Patrick Mahar

A systematic review of the management and outcome of toxic epidermal necrolysis treated in burns centres

INTRODUCTION Toxic epidermal necrolysis (TEN) is a rare condition characterised by mucocutaneous exfoliation of greater than 30% total body surface area (%TBSA), increasingly being treated in burns centres. The rate of mortality varies significantly in the literature, with recent prospective studies in non-burns centres reporting percentage mortality of approximately 45%. We undertook a systematic review of published studies that included TEN patients treated specifically in burns centres to determine a cumulative mortality rate. METHODS Electronic searches of MEDLINE, EMBASE and The Cochrane Library (Issue 4, 2010) databases from 1966 onwards were used to identify English articles related to the treatment of TEN in burns centres. RESULTS The systematic literature search identified 20 studies which specifically described patients with TEN grater than 30% %TBSA. Treatment regimens varied amongst studies, as did mortality. The overall percentage mortality of the combined populations was 30%. Risk factors commonly described as associated with mortality included age, %TBSA and delay to definitive treatment. CONCLUSION The review highlights the variation between principles of treatment and mortality amongst burns centres. It offers a standard that burns centre can use to internationally compare their mortality rates. The review supports the ongoing reporting of outcomes in TEN patients with epidermal detachment greater than 30%.

Clinical factors affecting mortality in elderly burn patients admitted to a burns service

INTRODUCTION The purpose of this retrospective study was to provide basic probabilistic predictors of mortality to assist in determining appropriate therapeutic aggression in elderly burns population. METHOD Eighty patients over the age of 70 years were admitted to the Victorian Adult Burns Service in Melbourne, Australia, over a period of 4 years. Retrospective data was analysed, taking into account patient demographics, type, site, depth and area of burn, presence of inhalation injury, number of co-morbidities, survival time and the number of operations performed, withdrawal of care and implementation of comfort measures only. RESULTS Comparing survivors and non-survivors, significant differences were found between age, percentage total burn surface area (TBSA%), percentage full thickness surface area (FTSA%), presence of inhalation injury, site of burn and number of operations. The number of co-morbidities and gender were not significant to outcome. FTSA%, presence of inhalation injury, site of burn, age and number of operations were all significantly related to survival time. When patients who obtained comfort care were excluded from analysis, age and the number of operations were not considered to be significantly related to mortality. CONCLUSION This study indicates that TBSA%, FTSA%, inhalation injury and age are significant predictors of death in the elderly burns population, although only the first three remain significant when patients who receive comfort care measures only are excluded.

Pseudomonas aeruginosa bacteraemia in burns patients: Risk factors and outcomes

INTRODUCTION We aimed to identify the risk factors for, and outcomes of Pseudomonas aeruginosa bacteraemia in adult burns patients. METHOD All adult burns patients who developed a Gram-negative bacteraemia over a period of 7 years were included. Retrospective data analysed included patient demographics, organisms cultured, antibiotic susceptibility patterns, isolation of P. aeruginosa in non-blood isolates, treatment, length of stay and mortality. RESULTS Forty-three patients developed a Gram-negative bacteraemia over the study period, 12 of whom had Pseudomonas bacteraemia during the course of their admission. In eight patients (18.6%) P. aeruginosa was the first Gram-negative isolated. The only factor predicting P. aeruginosa bacteraemia as a first episode (compared to another Gram-negative) was prior isolation of Pseudomonas at other sites (wound sites, urine or sputum). Overall length of stay was less in patients who developed P. aeruginosa as a first episode, mainly because of increased mortality in this group. Prior non-blood isolates of P. aeruginosa could have correctly predicted the sensitivity pattern of the strain of P. aeruginosa organism in 75% of patients who did not receive appropriate initial antibiotics. CONCLUSION Prior colonisation with P. aeruginosa predicts P. aeruginosa in blood cultures, as opposed to other Gram-negative bacteria. Clinicians should have a high index of suspicion for P. aeruginosa bacteraemia where a septic burns patient has a prior history of non-blood P. aeruginosa cultures. Empirical antibiotic regimes based on the antibiotic-sensitivity patterns of previous non-blood P. aeruginosa isolates in each patient should be given at the time blood cultures are taken.

Predictors of health status and health-related quality of life 12 months after severe burn

INTRODUCTION Sustaining a moderate to severe burn injury is associated with the potential for substantial impairments to long-term physical and psychosocial health, including health related quality of life (HRQoL). The objective of this study was to identify clinical and patient characteristics which predict HRQoL 12-months after injury. METHODS A total of 125 patients were recruited over the study period, although only 99 were included in the final analysis representing all those who completed both the pre-burn and 12-months after burn injury Short Form 36 Medical Outcomes Survey (SF-36v2). These patients also completed the Burn Specific Health Scale-Brief (BSHS-B). Patient demographics and burn injury characteristics and treatment factors were collected to identify which factors predict 12-month health status outcomes. Multiple linear regression analyses were conducted to identify important predictors of outcomes. The SF36v2 models were adjusted for pre-injury measurements. RESULTS Older age (regression coefficient -0.26, 95% confidence interval (95% CI) -0.38, -0.13), female gender (-8.08, 95% CI -12.8, -3.34) and increased percentage of full-thickness burns per body surface area (-0.51; 95% CI -0.88, -0.13) were important predictors of poorer physical health status at 12 months. Older age (-0.15, 95% CI -0.26, -0.04) and increased percentage of full-thickness burns per body surface area (-0.36, 95% CI -0.69, -0.03) were important predictors of poorer mental health status at 12 months. Older age (-0.38; 95%CI -0.66, -0.11) and female gender (-12.17; 95% CI -22.76, -1.57) were important predictors of poorer BSHS-B total score at 12 months after injury. CONCLUSIONS Given the complexity of burn care rehabilitation, physical and psychosocial screening and assessment within the first weeks after a burn injury along with adequate monitoring after discharge should be undertaken in burn injured patients. In this context, patients of specific demographics, such as female patients and older patients, and patients with a higher percentage of full thickness surface area burns are of greater risk for poorer physical and psychological outcomes and may benefit from additional monitoring and rehabilitation.

Frequency and use of pain assessment tools implemented in randomized controlled trials in the adult burns population: A systematic review

INTRODUCTION Pain continues to be an ongoing issue of concern in adult burn patients. Inadequate pain assessment hinders meaningful research, and prevents the optimal management of burn pain. The objective of this study was to examine the content of existing research in burn pain with the frequency and context of pain assessment tool use in randomized clinical trials in order to further inform their use for future researchers and clinicians. METHODS Electronic searches of MEDLINE, CINAHL, EMBASE and The Cochrane Library databases from 1966 onwards were used to identify English articles related to clinical trials utilising pain assessment in adult burns patients. RESULTS The systematic literature search identified 25 randomized clinical trials utilising pain assessment tools. Unidimensional pain assessment tools were most frequently used pain assessment tools, with multidimensional tools used less often, despite the multifaceted and complex nature of burn pain. CONCLUSION The review highlights the lack of consistency of pain assessment tool use in randomized clinical trials with respect to managing burn pain. We recommend a broader but consistent use of multidimensional pain assessment tools for researchers undertaking clinical trials in this field. The review supports the need for an international expert consensus to identify the necessary critical outcomes and domains for clinicians and researchers undertaking further research into burn pain.

Pulmonary embolism and the use of vena cava filters after major trauma

Major trauma patients are at significant risk of developing pulmonary embolism (PE). We aimed to (i) analyse the current incidence and timing of PE after injury; (ii) identify risk factors that predispose major trauma patients to the occurrence of PE; and (iii) describe the use of vena cava filters (VCFs) following major trauma.

Secondary bacterial infection and empirical antibiotic use in toxic epidermal necrolysis patients

The objective of this study was to determine rates of positive bacterial cultures in patients with extensive toxic epidermal necrolysis, the rate of bacteremia, whether empirical antibiotics had been commenced, and their effectiveness when commenced. The authors conducted a retrospective chart review of patients with extensive toxic epidermal necrolysis between January 2001 and December 2012 admitted to the Victorian Adult Burns Service, Melbourne, Australia, with respect to the amount of positive cultures, number and type of organisms identified, whether empirical antibiotics had been commenced, and whether antibiotics were effective against organisms cultured. A total of 27 patients were admitted over the study period of 11 years. Seventeen of these patients developed at least one positive bacterial culture. Patients who grew positive cultures had a longer length of stay in intensive care unit and in hospital overall compared with patients who did not grow positive cultures. Thirty-five positive cultures were collected overall, with empirical antibiotics commenced in 22 cases. In terms of sensitivity, antibiotics were appropriate in 19 cases. Four patients developed bacteremia, two of whom died. This study does not dispute the generally accepted practice of avoiding prophylactic antibiotics in toxic epidermal necrolysis patients, but in the context of a relatively low rate of bacteremia in this patient population, advises appropriate and targeted empirical antibiotic use where clinical infection is suspected.

Patient perceptions of the surgical ward round

than one, error-producing condition. Most errors occurred during after-hours shifts when the staff were treating an unfamiliar patient, often shortly after handover from another team. Many were associated with reports of tiredness or when the staff were busy and distracted by other demands. It is not difficult to understand how these conditions increase the risk of medication error, but the findings also suggest potential defensive strategies. Staff can be taught the importance of latent error-producing conditions when there is a need to be especially vigilant to the possibility of committing an error. The problem of distraction during drug prescribing and administration needs particular attention. The danger inherent in conducting seemingly routine tasks, including re-writing drug charts, needs to be acknowledged. A strategy akin to surgery ‘time out’ seems appropriate so that staff can complete all medication-related tasks and check for accuracy free from other distractions. The knowledge-based mistakes that were committed by doctors during the prescription of a new medication were also associated with latent conditions. Fatigue and distraction may explain why they failed to fill gaps in their knowledge during the prescribing process, but there were additional identifiable factors. The prescribing doctors were junior and quite often reported that they lacked guidance from experienced colleagues. Sometimes, low expectations of a helpful response lead to a reluctance to ask. Sometimes, they were too busy to check available drug information on the hospital computer system, and sometimes there were queues for the ward computer terminals. The main implication of these disturbing findings is that these doctors failed to recognize the dangers inherent in prescribing unfamiliar medications. Other studies have found that doctors often underestimate the dangers in prescribing. Another implication is that more education in clinical pharmacology or therapeutics will not necessarily improve the situation. Access to appropriate drug information at the time of prescribing is crucial, and prescribing doctors need strong encouragement to adhere to the rules of safe prescribing. We also found distinct differences in how ADEs were dealt with at our hospital. All the nurses and pharmacists had discussed the incident with supervisors, which had been reported to the Australian Incident Monitoring System. In contrast, no ADE committed by medical staff had been formally reported, and two-thirds of the doctors we interviewed had not known that their actions had lead to an ADE. They had received no feedback until being approached by the research team because the errors had been committed after hours on patients belonging to other teams. We interpreted this as a lost opportunity to learn from mistakes and also, possibly, a reluctance to acknowledge the ADE by the treating team. What lessons can be drawn to guide surgical practice? First, this is an important topic for surgeons. Errors and error-prone conditions are ubiquitous, and ADEs are likely to be a significant additional problem for surgical patients. Possibly the most important step would be for a surgeon to accept this reality and to consider how to improve the situation in their own practice. My personal recommendation would be to arrange for an audit of existing patients, and I would be very surprised if errors, potential ADEs and actual ADEs were not detected in quite a small sample. The hospital pharmacy service is generally happy to assist with drug audits. The second most important step would be to carry out some sensible action to attempt to improve the system of drug management. Possible strategies include insisting that safe prescribing habits are adopted by junior staff and advocacy for automated prescribing in your hospital. The clinical pharmacy service is an often under-utilized resource, and there is evidence that pharmacists can pick up potentially harmful prescribing errors before they occur. Senior surgeons have the capacity to take the lead and engender a change of culture surrounding the problem of suboptimal drug management.

Liability in the context of misdiagnosis of melanoma in Australia

Malignant melanoma is a serious and relatively common condition, the diagnosis of which may be difficult. In a recent Supreme Court of New South Wales case, misdiagnosis of melanoma occurred, but there was failure to establish causation of the patients poor prognosis. Aggressive melanomas may grow quickly, fail to conform to standard and commonly taught diagnostic criteria, and frequently escape early detection. In the event of uncertain diagnosis or failed treatment of a lesion, an appropriate standard of care is full excisional biopsy if not previously performed, or referral of the case to an appropriate specialist or melanoma centre. Clinicians should remain aware of the existence of higher‐risk, easily misdiagnosed melanomas with a high mortality rate. Therefore, they should aim to identify these at the earliest opportunity.

Effectiveness and risks of cricoid pressure during rapid sequence intubation

This is the protocol for a review and there is no abstract. The objectives are as follows: To identify and evaluate all randomized controlled trials (RCTs) involving people undergoing elective or emergency airway management via rapid sequence induction (RSI) and compare people who have cricoid pressure administered with people who do not have cricoid pressure administered.