Marion H. Jordan

Epidemiology of bloodstream infections in burn-injured patients: a review of the National Burn Repository.

Bloodstream infections (BSIs) are a major cause of morbidity and mortality in thermally injured patients. However, these infections have not been well defined in this patient population. Therefore, the authors performed a retrospective case-control study to characterize the epidemiology, microbiology, and outcomes of burn-associated BSIs. A retrospective review of all patients in the National Burn Repository (NBR) between the years 1981 and 2007 was performed. All cases that had infection listed under complications were included in this study. For each case, two randomly selected patients from the same time period served as controls. Patient demographic data, extent of %TBSA, and type of infection were extracted. Primary end point was mortality. Secondary endpoints were hospital length of stay (LOS), intensive care unit LOS, total ventilator days, and hospital charges. Further analysis of the data involved case-matching patients by TBSA deciles, adjustment for the effects of TBSA and other potential confounders, and a sensitivity analysis of the effects of including or excluding sites that might have failed to consistently capture BSI information. A total of 11,793 patients (3931 cases and 7862 control) were included in the study. Of cultures revealing a Gram-positive organism, Staphylococcus aureus (32%) was the most common. From samples where isolation of a Gram-negative species occurred, Pseudomonas aeruginosa (35%) was more prominent. Infected patients were older (40.9 vs 32.8, P < .05) and had higher %TBSA (22.2 vs 7.9, P < .05). BSI was associated with significantly higher mortality (21.9% vs 3.09%), hospital LOS (47.4 vs 8.8 days) intensive care unit LOS (30.8 vs 2.6 days), ventilator days (29.2 vs 1.4 days), and hospital charge (

Hospital length of stay--does 1% TBSA really equal 1 day?

339,909.91 vs

The results of a national survey regarding nutritional care of obese burn patients.

33,272.43); P < .001 for all values. On evaluation of case-matched controls, mortality was higher for patients with BSI only <50% TBSA strata. Conclusions were unaffected by adjustment for TBSA and other possible confounders and was not influenced by possible failure of some sites to consistently capture BSI information. Development of BSI in hospitalized burn patients is associated with significant increases in morbidity, mortality, and resource utilization.

Early serum (1→3)-β-D-glucan levels in patients with burn injury.

Length of stay (LOS) continues to be a standard variable when evaluating progress and outcomes in burn care. Common wisdom would dictate that this measure is linearly related to TBSA. Is this truly the case? A retrospective review of the National Burn Repository was conducted to evaluate factors that affect hospital LOS. The National Burn Repository data set was obtained from the American Burn Association. Data from the years 2002–2007 were extracted. Unique patients were identified by removing readmissions, outpatients, and patients not admitted. Patients whose “HOSPLOS” and/or “AREATOT” field was blank or 0 were excluded, as were nonthermally injured patients. Patients without an entry for age and dead patients were also excluded. This left a final data set of 52,712 patients for analysis. The data were then analyzed, with %TBSA burned as the independent variable. In patients who survived their entire LOS, the mean LOS increased linearly by decile. Females with a TBSA <40% have a trend toward increased LOS relative to their male counterparts of the same TBSA; however, this trend reverses for TBSA ≥40%. Age alone is not a significant predictor of increasing LOS. The cause of burns was predominantly flame related across all deciles of TBSA, and most etiologies for burn demonstrate the predicted increase in LOS per %TBSA. LOS was not significantly affected by insurance type or whether the injury was work related or not. This analysis was confounded by the small numbers of patients with burns >60% and age older than 70 years. Anticipating hospital LOS is not a simple task. Using complex statistical analysis, a linear trend associated with %TBSA can be seen; however, other variables do contribute. Until the precise role of these variables can be elucidated, anticipating patient LOS to be 1 day for every %TBSA is still a useful exercise.

Assessment of the Pathophysiology of Injured Tissue With an In Vivo Electrical Injury Model

Little is known about the nutritional needs of obese burn patients. Given the impact of obesity on the morbidity and mortality of these patients, a uniform understanding of perceptions and practices is needed. To elucidate current practices of clinicians working with the obese burn population, the authors constructed a multidisciplinary survey designed to collect this information from practitioners in United States burn centers. An electronic approach was implemented to allow for ease of distribution and completion. A portable document format (pdf) letter was e-mailed to the members of the American Burn Association and then mailed separately to additional registered dietitians identified as working in burn centers. This letter contained a link to a 29-question survey on the SurveyMonkey.com server. Questions took the form of multiple choice and free text entry. Responses were received from physicians, mid-level practitioners, registered dietitians, and nurses. Seventy-five percent of respondents defined obesity as body mass index >30. The Harris-Benedict equation was identified as the most frequently used equation to calculate the caloric needs of burn patients (32%). Fifty-eight percent indicated that they alter their calculations for the obese patient by using adjusted body weight. Calculations for estimated protein needs varied among centers. The majority did not use hypocaloric formulas for obese patients (79%). Enteral nutrition was initiated within the first 24 hours for both obese and nonobese patients at most centers. Sixty-three percent suspend enteral nutrition during operative procedures for all patients. Oral feeding of obese patients was the most preferred route, with total parenteral nutrition being the least preferred. Longer length of stay, poor wound healing, poor graft take, and prolonged intubation were outcomes perceived to occur more in the obese burn population. In the absence of supporting research, clinicians are making adjustments to the nutritional care of obese burn patients. This indicates the need for further research to determine consistent best practices.

The 2003 Carl A Moyer Award: real-time metabolic monitors, ischemia-reperfusion, titration endpoints, and ultraprecise burn resuscitation.

Serum (1→3)‐β‐D‐glucan (BG) is increasingly used as diagnostic marker for invasive fungal infections. Exposure to gauze may lead to false‐positive BG assays. The role of BG is unclear in thermally injured patients who frequently require extensive gauze coverage; therefore, we prospectively evaluated BG levels in burn‐injured patients. Serum BG levels were measured in 18 burn patients immediately before application of the first dressing and 12 h after. Patients were stratified by extent of total body surface area (TBSA) requiring gauze coverage: <20%, 20–39%, 40–60% and >60%. BG levels were obtained from patients with non‐burn trauma as controls. BG results were positive (>80 pg ml−1) in 9/18 (50%) patients at baseline and in 8/18 (44%) 12 h after application of the first dressing. BG levels were positive in 1/5 (20%) of patients with <20% TBSA requiring gauze and in 10/13 (77%) with ≥20% (P < 0.05). None of the control patients had positive BG at any time point and none of the patients had candidemia at baseline. Mean serum BG levels decreased (19.44 pg ml−1) after gauze placement. False‐positive serum BG elevations are common in this patient population. Positivity correlates with extent of TBSA injured, but is not impacted by the gauze itself.

Incidence of methemoglobinemia in patients receiving cerium nitrate and silver sulfadiazine for the treatment of burn wounds : A burn center's experience

Tissue destruction from electrical injury is devastating and hard to treat. Unfortunately, the pathophysiology of electrical trauma is still not well understood. We have developed a suite of tools aimed at investigating damage due to high voltage shock on the skin using a rat model. Electrical injuries were created with a custom made high-tension shock system and a spectroscopic system, based on spatial frequency domain imaging, was used to determine optical properties of electrically injured tissues. The extrapolated values of absorption and scattering coefficients at six different wavelengths were then utilized to monitor parameters of interest such as tissue oxygen saturation, methemoglobin volume fraction, and hemoglobin volume fraction at four time intervals post injury. An FLIR thermal camera was used to record skin temperature during the electrical shock. Finally, a laser Doppler imaging apparatus was used to assess tissue perfusion. In this paper, the results of experiments conducted on a rat model and discussions on the systemic changes in tissue optical properties before and after electrical shock are presented. A reduction in tissue oxygen saturation postinjury is observed as well as an increase in methemoglobin. Tissue perfusion increases immediately after the delivery of the electrical shock.