Stephen E. Morris

Plasmapheresis as an adjunct treatment in toxic epidermal necrolysis.

BACKGROUND Toxic epidermal necrolysis (TEN) is a severe, progressive disease characterized by the sudden onset of skin necrosis. It is frequently associated with systemic involvement and has a high rate of morbidity and mortality. Standard therapy includes meticulous wound care, fluid replacement, and nutritional support in an intensive care setting. OBJECTIVE We evaluated the outcomes of patients treated in a burn unit for TEN over a 9-year period and compared the outcomes of a subset of patients treated with plasmapheresis with those managed by conventional means. METHODS The records of 16 patients with a diagnosis of TEN obtained from a computerized database were reviewed. Parameters recorded included extent of body surface area involvement and number of mucous membranes involved at admission, complications such as sepsis or need for mechanical ventilation, length of stay, and disposition. RESULTS Sixteen patients were included in this study. Ten were treated with conventional support measures alone. Six were treated with plasmapheresis. The average age was 42.4 years; the male/female ratio was 1:2.2. Sulfamethoxazole/trimethoprim was implicated in causation in 6 patients. The average extent of involvement on admission in all patients was 51.5% total body surface area. The average length of stay in all patients was 14.8 days. Eight patients (50%) were discharged home, 4 (25%) were discharged to a rehabilitation facility, and 4 (25%) died (2 of sepsis, 2 of cardiopulmonary arrest). None of the plasmapheresis-treated patients died. CONCLUSION Plasmapheresis is a safe intervention in extremely ill TEN patients and may reduce the mortality in this severe disease. Prospective studies are needed to further define its usefulness.

Etiology and consequences of respiratory failure in thermally injured patients

Inhalation injury predisposes burn patients to pneumonia, respiratory failure, and death, but the incidence and consequences of respiratory failure in the absence of inhalation injury are not well known. In a review of 529 burn patients admitted over a 4-year period, patients with inhalation injury had a 73% incidence of respiratory failure (hypoxemia, multiple pulmonary infections, or prolonged ventilator support) and a 20% incidence of adult respiratory distress syndrome (ARDS). In patients without inhalation injury, respiratory failure developed in 5% of patients and ARDS in 2% (both p < 0.001). Patients with respiratory failure display a high incidence of multiple organ failure and mortality (27% to 50%), regardless of the presence of inhalation injury. All patients who died had multiple organ failure. This review demonstrates that respiratory failure, regardless of its cause, frequently leads to multiple organ failure and death. Inhalation injury, in the absence of respiratory failure, does not appear to contribute to mortality.

Telemedicine Evaluation of Acute Burns Is Accurate and Cost-Effective

BACKGROUND As the number of US burn centers has declined, access to burn care is increasingly limited. Inexperience in burn wound assessment by referring physicians often results in overtriage or undertriage. In an effort to improve access to burn care in our region, we instituted a program of telemedicine evaluation of acute burns. METHODS We created a telemedicine network linking our burn center to three hospitals located 298 to 350 air miles away. Participants agreed to perform telemedicine consultation for acutely burned patients admitted to their emergency departments. We compared consults and referrals from these facilities during the period July 2005 to August 2007 (TELE) to those during a 2-year period before instituting telemedicine (PRE-TELE). RESULTS During the TELE period, 80 patients were referred, of whom 70 were seen acutely by telemedicine, compared with 28 PRE-TELE referrals. The groups did not differ in age or burn size. Only 31 patients seen by telemedicine received emergency air transport (44.3%), compared with 100% of PRE-TELE patients (p < 0.05). Nine other TELE patients were transported by family; 30 other patients were treated locally. Ten remaining patients were transported without telemedicine evaluation. TELE patients transported by air had somewhat larger burn sizes (9.0% vs. 6.5% total body surface area; p = NS) and longer length of stay (13.0 days vs. 8.0 days; p = NS) than PRE-TELE patients. Burn size estimates by burn center physicians made either by telemedicine or direct inspection correlated closely but both differed significantly from those of referring physicians. Providers and patients expressed a high level of satisfaction with the telemedicine experience. CONCLUSIONS Acute evaluation of burn patients can be performed accurately by telemedicine. This can reduce undertriage or overtriage for air transport, improve resource utilization, and both enhance and extend burn center expertise to many rural communities at low cost.

Burn center management of necrotizing soft-tissue surgical infections in unburned patients

BACKGROUND Patients with necrotizing soft-tissue infections present great challenges in management from initial presentation through definitive care. Because burn centers concentrate expertise in critical care, wound management, and rehabilitation, we examined the effectiveness of burn center care for patients with necrotizing infections. METHODS We reviewed our burn centers experience with all patients admitted from 1990 through 1999 with a primary diagnosis of necrotizing fasciitis (NF) or Fourniers gangrene (FG). RESULTS Fifty-seven patients were identified, 18 with FG and 39 with NF. Patients had a high incidence of preexisting medical problems, including diabetes (37%), obesity defined as greater than 20% above ideal body weight (33%), and hypertension (33%). Seven of 57 (12%) patients died. Patients required a mean of 4.1 operative procedures (range 1 to 15) for definitive wound closure. The mean length of stay (survivors only) was 28.5 days, (range 3 to 70). Although costs increased throughout this period, a formal program of cost-containment resulted in no increase in actual charges per day, from a mean of

Intestinal Obstruction Secondary to Enteral Feedings in Burn Trauma Patients

4,735 in 1991 to

Colloid administration normalizes resuscitation ratio and ameliorates "fluid creep".

5,202 in 1999. CONCLUSIONS Burn centers can provide successful and cost-effective acute care, definitive wound closure, and rehabilitation for patients with NF and FG.

Early prediction of prolonged ventilator dependence in thermally injured patients

BACKGROUND Enteral feeding is preferred for maintaining gut integrity and providing nutrition in trauma patients. Recent reports suggest that use of early enteral feeds is successful and that complications are rare. A recent burn patient, who suffered apparent bowel obstruction and perforation secondary to enteral feedings, led us to review our experience with mechanical complications of tube feedings. METHODS We searched our registry of patients treated for acute burn trauma injury and identified patients treated for acute bowel obstruction in the past 3 years. RESULTS Four patients were identified, ages 22 to 44, with burns of 6 to 92% total body surface area. Each required intubation and ventilatory support during initial treatment, complicated by adult respiratory distress syndrome and sepsis. We began enteral feeds 1 to 3 days after admission. At approximately 14 days after admission, each patient deteriorated clinically, which led to emergent abdominal exploration; the tube feedings caused bowel obstruction and associated complications. Each patient improved with laparotomy. CONCLUSION Bowel obstruction, ischemic necrosis, or both, secondary to early and aggressive nutrition with a fiber supplemented enteral feeding is an uncommon, life-threatening complication. Understanding and early recognition of this potential complication are essential to prevention or successful treatment.

Resuscitation of thermally injured patients with oxygen transport criteria as goals of therapy

Although colloid was a component of the original Parkland formula, it has been omitted from standard Parkland resuscitation for over 30 years. However, some burn centers use colloid as “rescue” therapy for patients who exhibit progressively increasing crystalloid requirements, a phenomenon termed “fluid creep.” We reviewed our experience with this procedure. With Institutional Review Board approval, we reviewed all adult patients with ≥20%TBSA burns admitted from January 1, 2005, through December 31, 2007, who completed formal resuscitation. Patients were resuscitated using the Parkland formula, adjusted to maintain urine output of 30 to 50 ml/hr. Patients who required greater amounts of fluid than expected were given a combination of 5% albumin and lactated Ringers until fluid requirements normalized. Results were expressed as an hourly ratio (I/O ratio) of fluid infusion (ml/kg/%TBSA/hr) to urine output (ml/kg/hr). Predicted values for this ratio vary for individual patients but are usually less than 0.5 to 1.0. Fifty-two patients were reviewed, of whom 26 completed resuscitation using crystalloid alone, and the remaining 26 required albumin supplementation (AR). The groups were comparable in age, gender, weight, mortality, and time between injury and admission. AR patients had larger total and full-thickness burns and more inhalation injuries. Patients managed with crystalloid alone maintained mean resuscitation ratios from 0.13 to 0.40, whereas AR patients demonstrated progressively increasing ratios to a maximum mean of 1.97, until albumin was started. Administration of albumin produced a dramatic and precipitous return of ratios to within predicted ranges throughout the remainder of resuscitation. No patient developed abdominal compartment syndrome. Measuring hourly I/O ratios is an effective means of expressing and tracking fluid requirements. The addition of colloid to Parkland resuscitation rapidly reduces hourly fluid requirements, restores normal resuscitation ratios, and ameliorates fluid creep. This practice can be applied selectively as needed using predetermined algorithms.

Self-reported quality of life after electrical and thermal injury.

BACKGROUND Recent studies suggest that when prolonged ventilator dependence (PVD) can be predicted in trauma or intensive care unit patients, early tracheostomy may reduce hospital stay and improve utilization of resources. This study was performed to develop criteria predictive of PVD (> 14 days) in burn patients. METHODS We reviewed burn patients aged > or =16 years admitted between 1990 and 1994 who required ventilator support for > or =3 days. Using the variables full-thickness burn size, age, inhalation injury, and worst PaO2/FiO2 on ventilator day 3, an equation predicting PVD was created using logistic regression. The equation was tested by applying it to 1995 patients. RESULTS When a probability of >0.5 was considered predictive of PVD, the equation correctly predicted PVD in 82% of 1990 to 1994 patients (n = 110) and 90% of 1995 patients (n = 29). CONCLUSION PVD in burn patients can be predicted using objective variables in the early postburn period. Predictions can be used to select patients for prospective studies of early tracheostomy.

Glycosaminoglycan Hydrogels as Supplemental Wound Dressings for Donor Sites

Resuscitation from shock based on oxygen transport criteria has been widely used in trauma and surgical patients, but has not been examined in thermally injured patients. To study the possible efficacy of this type of resuscitation, the oxygen transport characteristics of burn resuscitation were studied in nine adults, of whom six had inhalation injuries, with a mean burn size of 45% total body surface area and a mean age of 33.4 years, who were resuscitated based on oxygen transport criteria. Pulmonary artery balloon flotation catheters were placed and hemodynamic and oxygen transport parameters (Fick method) were measured hourly for 6 hours. Patients received fluid boluses in addition to resuscitation calculated by the Parkland formula, until the pulmonary artery wedge pressure reached 15 mm Hg, after which dobutamine infusions (5 micrograms/kg/min) were initiated. Cardiac index increased from 2.51 to 6.57 L/min/m2 (p < 0.05), whereas systemic vascular resistance fell from 1534 to 584 dyne sec/cm5 (p < 0.05). Oxygen delivery (DO2I) and oxygen consumption (VO2I) indexes increased significantly during the study period (573 +/- 47 to 1028 +/- 57, and 132 +/- 8 to 172 +/- 16 ml/min/m2, respectively; p < 0.05). VO2I appeared dependent on DO2I at levels of DO2I less than 800 ml/min/m2. In this study, depressed cardiovascular function in patients with burn injuries responded to volume loading and inotropic support much as it does in patients with shock of other etiologies. Whether oxygen transport-based resuscitation is effective in improving survival or the incidence of multiple organ failure is unknown and will need to be evaluated in randomized trials.