization in regional burn centers.

Regional burn centers provide unique multidisciplinary care that has been associated with dramatically improved outcomes for burn victims. Patients with complex skin and soft tissue injuries are increasingly admitted to these centers for definitive care. This study was designed to assess current trends in burn center resource utilization. Members of the Multicenter Trials Group of American Burn Association were invited to participate in this retrospective review of all patients admitted to their respective regional burn centers during a 10-year period. Collected data included admission diagnosis, demographics, length of stay (LOS), hospital charges, and mortality. Five regional academic burn centers participated. They collectively admitted 18,246 patients during the study period, of whom 15,219 (83.4%) had a primary burn diagnosis and 3027 (16.6%) were patients with nonburn diagnoses. During this period, annual admissions for the five centers increased by 34.7%, ranging from 19 to 83% for individual centers. Simultaneously, mean burn size decreased from 12.3 to 8.8% TBSA. From 1998 to 2006, admissions for nonburn diagnoses increased by 244.9%, whereas burn admissions increased by 31.1%. Although mean LOS was reduced by >25%, total charges for all patients increased by 37.7% after adjustment for inflation. Nonburn patients had significantly higher mean age, longer LOS, greater mortality, and higher daily charges. This review of admissions to five academic burn centers reveals that these centers are treating more patients with smaller burns and an increasing number of complex nonburn conditions. Nonburn patients represent an older and more debilitated population that consumes disproportionately more resources than burn patients. These data show a dramatic shift in burn center resource utilization and the concurrent evolution of regional burn centers into centers for the care of complex wounds.

Enoxaparin and antifactor Xa levels in pediatric acute burn patients.

Previous work from the authors’ group showed a risk for inadequate enoxaparin dosing for venous thromboembolism prophylaxis in adult burn patients when traditional recommendations are used. The purpose of this study was to determine whether this also applied to pediatric burn patients. Included patients were acutely burned, aged 14 years or under, and admitted to the authors’ regional burn center between October 1, 2004 and December 15, 2012. Thirty-five patients included in this analysis received enoxaparin for venous thromboembolism prophylaxis dosed initially at 0.5 mg/kg and monitored with anti-factor Xa levels (anti-Xa) between 0.2 and 0.4U/ml. Of the included patients, 80% were male with a median age of 8 years, a median TBSA of 16%, and a median length of stay of 23 days. Initially 21 patients (60%) had an undetectable anti-Xa (<0.2 U/ml). Enoxaparin doses were increased but 18 patients (51%) never achieved target anti-Xa. There were no significant differences in sex, weight, dose, depth of injury, or body mass index between those who received appropriate prophylaxis and those who were undertreated. However, median size of burn was significantly larger, median age and height were significantly lower in those who did not reach target. The low number of patients achieving target prophylactic anti-Xa in this study demonstrates the need for routine anti-Xa monitoring in pediatric burns. Additionally, pediatric patients with major burn injury may require initial dosing of enoxaparin greater than published recommendations because of altered pharmacokinetics.