Lucy Wibbenmeyer

Predicting survival in an elderly burn patient population

The purpose of this study was to analyze the outcome of elderly burn victims and to determine an instrument to predict survival in this population. Charts of three hundred and eight burn patients > or =60 yr of age who were admitted to a university-based hospital between the years of 1977-1996 were retrospectively analyzed. The mean age of the population was 71.5+/-8.6, with a male predominance (1.8 to 1, P < 0.001). The majority of the burns were secondary to flame injuries (210, 68.6%). The median body surface area (BSAB) was 13.0% with an in-hospital mortality rate of 30.2%. We demonstrated improved survival in patients aged 60-74 yr as compared to 1965-1971 national burn survival data. A similar trend could not be shown in the very old (> 75 yr of age). Only age and BSAB were related to death by multiple stepwise forward linear regression. The Baux score, which adds age and BSAB, was predictive of outcome in 87.0% of our population. In conclusion, this study reinforces the high mortality associated with burn injuries in the elderly and the superior ability of the Baux score (age + percent burn) in predicting outcome in this population.

Positive fungal cultures in burn patients: A multicenter review

Fungal infections are increasingly common in burn patients. We performed this study to determine the incidence and outcomes of fungal cultures in acutely burned patients. Members of the American Burn Association’s Multicenter Trials Group were asked to review patients admitted during 2002–2003 who developed one or more cultures positive for fungal organisms. Data on demographics, site(s), species and number of cultures, and presence of risk factors for fungal infections were collected. Patients were categorized as untreated (including prophylactic topical antifungals therapy), nonsystemic treatment (nonprophylactic topical antifungal therapy, surgery, removal of foreign bodies), or systemic treatment (enteral or parenteral therapy). Fifteen institutions reviewed 6918 patients, of whom 435 (6.3%) had positive fungal cultures. These patients had mean age of 33.2 ± 23.6 years, burn size of 34.8 ± 22.7%TBSA, and 38% had inhalation injuries. Organisms included Candida species (371 patients; 85%), yeast non-Candida (93 patients, 21%), Aspergillus (60 patients, 14%), other mold (39 patients, 9.0%), and others (6 patients, 1.4%). Systemically treated patients were older, had larger burns, more inhalation injuries, more risk factors, a higher incidence of multiple positive cultures, and significantly increased mortality (21.2%), compared with nonsystemic (mortality 5.0%) or untreated patients (mortality 7.8%). In multivariate analysis, increasing age and burn size, number of culture sites, and cultures positive for Aspergillus or other mold correlated with mortality. Positive fungal cultures occur frequently in patients with large burns. The low mortality for untreated patients suggests that appropriate clinical judgment was used in most treatment decisions. Nonetheless, indications for treatment of fungal isolates in burn patients remain unclear, and should be developed.

Prospective analysis of nosocomial infection rates, antibiotic use, and patterns of resistance in a burn population.

Despite significant advances in burn care, infection remains a major cause of morbidity and mortality in burn patients. We sought to determine accurate infection rates, risk factors for infection, and the percentage of infections caused by resistant organisms. In addition, we attempted to identify interventions to decrease the use of antimicrobial drugs. Data were collected prospectively from 157 burn patients admitted to the University of Iowa Carver College of Medicine burn treatment center from October 2001 to October 2002. A research assistant reviewed the medical record for each patient identified by burn surgeons as being infected to determine whether these episodes met the infection control criteria for nosocomial infections. The infection control assessment agreed with the surgeon′s assessment for 16.7% of the pneumonias, 70.0% of the burn wound infections, 57.1% of the urinary tract infections, and 70.0% of the bloodstream infections. By multiple logistic regression analysis, body surface area burned, comorbidities, and use of invasive devices were significantly related to acquisition of nosocomial infections as identified by both the burn surgeons and the infection control criteria. Staphylococcus aureus and Pseudomonas were the most common resistant organisms identified. In our population, surgeons could decrease antimicrobial use by using explicit criteria for identifying patients with hospital-acquired infections, limiting perioperative prophylaxis to patients at highest risk of infection, and decreasing the incidence of nosocomial infection with reduced use of devices and strict adherence to aseptic technique.

The prevalence of venous thromboembolism of the lower extremity among thermally injured patients determined by duplex sonography.

BACKGROUND Morbidity and mortality from venous thromboembolism (VTE) remains a significant problem for hospitalized patients. Despite the ample prospective literature defining the prevalence of VTE in hospitalized patient populations, the prevalence of VTE in the thermally injured population remains largely unknown. METHODS We prospectively studied 148 thermally injured patients with hospital stays of greater than 3 days with lower extremity duplex ultrasonograms obtained at admission and discharge. RESULTS Nine patients experienced VTE (6.08%). Eight of the nine deep venous thromboses were proximal. One of the two pulmonary embolisms was fatal. Treatment risk factors that were associated with VTE were the presence of a central venous line (p = 0.020) and transfusion of more than 4 units of packed red blood cells (p = 0.023). These treatment factors were significantly related to each other (p < 0.0001), to body surface area burned, and to intervention. CONCLUSION The prevalence of VTE in burn patients is similar to that of moderate- to high-risk general surgical patients for whom VTE prophylaxis is recommended. VTE prophylaxis of burn patients, especially those requiring central venous lines and more than 4 units of packed red blood cells, should be considered.

Spontaneous Extraperitoneal Hemorrhage with Hemodynamic Collapse in Patients Undergoing Anticoagulation: Management with Selective Arterial Embolization

The authors report their experience with management of unstable spontaneous extraperitoneal hemorrhage (SEH) with selective transcatheter embolization. Five consecutive patients underwent angiographic evaluation for SEH complicated by hemodynamic collapse while undergoing anticoagulation therapy. Bleeding occurred via one or two lumbar arteries in psoas hematomas. Two abdominal wall hematomas were supplied by the inferior epigastric artery, with additional supply via the deep circumflex iliac artery in one. Microcoil embolization successfully controlled extravasation in all patients, with stabilization of hemodynamic parameters. Four of the five patients survived the immediate postprocedural interval. Selective transcatheter embolization may be a viable life-saving option in SEH-associated hemodynamic collapse.

Our chemical burn experience: exposing the dangers of anhydrous ammonia.

Although chemical injuries account for only a small number of one burn units cases, the diversity, resulting complications, and sequelae of these burns pose special problems. We reviewed a 19-year period of the chemical burn experience of our burn unit. The population of patients with these types of burns consisted of young men (mean age: 29.8 years), the majority of whom were injured on the job. Unique to our series is the largest collection of injuries (30%) resulting from the common fertilizer anhydrous ammonia. Another population of concern, accounting for 14% of the injuries in our unit, is that of patients injured at home with routine household cleaners. Nearly one half of those patients injured at home incurred injuries that required grafting. The cornerstone of chemical burn prevention and treatment involves education regarding the caustic nature of chemicals, proper handling, adequate protection, and copious irrigation of the wound at the scene. From the analysis of our retrospective review, adequate education and treatment at the scene appear to be well implemented in the industrial and farming communities. The focus of our education efforts should be directed toward the public and emphasize the safe use of household chemicals. Finally our review illuminated the potential benefit of immediate excision and grafting for decreasing the length of stay, complications, and loss of productivity.

Long-term outcomes of patients with necrotizing fasciitis.

Context:Necrotizing fasciitis is an aggressive infection affecting the skin and soft tissue. It has a very high acute mortality. The long-term survival and cause of death of patients who survive an index hospitalization for necrotizing fasciitis are not known. Objective:To define the long-term survival of patients who survive an index admission for necrotizing fasciitis. We hypothesize that survivors will have a shorter life span than population controls. Design:Long-term follow-up of a registry of patients from 1989 to 2006 who survived a hospitalization for necrotizing fasciitis. Last date of follow-up was January 1, 2008. Settings:A university-based Burn and Trauma Center. Patients:A prospective registry of patients with necrotizing fasciitis has been collected from 1989 to 2006. This registry was linked to data from the Department of Health, Department of Motor Vehicles, and the University Hospital Medical Records Department in January 2008 to obtain follow-up and vital status data. Intervention:None. Main Outcome Measures:Date and cause of death were abstracted from death certificates. Date of last live follow-up was determined from the medical record and by the last drivers license renewal. The death rate of the cohort was standardized for age and sex against 2005 statewide mortality rates. Cause of death was collated into infectious and noninfectious and compared with the statewide causes of death. Statistical analysis included standardized mortality rates, Kaplan-Meier survival curves, and Aalens additive hazard model. Results:Three hundred forty-five patients of the 377 in the registry survived at least 30 days and were analyzed. Average age at presentation was 49 years (range, 1–86; median, 49). Patients were followed up an average of 3.3 years (range, 0.0–15.7; median, 2.4). Eighty-seven of these patients died (25%). Median survival was 10.0 years (95% confidence interval: 7.25–13.11). There was a trend toward higher mortality in women. Twelve of the 87 deaths were due to infectious causes. Using three different statistical analytic techniques, there was a statistically significant increase in the long-term death rate when compared with population-based controls. Infectious causes of death were statistically higher than controls as well. Conclusions:Patients who survive an episode of necrotizing fasciitis are at continued risk for premature death; many of these deaths were due to infectious causes such as pneumonia, cholecystitis, urinary tract infections, and sepsis. These patients should be counseled, followed, and immunized to minimize chances of death. Modification of other risk factors for death such as obesity, diabetes, smoking, and atherosclerotic disease should also be undertaken. The sex difference in long-term survival is intriguing and needs to be addressed in further studies.

Population-based assessment of burn injury in southern Iowa: identification of children and young-adult at-risk groups and behaviors.

Although nonfatal burn injuries vastly outnumber fatal injuries, their epidemiology is not well defined. We sought to determine the epidemiology of nonfatal burn injuries in a largely rural region of a midwestern state to target intervention efforts at populations and injury mechanisms at risk. Data were retrospectively collected on a population-based sample of medically treated burn injuries in 10 counties in southern Iowa from 1997 to 1999 using International Classification of Diseases, 9th Revision, Clinical Modification codes (ICD-9-CM, Ncode 940-949) to identify burn-related emergency room visits from computerized lists. A total of 1430 emergency room visits were identified, with 1382 records available for review. Injuries were grouped into etiology subcategories to better delineate common mechanisms and determine methods of prevention. Scald and hot-object contact and flame-related injuries were the leading causes of burn injury. Scald and contact injuries were subdivided into three major sets of scenarios, scald and contact injuries related to household food preparation and consumption, work-related scald and contact injuries. and injuries resulting from contact with nonfood and nonbeverage-related household objects. Children ages 0 to 4 had the highest population-based scald and hot-object contact injury rate of all age groups, with an average annual incidence rate of 35.9 per 10,000. Injuries in this age group were most commonly related to household objects (34.7%) followed by food preparation (25.3%). Children and young adults ages 5 to 24 were also the most likely to be injured by flame and fire-related causes secondary to open fires. Nonfatal burn injuries typically afflict children and young adults in definable patterns, suggesting intervention strategies. Future studies need to better delineate the contributing factors associated with these injuries to refine the intervention strategies.

Risk Factors for Acquiring Vancomycin-Resistant Enterococcus and Methicillin-Resistant Staphylococcus aureus on a Burn Surgery Step-Down Unit

The incidence of hospital-associated infections secondary to methicillin-resistant Staphylococcus aureus (MRSA) and those caused by vancomycin-resistant enterococci (VRE) continue to increase, despite the publication of evidence-based guidelines on infection control. We sought to determine modifiable risks factors for acquisition of MRSA or VRE or both on a burn trauma unit (BTU). We performed a retrospective single-center–matched control study. Our study group comprised 94 patients who acquired MRSA or VRE or both while on the BTU from January 1, 2001 to December 31, 2005. The case-patients were matched 1:1 to control-patients based on the time the cases were exposed to the BTU before they became colonized or infected. Logistic regression was used to analyze the relationship of demographic, procedure, and antimicrobial exposure variables to acquisition of MRSA or VRE. Acquisition of MRSA or VRE was related to patient factors, antimicrobial exposure, and device use. Younger age and prior vancomycin treatment while on the BTU were independently associated with MRSA acquisition. The presence of a Foley catheter was related to VRE acquisition. Sixteen study patients (17.0%) who became colonized on the BTU subsequently acquired 17 infections: six patients had MRSA bloodstream infections, nine had MRSA burn wound infections, and two had VRE urinary tract infections. Younger age, exposure to vancomycin, or Foley catheters were associated with increased risk of acquiring MRSA or VRE. Protocols or algorithms that help physicians remember to assess the necessity of antimicrobial agents and devices may help limit the duration of exposure to these risk factors, which may enhance infection prevention efforts. Future studies need to explore the effect of these variables on cross-transmission and their impact predominately in a burn unit.

Illicit drug exposure in patients evaluated for alleged child abuse and neglect.

Background: Substantiation of drug exposure in cases with alleged maltreatment is important to provide proper treatment and services to these children and their families. A study performed at University of Iowa Hospitals and Clinics showed that 30% of pediatric patients with burn injuries, which were due to child maltreatment, were also exposed to illicit drugs. Objective: The children presenting to the University of Iowa Hospitals and Clinics with alleged maltreatment have been tested for illicit substances since 2004. The objective of this study was to analyze the presence of illicit drug exposure in the pediatric subpopulation admitted to pediatric inpatient and outpatient units for an evaluation for abuse/neglect. Design and Methods: The study design is a retrospective chart review. Using hospital databases, every pediatric chart with a child abuse/neglect allegation was retrieved. The association between risk factors and clinical presentation and illicit drug test result was assessed. Excel and SAS were used for statistical analysis. Institutional review board approval was obtained to conduct this study. Results: Six hundred sixty-five charts met study inclusion criteria for child abuse/neglect allegation. Of those, 232 cases were tested for illicit drugs between 2004 and 2008 per the testing protocol. Thirty-four cases (14.7%) tested positive on a drug test. Positive test rates based on clinical presentation were 28.6% (18/63) in neglect cases, 16.1% (5/31) in cases with soft tissue injuries, 14.3% (4/28) in burn injuries, 10.0% (2/20) in cases with sexual abuse, 7.1% (2/28) in cases with fractures, and 4.8% (3/62) in abusive head trauma cases. There were long-term abuse findings in 129 children (55.6%). Logistic regression analysis revealed that positive drug testing was most significantly associated with clinical symptoms suggesting physical abuse or neglect versus sexual abuse (odds ratio [OR] = 6.70; 95% confidence interval [CI], 1.26-35.49; P = 0.026), no or public health insurance versus those with private insurance (OR = 4.49; 95% CI, 1.47-13.66; P = 0.008), history of parental drug abuse versus those without parental history of drug abuse (OR = 3.42; 95% CI, 1.38-8.46; P = 0.008), and history of domestic violence versus those without a history of domestic violence (OR = 2.81; 95% CI, 1.08-7.30; P = 0.034). Conclusions: The results of this study showed that an illicit drug screening protocol used in the assessment of children evaluated for child abuse identified almost 15% of the population of allegedly abused and neglected children who were tested according to a protocol being exposed to illicit drugs. Thus, routine drug testing of at least children assessed for neglect and nonaccidental burn and soft tissue injuries, children with a history of either parental drug use or domestic violence is recommended.