Manuel Gomez

An Outbreak Due to Multiresistant Acinetobacter baumannii in a Burn Unit: Risk Factors for Acquisition and Management

OBJECTIVES To describe the investigation and management of an outbreak due to multiresistant Acinetobacter baumannii and to determine risk factors for acquisition of the organism. SETTING A 14-bed regional burn unit in a Canadian tertiary-care teaching hospital. DESIGN Case-control study with multivariate analysis of potential risk factors using logistic regression analysis. Surveillance cultures were obtained from the hospital environment, from noninfected patients, and from healthcare providers. RESULTS A total of 31 (13%) of 247 patients with acute burn injuries acquired multiresistant A. baumannii between December 1998 and March 2000; 18 (58%) of the patients were infected. The organism was recovered from the hospital environment and the hands of healthcare providers. Significant risk factors for acquisition of multiresistant A. baumannii were receipt of blood products (odds ratio [OR], 10.8; 95% confidence interval [CI95], 3.4 to 34.4; P < .001); procedures performed in the hydrotherapy room (OR, 4.1; CI95, 1.3 to 13.1; P = .02); and increased duration of mechanical ventilation (OR, 1.1 per day; CI95, 1.0 to 1.1; P= .02). INTERVENTIONS Improved compliance with hand hygiene, strict patient isolation, meticulous environmental cleaning, and temporary closure of the unit to new admissions. CONCLUSIONS Acquisition of multiresistant A. baumannii was likely multifactorial, related to environmental contamination and contact with transiently colonized healthcare providers. Control measures addressing these potential sources of multiresistant A. baumannii were successful in terminating the outbreak. Ongoing surveillance and continued attention to hand hygiene and adequate environmental cleaning are essential to prevent recurrent outbreaks due to antibiotic-resistant bacteria in burn units.

The use of silver coated dressings on donor site wounds : a prospective, controlled matched pair study

Acticoat, a new silver-coated dressing, produces a moist healing environment along with the sustained release of ionic silver for improved microbial control. These properties suggest that Acticoat might be a useful donor site dressing. However, there are no human studies which assess Acticoat for this use. The purpose of this study was to compare the healing of human skin graft donor sites dressed with Acticoat, to the healing of those dressed with Allevyn, an occlusive moist-healing environment material, which is our standard donor site dressing. In burn patients who had undergone burn excision and grafting, identical side-by-side split thickness donor site wound pairs were dressed with Allevyn and Acticoat. Re-epithelialization was directly assessed daily by a single observer from post-operative day 6 onward, and by four independent observers who rated the extent of re-epithelialization by viewing standardized digital images of the wounds that had been obtained on post-operative days 6, 8, 10,and 12. Donor sites were swabbed for bacterial culture on days 3, 6, and 9. Subsequently, each study donor site scar was rated by a blinded observer using the Vancouver Scar Scale at 1, 2, and 3 months. Sixteen paired sites in 15 patients (3 female, 12 male) were studied. Donor sites dressed with Allevyn were >90% re-epithelialized at a mean of 9.1+/-1.6 days while donor sites dressed with Acticoat required a mean of 14.5+/-6.7 days to achieve >90% re-epithelialization (P=0.004). The Allevyn sites had significantly greater estimated re-epithelialization at days 6, 8, 10 and 12 than the Acticoat sites based on the observations of the digital images. There were no significant differences in the incidence of positive bacterial cultures with either dressing at days 3, 6, and 9. Donor sites dressed with Acticoat had significantly worse scars at 1 and 2 months but this difference resolved by 3 months. Our findings do not support the use of Acticoat as a skin graft donor site dressing.

Evaluation of predictive ability of APACHE II system and hospital outcome in Canadian intensive care unit patients.

OBJECTIVES To evaluate the ability of the acute Physiology and Chronic Health Evaluation II (APACHE II) scoring system to predict patient outcome in two Canadian intensive care units (ICUs). To compare the severity of illness and outcome of Canadian ICU patients with existing United States data. DESIGN Prospective data collection on 1,724 Canadian ICU patients for validation of the APACHE II system. Comparison of the outcome of Canadian ICU patients to retrospective United States data on 4,087 patients from the 1985 APACHE II multicenter study. SETTING Canadian data from two university teaching hospital ICUs. United States data from 13 ICUs, ten of which were in university teaching hospitals. PATIENTS Consecutive patients admitted to adult medical/surgical ICUs. Coronary care unit, neurosurgical and cardiac surgery patients were excluded. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS For each patient, demographic data, diagnosis, APACHE II score and hospital survival data were collected. The predicted risk of death was calculated for each patient using the APACHE II risk of death equation. The accuracy in outcome prediction of the APACHE II system was assessed by means of the receiver operating characteristic curve, 2 x 2 decision matrices and linear regression analysis. The severity of illness and hospital mortality for the Canadian patients was compared with that of United States patients from the 1985 APACHE II multicenter study. In 1,724 Canadian ICU patients, the mean +/- SEM APACHE II score was 16.5 +/- 0.2. The predicted death rate was 24.7% and the observed death rate was 24.8%. Using receiver operating curve analysis, good correlation was found between predicted outcome and observed outcome. The area under the curve was 0.86. From the 2 x 2 decision matrix constructed for a predicted risk of death of 0.5, 83% of patients were correctly classified. The sensitivity was 50.9% and the specificity was 93.6%. When observed death rate was plotted against predicted death rate, linear regression analysis gave an r2 of .99. Canadian patients had a higher death rate and APACHE II score than the United States patients. After controlling for severity of illness using the APACHE II score, the Canadian and United States death rates were similar. CONCLUSIONS The ability of the APACHE II system in predicting group outcome is validated in this Canadian ICU population by receiver operating characteristic curve, 2 x 2 decision matrices and linear regression analysis. The Canadian patients had a higher overall hospital death rate than the United States patients. After controlling for severity of illness using APACHE II scores, the hospital death rate was comparable between the Canadian and United States patients.

Intravenous immunoglobulin does not improve outcome in toxic epidermal necrolysis.

Intravenous Immunoglobulin (IVIG) has been proposed as a beneficial therapy for toxic epidermal necrolysis (TEN). However, this has been based on a limited amount of Class 5 evidence. To compare outcomes in TEN patients treated in our burn unit since 1999, when we began to use IVIG (IG group), with TEN patients treated between 1995 and 1999 who did not receive IVIG (control group). Retrospective cohort review of the records of all TEN patients admitted between April 5, 1995 and December 4, 2002. There were 16 patients in the IG group (age 53 +/- 21 years, with initial rash involving 65 +/- 29% TBSA) and 16 patients in the control group (age 52 +/- 20 years, with initial rash involving 65 +/- 27% TBSA). The IG group received 0.7 +/- 0.2 g/kg/day of IVIG for 4 +/- 1 days. There were no significant differences between the groups with respect to the length of stay, duration of mechanical ventilation, severity of systemic inflammatory response syndrome and multiple organ dysfunction syndrome, or the incidence of sepsis. Significant progression of the wound occurred in 13% of the IG patients and in 27% of control patients, whereas no wound progression was observed in 47% of the IG patients and in 18% of the control patients (P =.299). The time to healing did not differ between IG and control groups (11.2 +/- 3.6 vs 11.4 +/- 2.6 days, respectively). There was no significant difference in the mortality rate between the IG group (25%) and the control group (38%). There were no complications from IVIG aside from one case of hyponatremia from the hypotonic IVIG solution. Although there may have been a trend towards less severe wound progression in patients who received IVIG, this was not associated with any substantial improvement in outcome in our TEN patients. A prospective randomized study with a larger sample size is needed to confirm our findings.

How well does the Parkland formula estimate actual fluid resuscitation volumes

We had anecdotally observed that fluid resuscitation volumes often exceed those estimated by the Parkland Formula in adults with isolated cutaneous burns. The purpose of this study was to compare estimated and actual fluid resuscitation volumes using the Parkland Formula. We performed a retrospective study of fluid resuscitation in patients with burns > or = 15% TBSA. Patients with inhalation injury, high voltage electrical injury, delayed resuscitation, or associated trauma were excluded. We studied 31 patients (mean age 51 +/- 20 years, mean TBSA burn 27 +/- 10%). The 24 hour resuscitation volume of 13 354 +/- 7386 ml (6.7 +/- 2.8 ml/kg/%TBSA) was significantly greater than predicted (P = 0.001) and exceeded estimated volume in 84% of the patients. The mean urine output in the first 24 hrs was 1.2 +/- 0.6 ml/kg/hr. After the first 8 hours of resuscitation, the infusion rate decreased by 34% in 16 patients (DCR group), while in 15 patients the rate increased by 47% (INCR group). Both the DCR and INCR groups received significantly more fluid than predicted, (5.6 +/- 2.1 ml/kg/%TBSA and 7.7 +/- 3.1 ml/kg/%TBSA respectively). The INCR patients had significantly larger full thickness burns (14 +/- 11% vs 3 +/- 6%, P < 0.001). Our findings reveal that despite its effectiveness, the Parkland Formula underestimated the volume requirements in most adults with isolated cutaneous burns, and especially in those with large full thickness burns.

ARDS in patients with thermal injury

Objective: To determine the time to onset of the adult respiratory distress syndrome (ARDS) in patients with thermal injury requiring mechanical ventilation. Secondarily, to consider the burn-related risk factors, demographics, incidence, and mortality for ARDS in this population.¶Design: Retrospective chart review; ARDS defined according to the American-European Consensus Conference and the Lung Injury Severity Score definitions.¶Setting: Regional, tertiary referral, adult burn unit in a university teaching hospital.¶Patients and participants: Patients with thermal injury requiring mechanical ventilation, admitted between 1 January 1991 and 28 February 1995.¶Interventions: None.¶Measurements and results: Of 469 consecutive admissions, 126 (26.9 %) received intubation and mechanical ventilation. ARDS was defined according to the American-European Consensus and Lung Injury Severity Score (score > 2.5) definitions. The mean time to onset of ARDS from admission to the burn unit was 6.9 ± 5.2 and 8.2 ± 10.7 days when defined by the American-European Consensus and Lung Injury Severity Score definitions respectively (p = 0.41). Of the intubated patients, 53.6 and 45.2 % developed ARDS according to the American-European Consensus and Lung Injury Severity Score definitions, respectively (p = 0.19). Using multivariate logistic analysis, only age proved to be an independent risk factor for the development of ARDS (p = 0.03), although there was a trend toward an increased incidence of inhalation injury in patients with ARDS. Mortality was not significantly greater (41.8 vs 32.2 %) in those with ARDS compared to those without (p = 0.27).¶Conclusions: According to the American-European Consensus Conference and the Lung Injury Severity Score definitions, ARDS is common in the adult burn population and has a delayed onset compared to most critical care populations. We found age to be a major predisposing factor for ARDS.

National Burn Repository 2005: a ten-year review.

In the early 1990s, the American Burn Association (ABA) started its first burn registry development initiatives. The impetus for the registry development software originated from several directions, including the following: (1) the recognition that national registries were widespread and of proven benefit; (2) growing demands from accrediting institutions, payers, and patient advocacy groups for objective and verifiable data regarding patient costs, treatments, and outcomes; and (3) the shift toward “evidence-based” medicine and the ongoing analysis of treatment effectiveness. The ABA has issued three calls for burn registry data for its National Burn Repository (NBR): 1994, 2002, and 2005. In 1994, 28 burn centers contributed data for more than 6,400 patients treated from 1991 to 1993. The ABA announced its second call for data in 2001 and distributed the published results of more than 54,000 acute burn admissions treated from 1974 to 2002 at the Association’s 2002 Annual Meeting. The third ABA call for data was issued in the Fall of 2005. The results are detailed in this report, which provides a summary of more than a quarter million acute burn admissions from 1995 to 2005, representing 70 hospitals from 30 states plus the District of Columbia. Statistics are presented in chart and table format to illustrate such key factors as patient age, burn size group, types of injuries, mortality rates, and average hospital charges by etiology and length of hospital stay. The data presented herein should help stimulate quality improvement programs in burn care, as burn centers compare their performance with the national data and as research is expanded using the NBR. The NBR will be published annually and, with continued refinements to the registry software, should become of increasing importance to clinicians, payers, researchers, and the public.

National burn repository 2006: A ten-year review

This article presents findings from the National Burn Repository (NBR) 2006 Annual Report. Data reported herein cover a 10-year period from January 1, 1996, through June 30, 2006. This year’s report includes the first comparative presentations of data over time to show what appear to be trends in the dataset. The purpose of this report is to share information about the current state of care for burned patients in the United States. Some of the implications include epidemiology, burn-prevention efforts, research, education, acute care and quality improvement in burn programs, resource allocation, and reimbursement issues.

Minimizing blood loss in burn surgery

BACKGROUND Significant blood loss continues to plague early tangential excision of the burn wound. Although various techniques to reduce intraoperative blood loss have been described, there is an absence of uniformity and consistency in their application. Furthermore, it is unclear whether these techniques compromise intraoperative tissue assessment and wound outcome. The purpose of this study was to evaluate the effects of a comprehensive intraoperative blood conservation strategy on blood loss, transfusion requirements, and wound outcome in burn surgery. METHODS An intraoperative blood conservation strategy (CONSV) that included donor site and burn wound adrenaline tumescence, donor site and excised wound topical adrenaline, and limb tourniquets was prospectively evaluated and compared with a historical control group (HIST) where only topical adrenaline and thrombin were applied to donor sites and excised wounds. RESULTS Estimated blood loss was reduced from 211 +/- 166 mL per percentage body surface area excised and grafted in the HIST group to 123 +/- 106 mL in the CONSV group (p = 0.02). Similarly, the intraoperative transfusion requirement in the HIST group was reduced from 3.3 +/- 3.1 units per case to 0.1 +/- 0.3 units per case in the CONSV group (p < 0.001). There was no compromise in wound outcome in the CONSV group, which had a mean skin graft take rate of 96 +/- 4.2%. CONCLUSION The application of a strict and comprehensive intraoperative blood conservation strategy during burn excision and grafting resulted in a profound reduction in blood loss and transfusion requirements, without compromising wound outcome.

Evaluation of the Extent of Under-Reporting of Serious Adverse Drug Reactions The Case of Toxic Epidermal Necrolysis

AbstractIntroduction: Toxic epidermal necrolysis (TEN) is a life-threatening adverse drug reaction (ADR) that is primarily the result of drug exposure (incidence 0.4–1.3 per million person-years). Life-threatening ADRs such as TEN should be reported to ADR monitoring programmes, which collect reports for suspected ADRs and alert the public and medical practitioners to new drug hazards. In Canada, reports are made to the Canadian Adverse Drug Reaction Monitoring Program (CADRMP). Objective: To examine the extent of under-reporting for TEN in Canada. Design: A retrospective case series design was used to collect all TEN cases for the period January 1995 to December 2000. Methods: The CADRMP and 22 burn centres across Canada were contacted for all TEN patients treated during the specified time period. Patient Groups Studied: The study population consisted of patients admitted to burn treatment sites across Canada, patient cases reported to the CADRMP and patient cases recorded by the Canadian Institute for Health Information (CIHI) hospital discharge summaries as the International Classification of Diseases Version 9 Clinical Modification (ICD-9-CM) code 695.1. Results: Twenty-five TEN cases (six fatal) were reported to CADRMP from January 1995 to December 2000. During this period, 14 (63.6%) burn treatment sites reported admission of 250 TEN cases. Hospital discharge summaries using the ICD-9-CM code 695.1 indicated that 4349 cases were admitted to hospital during this time period and it was estimated that 15.5% (n = 674) of these cases were TEN. Using the burn facility data as the denominator, 10% (25 of 250) of TEN cases were reported to CADRMP. Using CIHI data as a denominator, only 4% (25 of 674) of TEN cases were reported to CADRMP. Conclusions: There is serious under-reporting of TEN. Lack of reporting of life-threatening ADRs can compromise population safety. There is a need to increase awareness of ADR reporting programmes.