Renata Fabia

ACETIC ACID-INDUCED COLITIS IN THE RAT - A REPRODUCIBLE EXPERIMENTAL-MODEL FOR ACUTE ULCERATIVE-COLITIS

There exists no ideal model for experimental ulcerative colitis in common laboratory animals. Therefore, we tried in the present study to establish a reproducible model for inducing colitis in rats by using acetic acid. A blind loop of the colon including the cecum, ascending colon and part of the transverse colon, was brought out through two colostomies. After mechanical washing with warm normal saline, acetic acid was instilled at different doses (4, 6 and 8%) for different exposure times (10, 15, 20, 25 and 30 s). The excluded colon was examined by light microscopy on the 1st, 2nd, 3rd, 4th, 7th and 14th days after operation and acetic acid instillation. We found that 4% acetic acid for 15 s produced a moderate, superficial colitis on the 1st day after operation, whereafter a uniform colitis evolved in all rats on the 4th day after operation. The developed colitis showed morphological similarities with human ulcerative colitis. Signs of healing and regeneration of the mucosa were seen on the 7th day, and the mucosa became almost normal at the 14th day after operation. 6 or 8% acetic acid solution or exposure times exceeding 15 s resulted in severe, deep colitis with a concomitant high mortality rate. In contrast, at exposure times less than 15 s, acetic acid induced only mild superficial colitis. We conclude that by using 4% acetic acid for 15 s in the excluded colon a uniform and reproducible colitis pathologically resembling human ulcerative colitis could be achieved. Furthermore, no mortality was encountered and the general health of the rats was similar to that of the controls.(ABSTRACT TRUNCATED AT 250 WORDS)

A Silver Impregnated Antimicrobial Dressing Reduces Hospital Length of Stay for Pediatric Patients With Burns

We sought to study whether the application of a novel silver impregnated antimicrobial dressing (Aquacel ®Ag, ConvaTec, Princeton, NJ) affects the hospital length of stay in pediatric patients with partial-thickness burns. A retrospective review of Burn Registry Data from a large childrens hospital burn unit was conducted to answer this question. Pediatric patients admitted with partial-thickness burns treated with Aquacel ®Ag from January 2005 through August 2005 were included in the study (n = 39). The comparison group of patients treated with silver sulfadiazine (SSD®; Par Pharmeceuticals, Woodcliff, NJ) cream was matched for age and %TBSA burned from the same time period the previous year (n = 40). Analysis was conducted for intent to treat. Mean length of stay for control patients treated with SSD® was significantly longer (8.36 days) compared with Aquacel Ag-treated patients (4.48 days; p = .002, t-test for unequal variances). Length of stay for both groups was significantly associated with %TBSA burned (p < .001, r2 = .38). Post-hoc analysis controlling for %TBSA burned revealed an adjusted mean length of stay for the control group that was longer than that of the Aquacel ®Ag group (5.9 days vs. 3.8 days, respectively). These data confirm that application of a new burn dressing (Aquacel Ag) reduces hospital length of stay. Reduction in the complexity and number of dressing changes needed with use of Aquacel ®Ag, in combination with significantly reduced length of stay, should result in a significant cost savings in the care of this patient population.

Extracorporeal membrane oxygenation as a lifesaving modality in the treatment of pediatric patients with burns and respiratory failure

PURPOSE Several case series have described successful utilization of extracorporeal membrane oxygenation (ECMO) for the treatment of pediatric burn patients with respiratory failure. This study examines the Extracorporeal Life Support Organization registry experience in the treatment of these patients. METHODS The Extracorporeal Life Support Organization registry was queried from 1999 to 2008 for all patients not older than 18 years who suffered a burn-related injury. RESULTS Thirty-six patients met inclusion criteria. The mean age was 4.45 years, with an average weight of 20.9 kg. Survivors vs nonsurvivors had a shorter average time to ECMO (97 vs 126 hours, P = .890) and shorter average ECMO run times (193 vs 210 hours, P = .745). Seventeen patients underwent venovenous ECMO and 19 patients underwent venoarterial ECMO, with survival of 59% (n = 10) and 47% (n = 9), respectively (P = .493; odds ratio, 1.587; 95% confidence interval, 0.424-5.945). Overall survival was 53% (n = 19). Complications occurred in 28 patients (33 mechanical, 101 medical). The venoarterial group had 21 mechanical (n = 8) and 61 medical complications (n = 17), compared with the venovenous group with 12 mechanical (n = 8) and 40 medical complications (n = 11). CONCLUSIONS Extracorporeal membrane oxygenation can be a lifesaving modality for pediatric burn patients with respiratory failure. Survival is comparable to the reported survival of non-burn-related pulmonary failure pediatric patients requiring ECMO.

Advances in the Care of Children with Burns

Burns remain a significant cause of death and disability in the pediatric population. According to the Centers for Disease Control and Prevention (CDC), there were 1168 burn-related deaths among 77,546,344 children ages newborn to 18 years in the United States in 2005, for a crude rate of 1.5 per 100,000. A review of 5 years of data from the authors’ burn center, which serves a total population of approximately 1.5 million people, reveals that there are on average 135 admissions to the pediatric burn unit and 2 pediatric burn deaths per year. The mean age for burn admissions is 5 years old, and the mean length of stay is 2.5 days. Approximately 44% of the patients admitted to the burn unit are transferred from other hospitals in the region. BURN EPIDEMIOLOGY AND ETIOLOGY Seventy-nine patients age birth to 4 years are admitted to the burn unit each year, and the leading injury mechanisms in this age group are hot liquids (scalds), followed by hot objects and outdoor fires (bonfires, camp fires, trash fires). Nineteen admissions per year occur in the 5- to 9-year age group, and the mechanisms for this age are (in order) hot liquids, house fires, and ignition of flammable materials. There were 22 admissions per year among the 10- to 14-year age group, and hot liquids also leads the mechanisms in this group, followed by ignition of flammable materials and outdoor fires. These statistics indicate that injury prevention programs directed toward scald injuries and reducing outdoor fires could reduce thermal injuries in children. There are also significant ethnic disparities in the rate of burn injury. Data collected from Ohio’s 6 pediatric trauma centers in 2005 indicated that African American children had a burn admission rate that was 7.70 times greater than the admission rate for white children. The admission rate for all minorities was 6.64 times greater than the white admission rate. Furthermore, data from this study demonstrates that thermal injury is a disease of poverty. A zip code analysis of the rate of burn injuries in the minority population found that the rate of burn hospitalizations correlates with the number of vacant housing units, the

Prevalence and correlates of posttraumatic stress in parents of young children postburn.

This study examined the prevalence and correlates of posttraumatic stress symptoms (PTSS) in the parents of very young children who sustained a minor to moderate size burn injury. Although prior research has explored this relationship in families of children with major burns, only minimal research has focused on children with minor to moderate injuries. Forty-five parents of young children (<6 years) with a burn injury (mean TBSA = 2.67%, SD = 2.40) completed questionnaires regarding PTSS and demographics at an outpatient burn clinic. Injury-related information was collected from medical records. Parents reported clinically significant levels of PTSS, although in most cases, full diagnostic criteria for posttraumatic stress disorder were not met. The amount of distress was related to the age of the child at burn, child PTSS, and the source of burn. Variables such as size of burn, days spent as inpatient, or parental presence at the time of burn were not found to be related to parental distress. PTSS assessment should be made mandatory for all parents of young children experiencing a burn injury, regardless of size and severity of burn or parental presence at the time of burn.

Inter-facility transfer of pediatric burn patients from U.S. emergency departments

PURPOSE To describe the epidemiology of pediatric burn patients seen in U.S. emergency departments (EDs) and to determine factors associated with inter-facility transfer. METHODS We analyzed data from the 2012 Nationwide Emergency Department Sample. Current American Burn Association (ABA) Guidelines were used to identify children <18 who met criteria for referral to burn centers. Burn patient admission volume was used as a proxy for burn expertise. Logistic models were fitted to examine the odds of transfer from low volume hospitals. RESULTS In 2012, there were an estimated 126,742 (95% CI: 116,104-137,380) pediatric burn ED visits in the U.S. Of the 69,003 (54.4%) meeting referral criteria, 83.2% were in low volume hospitals. Only 8.2% of patients meeting criteria were transferred from low volume hospitals. Of the 52,604 (95% CI: 48,433-56,775) not transferred, 98.3% were treated and released and 1.7% were admitted without transfer; 54.7% of burns involved hands. CONCLUSIONS Over 90% of pediatric burn ED patients meet ABA burn referral criteria but are not transferred from low volume hospitals. Perhaps a portion of the 92% of patients currently receiving definitive care in low volume hospitals are under-referred and would have improved clinical outcomes if transferred at the time of presentation.

Evaluation of nurse accuracy in rating procedural pain among pediatric burn patients using the Face, Legs, Activity, Cry, Consolability (FLACC) Scale

BACKGROUND Accurate pain assessment is essential for proper analgesia during medical procedures in pediatric patients. The Faces, Legs, Activity, Cry, and Consolability (FLACC) scale has previously been shown to be a valid and reliable tool for assessing pediatric procedural pain in research labs. However, no study has investigated how rater factors (gender, number of dressing changes performed/week, burn history, having children, nursing experience, stress at home/work) and patient factors (pain intensity) affect the accuracy of FLACC ratings for procedural pain when implemented by bedside care providers. METHOD Twenty-four nurses in an ABA verified Pediatric Burn Center watched four videos of dressing changes for pediatric burn patients in random order three times and rated the childrens procedural pain using the FLACC scale. The four videos had standard FLACC scores established by an interdisciplinary panel. RESULTS Descriptive and mixed modeling analysis was conducted to explore nurse rating accuracy and to evaluate the rater and patient factors that influenced the rating accuracy. The highest accuracy was reached when rating high procedural pain (with a FLACC of 6). Nurses underrated both mild and severe procedural pain. Nurses who had less nursing experience demonstrated significantly higher accuracy than those with more experience. CONCLUSIONS The present study is the first study in the literature to systematically examine the factors influencing the accuracy of FLACC rating for pediatric procedural pain among bedside care providers. The findings suggest that nurse clinical experience and patient pain intensity are two significant contributors to rating accuracy.

Respiratory failure after pediatric scald injury.

OBJECTIVE A subset of children with scald burns develops respiratory failure despite no direct injury to the lungs. We examined these patients in an effort to elucidate the etiology of the respiratory failure. METHODS The charts of pediatric patients with greater than 10% total body surface area (TBSA) scald burns were reviewed. Age, weight, burn distribution, percentage of TBSA burned, resuscitation volumes, Injury Severity Score, evidence of abuse, length of stay, days in the intensive care unit, and time and duration of intubation were recorded. RESULTS Two hundred thirty-two patients met our inclusion criteria. Of these, 220 patients did not require intubation, and 12 of the patients did. No patient older than 3 years or with burns less than 15% TBSA required intubation. Fluid over resuscitation was not directly associated with respiratory failure requiring mechanical ventilation. CONCLUSIONS We report the largest published series of patients with scald burns requiring mechanical ventilation in the absence of direct airway injury. Five percent of pediatric patients required mechanical ventilation after scald injury. We believe that a combination of causes including fluid resuscitation, young patient age, small patient size, and possible activation of the systemic inflammatory immune response may be responsible for the respiratory failure.

Complete Bilateral Tracheobronchial Disruption in a Child With Blunt Chest Trauma

Tracheobronchial injuries after blunt trauma to the thorax are uncommon in the pediatric population. The severity of these injuries ranges from death before reaching the hospital, to life-threatening hemodynamic instability requiring urgent operative management, to clinical stability allowing delayed operative repair. Localization and extent of the tracheobronchial disruption, along with the presence of coexisting injuries, are the main determining factors in survivability. Because of a specific, though not uniformly established, mechanism of upper airway trauma, the majority of ruptures occur within a few centimeters from the carina. They may involve isolated tracheal disruption, unilateral bronchial disruption or avulsion, or bilateral tracheobronchial disruption. The latter is exceedingly uncommon in a trauma patient who reaches the Emergency Department alive and clearly represents a life-threatening situation. It requires timely diagnosis, skillful airway management, and prompt repair. There are only a few reported cases of successful management of complex carinal trauma involving bilateral bronchial avulsion. We report our experience with this injury in a young child.

U.S. Pediatric Burn Patient 30-Day Readmissions

The objectives of the study were to determine unscheduled 30-day readmission rates for pediatric burn patients and to identify readmission reasons. We used the 2013-2014 National Readmission Database to produce 30-day all-cause unscheduled readmission rates by patient and hospital characteristics. Readmission risk factors were evaluated with multivariable logistic regression. An estimated 11,940 U.S. pediatric burn patients were discharged in January through November 2013 and 2014, and 325 had unscheduled readmissions within 30 days (2.7%; 95% confidence interval [CI], 1.5-3.9). This rate is higher than that seen in pediatric trauma patients (1.7%; P = 0.04]. Higher rates were seen in children with TBSA burned ≥ 10% (4.1%; 95% CI, 2.3-6.0) and patients with third-degree burns (5.5%; 95% CI, 1.4-9.6). The majority (86%) had index admissions in hospitals treating 100 or more burn patients annually, and 98% returned to the same hospital. Over two-thirds had an operating room procedure during their readmission; 15% had infections. The highest adjusted odds of readmission (AOR = 2.7; 95% CI, 1.7-4.2) was for patients with third-degree burns. When compared with patients with lengths of stay (LOS) of 1 day, those with LOS of 2 to 3 days had a higher odds (AOR = 1.7; 95% CI, 1.03-2.9), but the AOR was not different for those with LOS > 3 days. TBSA, index operating room procedure, and patient residence were associated with readmission. This national dataset enhances our ability to predict patients at risk for unscheduled readmission and to plan for appropriate patient discharge, potentially reducing readmissions.