Tina L. Palmieri

American Burn Association consensus conference to define sepsis and infection in burns.

Because of their extensive wounds, burn patients are chronically exposed to inflammatory mediators. Thus, burn patients, by definition, already have “systemic inflammatory response syndrome.” Current definitions for sepsis and infection have many criteria (fever, tachycardia, tachypnea, leukocytosis) that are routinely found in patients with extensive burns, making these current definitions less applicable to the burn population. Experts in burn care and research, all members of the American Burn Association, were asked to review the literature and prepare a potential definition on one topic related to sepsis or infection in burn patients. On January 20, 2007, the participants met in Tucson, Arizona to develop consensus for these definitions. After review of the definitions, a summary of the proceedings was prepared. The goal of the consensus conference was to develop and publish standardized definitions for sepsis and infection-related diagnoses in the burn population. Standardized definitions will improve the capability of performing more meaningful multicenter trials among burn centers.

A multicenter review of toxic epidermal necrolysis treated in U.S. burn centers at the end of the twentieth century.

Toxic epidermal necrolysis (TEN) is a potentially fatal disorder that involves large areas of skin desquamation. Patients with TEN are often referred to burn centers for expert wound management and comprehensive care. The purpose of this study was to define the presenting characteristics and treatment of TEN before and after admission to regional burn centers and to evaluate the efficacy of burn center treatment for this disorder. A retrospective multicenter chart review was completed for patients admitted with TEN to 15 burn centers from 1995 to 2000. Charts were reviewed for patient characteristics, non-burn hospital and burn center treatment, and outcome. A total of 199 patients were admitted. Patients had a mean age of 47 years, mean 67.7% total body surface area skin slough, and mean Acute Physiology and Chronic Health Evaluation (APACHE II) score of 10. Sixty-four patients died, for a mortality rate of 32%. Mortality increased to 51% for patients transferred to a burn center more than one week after onset of disease. Burn centers and non-burn hospitals differed in their use of enteral nutrition (70 vs 12%, respectively, P < 0.05), prophylactic antibiotics (22 vs 37.9%, P < 0.05), corticosteroid use (22 vs 51%, P < 0.05), and wound management. Age, body surface area involvement, APACHE II score, complications, and parenteral nutrition before transfer correlated with increased mortality. The treatment of TEN differs markedly between burn centers and non-burn centers. Early transport to a burn unit is warranted to improve patient outcome.

Effects of oxandrolone on outcome measures in the severely burned: a multicenter prospective randomized double-blind trial.

Severe burns induce pathophysiologic problems, among them catabolism of lean mass, leading to protracted hospitalization and prolonged recovery. Oxandrolone is an anabolic agent shown to decrease lean mass catabolism and improve wound healing in the severely burned patients. We enrolled 81 adult subjects with burns 20% to 60% TBSA in a multicenter trial testing the effects of oxandrolone on length of hospital stay. Subjects were randomized between oxandrolone 10 mg every 12 hours or placebo. The study was stopped halfway through projected enrollment because of a significant difference between groups found on planned interim analysis. We found that length of stay was shorter in the oxandrolone group (31.6 ± 3.1 days) than placebo (43.3 ± 5.3 days; P < .05). This difference strengthened when deaths were excluded and hospital stay was indexed to burn size (1.24 ± 0.15 days/% TBSA burned vs 0.87 ± 0.05 days/% TBSA burned, P < .05). We conclude that treatment using oxandrolone should be considered for use in the severely burned while hepatic transaminases are monitored.

Positive fungal cultures in burn patients: A multicenter review

Fungal infections are increasingly common in burn patients. We performed this study to determine the incidence and outcomes of fungal cultures in acutely burned patients. Members of the American Burn Association’s Multicenter Trials Group were asked to review patients admitted during 2002–2003 who developed one or more cultures positive for fungal organisms. Data on demographics, site(s), species and number of cultures, and presence of risk factors for fungal infections were collected. Patients were categorized as untreated (including prophylactic topical antifungals therapy), nonsystemic treatment (nonprophylactic topical antifungal therapy, surgery, removal of foreign bodies), or systemic treatment (enteral or parenteral therapy). Fifteen institutions reviewed 6918 patients, of whom 435 (6.3%) had positive fungal cultures. These patients had mean age of 33.2 ± 23.6 years, burn size of 34.8 ± 22.7%TBSA, and 38% had inhalation injuries. Organisms included Candida species (371 patients; 85%), yeast non-Candida (93 patients, 21%), Aspergillus (60 patients, 14%), other mold (39 patients, 9.0%), and others (6 patients, 1.4%). Systemically treated patients were older, had larger burns, more inhalation injuries, more risk factors, a higher incidence of multiple positive cultures, and significantly increased mortality (21.2%), compared with nonsystemic (mortality 5.0%) or untreated patients (mortality 7.8%). In multivariate analysis, increasing age and burn size, number of culture sites, and cultures positive for Aspergillus or other mold correlated with mortality. Positive fungal cultures occur frequently in patients with large burns. The low mortality for untreated patients suggests that appropriate clinical judgment was used in most treatment decisions. Nonetheless, indications for treatment of fungal isolates in burn patients remain unclear, and should be developed.

Topical treatment of pediatric patients with burns: a practical guide.

Over 440 000 children receive medical attention for burn injuries each year in the US. Burn wound infections are a major source of morbidity and mortality in these patients. Infected wounds not only heal more slowly, but also may lead to systemic infections. The factors that contribute to wound complications are both the size and depth of the wound.Burn depth is usually categorized into first-degree (superficial, involving only the epidermis), second-degree (partial thickness, involving both epidermis and dermis), and third-degree (full thickness, through the epidermis, dermis, and into fat). Burns that will not heal within 2 weeks are at least second-degree and should generally be referred to a burn surgeon for possible excision and grafting, due to the increased risk of infection and scarring.The burn wound is dynamic. Proper treatment minimizes the extent of the burn injury, whereas improper treatment (lack of proper wound-care, edema formation, lack of resuscitation) may actually increase the size and/or depth of the wound. Topical antimicrobial agents have been shown to decrease wound-related infections and morbidity in burn wounds when used appropriately. The goal of topical antimicrobial therapy is to control microbial colonization, thus preventing development of invasive infections. A wide variety of agents are available for treatment of burn wounds, including ointments, creams, biological and nonbiological dressings. Topical antimicrobials of choice include bacitracin, neomycin, silver sulfadiazine and mafenide.

Predisposing factors for self-inflicted burns

Self-inflicted burn injuries, although uncommon, are a significant source of morbidity and mortality. The purpose of this study was to delineate the characteristics of these burns and to examine their impact on society. Records of 32 adult patients admitted for self-inflicted burns at our regional burn center between January 1996 and August 2001 were retrospectively reviewed. The mean burn size was 34 +/- 29% TBSA, with the majority of burns being the result of self-immolation using a flammable liquid. There was a slight male predominance (59%) and a significant mortality rate (25%). Ninety-one percent of patients had an active psychiatric diagnosis, with 47% having had a previous suicide attempt. Two thirds had a chronic stressor, such as a chronic medical illness and/or long-term disability. Only four patients had private insurance, whereas the remainder relied on underfunded state- and county-sponsored programs or were uninsured. In addition to well-described psychiatric factors, common characteristics predisposing to self-inflicted burns include chronic medical illnesses, long-term disability, and a lack of access to adequate mental health care. Better treatment of mental illness in the underfunded population might ultimately save the high costs of these burn injuries.

Current management of purpura fulminans: a multicenter study.

Seven burn centers performed a 10-yr retrospective chart review of patients diagnosed with purpura fulminans. Patient demographics, etiology, presentation, medical and surgical treatment, and outcome were reviewed. A total of 70 patients were identified. Mean patient age was 13 yr. Neisseria meningitidis was the most common etiologic agent in infants and adolescents whereas Streptococcus commonly afflicted the adult population. Acute management consisted of antibiotic administration, volume resuscitation, ventilatory and inotropic support, with occasional use of corticosteroids (38%) and protein C replacement (9%). Full-thickness skin and soft-tissue necrosis was extensive, requiring skin grafting and amputations in 90% of the patients. One fourth of the patients required amputations of all extremities. Fasciotomies when performed early appeared to limit the level of amputation in 6 of 14 patients. Therefore, fasciotomies during the initial management of these patients may reduce the depth of soft-tissue involvement and the extent of amputations.

Ketamine: a safe and effective agent for painful procedures in the pediatric burn patient.

Ketamine is an effective agent when used for sedation during painful bedside procedures. We developed a ketamine administration protocol for nonanesthesiologists for the purpose of establishing safe monitoring and documentation during ketamine sedation procedures. From June 1, 2002, through June 30, 2003, a total of 522 sedation events using ketamine were performed; 347 of these events were analyzed. Seventeen (4.9%) events contained potentially adverse outcome indicators, 10 (2.9%) of which required intervention. Eight events were airway related and responded to repositioning, supplemental oxygen, or bag-valve-mask ventilation. Two patients had a decrease in blood pressure, which responded to fluid administration. Total doses of ketamine administered were between 6 and 800 mg, for procedures ranging from 1 to 105 minutes, in patients weighing between 3 and 111 kg. The development of a strict protocol ensures the safe administration of ketamine for the pediatric burn patient.

Temperature threshold for burn injury: An oximeter safety study

Pulse oximeters have become essential devices for evaluating and monitoring patient oxygenation. The probe emits a small amount of heat into the skin in the process of signal detection. Regulations set by the Food and Drug Administration currently limit the maximum allowable temperature of an oximeter probe to 41 degrees C. As a result of the prolonged exposure of extremities to these devices, we sought to determine the actual temperature threshold for burn injury in patients. Eighteen patients undergoing surgery for removal of redundant skin (abdominoplasty, breast reduction) consented to the application of a temperature-controlled custom probe with four light-emitting diodes that had temperatures set randomly at the expected threshold for burn injury (42.5 degrees C, 43 degrees C, 43.5 degrees C, and 44 degrees C). The probe was left in place for 8 hours (or less if significant pain was noted). The sites covered by the probes were then checked for signs of injury. On the next day, the redundant skin was removed as a scheduled procedure, and histopathology was performed to detect the extent of burn injury. The study was approved by the local institutional research board. Two patients were excluded because of technical problems with the probe, one of whom had the probe turned off because of pain. The only observed sign of injury was either erythema or a superficial blister that was usually unobservable or slightly red at operation. These subtle signs of a burn were noted in one patient at 43 degrees C, four at 43.5 degrees C, and nine at 44 degrees C. No burns were noted in two patients. Minimal or no signs of injury frequently were noted by histopathology. Pulse oximeter probes are safe up to a temperature of 43 degrees C for at least 8 hours in well-perfused skin. Above that temperature, there is a risk of burn injury. Performing temperature threshold tests in redundant skin that is planned for excision is a potential method for testing the safety of devices or materials.

Effects of a restrictive blood transfusion policy on outcomes in children with burn injury.

A restrictive blood transfusion policy decreases blood utilization and improves outcomes in critically ill adults, but the impact of a restrictive blood transfusion policy in critically ill children is unclear. The study purpose was to compare the effects of a restrictive with a traditional blood transfusion policy in children with major burn injury. A retrospective review of all blood transfusions administered in a pediatric burn center during a 5-year period was conducted. Children in the traditional group (January 1, 2000, to June 30, 2002), were transfused at a hemoglobin level of less than 10 g/dl. Children in the restrictive group (January 1, 2003, to June 30, 2005, 6 months after the adoption of a restrictive protocol) were transfused at a hemoglobin level of less than 7 g/dl. Patient groups were compared for demographics, ventilator requirements, blood transfusion number, transfusion costs, and outcomes. Of the 1140 patients studied, 266 (24%) received a total of 2577 units of blood. There was no difference in age, TBSA burn, sex, inhalation injury, or mortality between groups. Patients in the traditional group received more blood than the restrictive group (12.3 ± 1.8 vs 7.2 ± 1.2 units/patient, P < .001). The mean cost of blood per patient was