Karel D. Capek

Reversal of Growth Arrest with the Combined Administration of Oxandrolone and Propranolol in Severely Burned Children

Background: The hypercatabolic response in severely burned pediatric patients is associated with increased production of catecholamines and corticosteroids, decreased formation of testosterone, and reduced strength alongside growth arrest for up to 2 years after injury. We have previously shown that, in the pediatric burned population, the administration of the testosterone analog oxandrolone improves lean body mass accretion and bone mineral content and that the administration of the &bgr;1-, &bgr;2-adrenoceptor antagonist propranolol decreases cardiac work and resting energy expenditure while increasing peripheral lean mass. Here, we determined whether the combined administration of oxandrolone and propranolol has added benefit. Methods: In this prospective, randomized study of 612 burned children [52% ± 1% of total body surface area burned, ages 0.5–14 years (boys); ages 0.5–12 years (girls)], we compared controls to the individual administration of these drugs, and the combined administration of oxandrolone and propranolol at the same doses, for 1 year after burn. Data were recorded at discharge, 6 months, and 1 and 2 years after injury. Results: Combined use of oxandrolone and propranolol shortened the period of growth arrest by 84 days (P = 0.0125 vs control) and increased growth rate by 1.7 cm/yr (P = 0.0024 vs control). Conclusions: Combined administration of oxandrolone and propranolol attenuates burn-induced growth arrest in pediatric burn patients. The present study is registered at clinicaltrials.gov: NCT00675714 and NCT00239668.

Management of Contractural Deformities Involving the Shoulder (Axilla), Elbow, Hip, and Knee Joints in Burned Patients

Release of scar contracture across joints restores function and allows the burned patient to recover more completely. This chapter discusses the etiology and treatment of burn scar contractures restricting movement of major joints. The reader will find a concise discussion of the random fasciocutaneous local rotation/interposition flap. In the vast majority of functionally significant burn scar contractures, this operation affords the most efficient and effective means of providing living autologous tissue to the area of tissue deficit wherein arises the burn scar contracture. The interposition of an intact “integumentary functional unit” comprising epidermal, dermal, adipose, and fascial tissues with native nervous, vascular, and lymphatic connections allows this flap to release the intrinsic tissue tension driving scar hypertrophy and contraction. Accumulating cellular evidence indicates that this mechanically transduced signal may lead to myofibroblast apoptosis and more rapid resolution of scar hypertrophy.

Etiology and Prevention of Multisystem Organ Failure

Abstract Anticipation, identification, and treatment of organ failure syndromes is the work of the critical care physician and is necessary for intensive care unit survival. This chapter describes organ failure syndromes during burn convalescence.

Burn Injuries of the Eye

This chapter discusses eye pathology frequently seen in the burn unit. It begins with a discussion of the relevant anatomy and histology. Eye examination in the burn unit is described, along with tips particularly applicable to critically-ill patients in the intensive care unit. The spectrum commonly-observed ocular surface disease with associated histopathological findings is described along with the predictive value of early findings such as eyelid burns and singed eyelashes. Salient features of special cases, such as electrical injury and toxic epidermal necrolysis are covered. The diagnosis and treatment of bacterial, viral and fungal corneal ulcers is discussed. Several acute and reconstructive surgical techniques that the burn surgeon may find useful for sight preservation are also described.

The P50 Research Center in Perioperative Sciences: How the investment by the National Institute of General Medical Sciences in team science has reduced postburn mortality

ABSTRACT Since the inception of the P50 Research Center in Injury and Peri-operative Sciences (RCIPS) funding mechanism, the National Institute of General Medical Sciences has supported a team approach to science. Many advances in critical care, particularly burns, have been driven by RCIPS teams. In fact, burns that were fatal in the early 1970s, prior to the inception of the P50 RCIPS program, are now routinely survived as a result of the P50-funded research. The advances in clinical care that led to the reduction in postburn death were made by optimizing resuscitation, incorporating early excision and grafting, bolstering acute care including support for inhalation injury, modulating the hypermetabolic response, augmenting the immune response, incorporating aerobic exercise, and developing antiscarring strategies. The work of the Burn RCIPS programs advanced our understanding of the pathophysiologic response to burn injury. As a result, the effects of a large burn on all organ systems have been studied, leading to the discovery of persistent dysfunction, elucidation of the underlying molecular mechanisms, and identification of potential therapeutic targets. Survival and subsequent patient satisfaction with quality of life have increased. In this review article, we describe the contributions of the Galveston P50 RCIPS that have changed postburn care and have considerably reduced postburn mortality.

Co-administration of vancomycin and piperacillin-tazobactam is associated with increased renal dysfunction in adult and pediatric burn patients

BackgroundBurn patients are prone to infections which often necessitate broad antibiotic coverage. Vancomycin is a common antibiotic after burn injury and is administered alone (V), or in combination with imipenem-cilastin (V/IC) or piperacillin-tazobactam (V/PT). Sparse reports indicate that the combination V/PT is associated with increased renal dysfunction. The purpose of this study was to evaluate the short-term impact of the three antibiotic administration types on renal dysfunction.MethodsAll pediatric and adult patients admitted to our centers between 2004 and 2016 with a burn injury were included in this retrospective review if they met the criteria of exposition to either V, V/IC, or V/PT for at least 48 h, had normal baseline creatinine, and no pre-existing renal dysfunction. Creatinine was monitored for 7 days after initial exposure; the absolute and relative increase was calculated, and patient renal outcomes were classified according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria depending on creatinine increases and estimated creatinine clearance. Secondary endpoints (demographic and clinical data, incidences of septicemia, and renal replacement therapy) were analyzed. Antibiotic doses were modeled in logistic and linear multivariable regression models to predict categorical KDIGO events and relative creatinine increase.ResultsOut of 1449 patients who were screened, 718 met the inclusion criteria, 246 were adults, and 472 were children. Between the study cohorts V, V/IC, and V/PT, patient characteristics at admission were comparable. V/PT administration was associated with a statistically higher serum creatinine, and lower creatinine clearance compared to patients receiving V alone or V/IC in adults and children after burn injury. The incidence of KDIGO stages 1, 2, and 3 was higher after V/PT treatment. In children, the incidence of KDIGO stage 3 following administration of V/PT was greater than after V/IC. In adults, the incidence of renal replacement therapy was higher after V/PT compared with V or V/IC. Multivariate modeling demonstrated that V/PT is an independent predictor of renal dysfunction.ConclusionCo-administration of vancomycin and piperacillin-tazobactam is associated with increased renal dysfunction in pediatric and adult burn patients when compared to vancomycin alone or vancomycin plus imipenem-cilastin. The mechanism of this increased nephrotoxicity remains elusive and warrants further scientific evaluation.

53 – Management of Contractural Deformities Involving the Shoulder (Axilla), Elbow, Hip, and Knee Joints in Burned Patients

Release of scar contracture across joints restores function and allows the burned patient to recover more completely. This chapter discusses the etiology and treatment of burn scar contractures restricting movement of major joints. The reader will find a concise discussion of the random fasciocutaneous local rotation/interposition flap. In the vast majority of functionally significant burn scar contractures, this operation affords the most efficient and effective means of providing living autologous tissue to the area of tissue deficit wherein arises the burn scar contracture. The interposition of an intact “integumentary functional unit” comprising epidermal, dermal, adipose, and fascial tissues with native nervous, vascular, and lymphatic connections allows this flap to release the intrinsic tissue tension driving scar hypertrophy and contraction. Accumulating cellular evidence indicates that this mechanically transduced signal may lead to myofibroblast apoptosis and more rapid resolution of scar hypertrophy.

Significance of the Hormonal, Adrenal, and Sympathetic Responses to Burn Injury

Abstract Under cognitive stress, hormone and neurotransmitter release is conventionally thought to serve in a compensatory manner facilitating the heightened mental awareness along with metabolic and cardiovascular activity that supports rapid increases in muscular work. Thermal injury unquestionably initiates a stress response, with a magnitude proportional to the severity of the injury. However, there are important characteristics of the injury response that contrast with the fight-or-flight response. These include prolonged hormone/neurotransmitter elevation, the absence of increased muscle work limiting metabolic demand, and the presence of massive tissue injury. The second surge of stress hormones is evoked by surgical debridement and complicates the severe metabolic derangements and compromised immune capacity characteristic of the burn course during the initial 7–10 days following injury. In this chapter we present the adrenomedullary-neurotransmitter activation and actions as separate from the adrenocortical activation and actions to clarify specific responses as we currently understand them.

Hematology, Hemostasis, Thromboprophylaxis, and Transfusion Medicine in Burn Patients

Abstract Severely burned patients suffer significant hematologic pathologies. Anemia develops from burn excisions and the anemia of critical illness. Fluid shifts, resuscitation, and factor consumption can cause significant coagulopathy. Transfusion of red blood cells to treat anemia, plasma to treat coagulopathy, and other blood products are critical to burn management. Critical illness, injury, immobilization, and other factors create a hypercoagulable state requiring venothromboembolic prophylaxis. Hematopoietic changes reduce red blood cell generation as well as affecting downstream immunologic function. Facile management of these hematologic pathologies is essential to the medical and surgical management of burn patients.

Acute and Reconstructive Care of the Burned Hand

Abstract Hands are commonly injured in burned patients. Optimal outcome is predicated on prompt and comprehensive action in diagnosing the depth of the burn, decompressing compartment syndromes, early and aggressive therapy, early excision and grafting, and coordinated secondary reconstructions. Rapid closure of hand burns is associated with better functional outcomes. Hand therapy is central to outcome and sufficient staff is central to care. When contractures occur, aggressive reconstruction can improve function. The most common debilitating pathology is insufficient skin coverage to allow proper range of motion. Surgical release results in a defect that can be covered with grafts or flaps. Electrical injuries commonly affect the hands. Total care of the burned hand is predicated on aggressive management and takes years to reach maximal medical benefit. Patients should be offered the full range of acute and reconstructive options in a comprehensive burn center environment.