bluuebunny/crossref_metadata_2025 huggingface dataset:
703 Extubation Success in Pediatric Burn Patients: A 10-Year Review
Authors: Cartie Richard , Prasad Balakrishna , Pierzchajlo Noah , Price Austin
Published: May 2023

Introduction

Pediatric burn care presents two unique population subsets that require distinctive care from adult and non-burn patients, respectively. While prior research has led to the creation of best practices for burned adults and non-burn pediatric patients, the standard of care regarding long-term pediatric burn intubation varies widely and deviates from accepted standards in the non-burn pediatric world. In this retrospective review, we analyze one burn center’s experience managing ventilation and extubation of pediatric patients.

Methods

We reviewed all pediatric patients admitted to the burn and wound care ICU who were intubated for more than 24 hours. Patient data was collected from 2012 through 2022. 442 patients were initially identified and 142 remained after removing screen failures. We analyzed 3 groups which included total burn surface area (TBSA), inhalation injury, and time on the ventilator.

Results

The first group broken down by TBSA yielded the most significant results in our 7 of 10 metrics. All significant metrics including mortality, length of stay (LOS), and pulmonary hypertension (HTN) were directly correlated to burn TBSA. Patients with higher TBSA were also significantly more likely to require reintubation after coming off the ventilator. Inhalation injury presented on admission was also a significant indicator for developing acute respiratory distress syndrome (ARDS). Patients who remained on the ventilator for >7 days were significantly more likely to develop pulmonary HTN, however mortality and reintubation rates notably did not increase in this group.

Conclusions

There is much debate in the burn world as to whether standard practices should carry over from other specialties when treating severely burned patients. Much of our data confirms, in pediatric patients, findings of adult patients found in the literature. Mortality, LOS, and time on the ventilator expectedly increased with burn TBSA. Inhalation injury was a significant indicator for ARDS which implies that proper screening for this type of injury is a key to predicting long-term treatment. What is perhaps most notable in this data is the fact that, unlike in the adult burn population, there was no significant difference in mortality between short and long-term intubations. Additionally, patients who required reintubation (n=7) were significantly more likely to have a TBSA >40%, but those who remained on the ventilator >7 days were not more likely to require intubation after extubation. This implies that patients should be left on the ventilator, if necessary, without resorting to aggressive challenge breathing trials for early extubation as is common in adult population. With this data we will also identify our rare cases of pediatric tracheostomy placement and indications for its use.

Applicability of Research to Practice

This projects shows how intubation of pediatric burn patients can be maintained safely and effectively in the critical care setting.
704 Extubation Success in Pediatric Burn Patients with Neuromuscular Blockade: A 10-year review
Authors: Pierzchajlo Noah , Cartie Richard
Published: May 2023

Introduction

The use of neuromuscular blockade in ventilated pediatric burn patients is controversial and varied. While standard of care, including neuromuscular blockade in pediatric patients, has been long established for the non-burned population, no such literature exists for burns. We analyzed use of neuromuscular blockade in pediatric burn patients and its association of mechanical intubation and extubation success.

Methods

We reviewed all pediatric patients admitted to the burn and wound care ICU who were intubated for more than 24 hours. Patient data was collected from 2012 through 2022. 442 patients were initially identified and 142 remained after removing screen failure. We compared patients based on administration of neuromuscular blockade (n=125).

Results

Mortality (n=7) and reintubation (n=7) rates were not significantly affected by use of neuromuscular blockade. Patients who received blockade were also not significantly more likely to develop acute respiratory distress syndrome (ARDS) or pulmonary hypertension (HTN). Length of stay (LOS) in the hospital, intensive care unit (ICU), and time on the ventilator were all significantly increased with patients who received neuromuscular blockade. Patients who received blockade also had a significantly higher total burn surface area (TBSA). Conversely, patients who did not receive blockade were significantly more likely to be older.

Conclusions

Our data shows that mortality and the need for reintubation is not significantly increased with the use of neuromuscular blockade, nor are the complications of prolonged paralysis such as ARDS and pulmonary HTN. LOS in the hospital, ICU, and time on the ventilator were expectedly increased with blockade, although these patients carried more injury than their non-paralyzed counterparts.

Applicability of Research to Practice

This project illustrates how the use of neuromuscular blockade can be implemented safely and effectively in the critical care setting.
715 Ocular Complications of Facial Burns in the Pediatric Population
Authors: Teitelbaum Abigail , Craig Annmarie , Ridelman Elika , Bohra Lisa , Shanti Christina , Segar Sharmila
Published: May 2023

Introduction

Pediatric burns commonly involve the face and periocular areas, with a risk of impairing vision. The aim of this study is to characterize ocular injuries in burn patients and identify the patients at most risk of ocular complications.

Methods

This study is a retrospective review within a single academic, urban pediatric burn center. All burn patients under 18 years of age admitted from January 2010 to December 2020 with periorbital or ocular involvement were included. Variables analyzed included patient demographics, burn characteristics, presence of ophthalmology consultation, ocular exam findings, follow up time period, and early and late ocular complications.

Results

In the study period, 2,781 patients were admitted to our burn center, 300 of whom had facial burns involving the eyes and/or eyelids. Etiologies of burn injuries were as follows: 112 (37.5%) scald, 80 (26.8%) flame, 35 (11.7%) contact, 31 (10.4%) chemical, 28 (9.4%) grease, and 13 (4.3%) friction. Overall, 70.9% of patients with ocular burns received an ophthalmology consult. Of these patients, 61.5% had periorbital swelling and 39.8% had corneal injuries. Of the 207 patients who were followed as inpatients by ophthalmology, only 61 (29.5%) presented for a follow-up visit, as recommended, 6 of which had serious ocular sequelae including ectropion, entropion, symblepharon, and corneal decompensation, and 4 of whom had a firework-related injury.

Conclusions

While burns involving the ocular surface and eyelid margins are infrequent overall, they can lead to long-term sequelae. Ophthalmology consultation is critical, particularly in the setting of chemical and firework-related injury. As ocular and periocular burns can cause immediate as well as delayed sequelae, ophthalmologic evaluation is a key component of assessment.

Applicability of Research to Practice

This paper characterizes ocular injuries in pediatric patients with facial burn injuries and identifies patients most at risk for ocular complications. We believe this will be valuable for many burn researchers and clinicians in order to better identify patients who could benefit from ophthalmologic evaluation and those at risk for both immediate as well as delayed sequelae from periocular burns.
721 The Rising Use of Fire as a Weapon
Authors: Woods Jason , Carter Jeffrey , Conlon Kathe , Flores Carl , Kearns Randy
Published: May 2023

Introduction

Disaster planning and preparedness for a Burn Mass Causality Incident (BMCI) must consider both worst-case scenarios as well as most likely events that could strain a burn center (BC) resources. This study evaluates the growing threat of utilizing fire as a weapon for terrorist attacks and criminal acts in the United States.

Methods

Statistics regarding the use of fire as a weapon over a 2-year period were reviewed and summarized along with a review of significant events over 30 years. In addition, data regarding the type of weapon used in these attacks, intended target, and motives were collected and compared.

Results

According to the Cyber Security and Infrastructure Security Agency (CSISA), incidents related to arson or fire as a weapon in the US increased by 56.9% in cities with populations over 1 million people between 2019 and 2020 and 11.3% in towns with populations under 10,000. In addition, improvised Incendiary Device (IID) incidents increased by 210% at government facilities, 113% at commercial facilities, and 114% at critical infrastructure facilities during the same time frame.

Conclusions

The US continues to face complex and evolving threats from extremists, criminals, and terrorists. Methods have included attacks utilizing arson, IIDs, deliberate forest fires, and more. Assailants have used fire as a weapon to target public gatherings, individuals, and government property and as a component of complex coordinated attacks. These attacks have resulted in both large numbers of fatalities and burn injuries. The materials required to create a weapon utilizing fire are cheap, readily available, and require no formal training.

Applicability of Research to Practice

Criminal or terrorism-related incidents involving the use of fire as a weapon can result in mass causality events with large numbers of burn patients. These incidents can potentially overwhelm both first responders and local BC quickly. Therefore, BCs must have an updated disaster plan that has been evaluated and communicated with local fire and EMS, neighboring hospitals, and regional BCs.
728 A Survey of Health Professionals' Attitudes Regarding Substance Abuse Disorder in Burn Patients
Authors: Richey Karen , Dobbe Van , Kesler Natalie , Mouch Steven , Foster Kevin
Published: May 2023

Introduction

Substance abuse disorder (SAD) is complex, involving the continued use of drugs or alcohol despite harmful consequences. The diagnosis of this disorder carries a stigma that can bring shame to the individual, and healthcare providers are not immune to attitudes that worsen this shame. This coupled with patient behaviors can make caring for these patients challenging. We have seen an ever-increasing number of patients admitted to the burn center with this preexisting comorbidity. The purpose of this study was to better understand our own attitudes and potential bias or barriers that may be present in caring for this population.

Methods

A modified version of the 11-item Medical Condition Regard Scale (MCRS) was distributed to burn center personnel via REDCap. An additional 6 burn specific questions were asked. Participants were asked to respond on a 6-point Likert scale. There were both positively (POS) and negatively (NEG) phrased questions. No personal or professional demographic data was collected to ensure the anonymity of respondents.

Results

A total of 52 individuals responded to the survey. When responding to POS questions, the majority agreed that insurance coverage should be equal to other conditions (96%), would not mind being called in to care for this population (75%), felt they could find something to help the patient feel better (65%), felt compassion (65%), found working with SAD patients satisfying (65%) and enjoyed giving extra time to these patients (51%). When asked NEG questions, 40% responded it was difficult to work with these patients, 25% reported irritation, 23% preferred not to work with SAD patients, 13% felt there was little they could do to help, and 2% felt it was a waste of medical dollars. When asked POS burn specific questions, the sample was split 50/50 in regard to efficacy of current practice to manage withdrawal symptoms, 92% felt that these patients experienced more anxiety, had other mental health disorders (98%) and that pain management was particularly difficult (98%). When asked NEG burn specific questions 48% felt the care they provided was appreciated, and only 62% felt safe when providing care.

Conclusions

The majority of staff reported willingness to help these patients yet reported difficulty in working with the population. Staff felt that these patients were more apt to have concurrent mental health disorders and increased anxiety. Management of pain and withdrawal symptoms were identified as areas of care that need improvement. It is concerning that 38% of staff felt unsafe in providing care. Identification of bias and barriers is the first step in an initiative to optimize protocols that will improve patient outcomes and work experiences.

Applicability of Research to Practice

Protocols specific to the burn population that suffers from concurrent SAD are needed to optimize care.
749 Does a Dedicated Burn Therapist Add Value in an Outpatient Setting?
Authors: Rainey Kristin , Rosenthal Jennifer
Published: May 2023

Introduction

Caring for burn patients requires specific knowledge, skill, and a collaborative team approach from multiple disciplines including occupational therapy. In the hospital system, therapists are often under direction of rehabilitative services, not nursing administration. There are specific productivity expectations within the rehabilitation department which rely heavily on time-based billed interventions. This hospital had an occupational therapist (OT) assigned to the burn clinic as well as acute care patients to help improve the therapist’s productivity. With a growing burn clinic, some patients were missed by the OT while they were providing services elsewhere in the hospital. With support and advocacy from the nursing Director of burn services, a full-time occupational therapist was hired solely for the outpatient burn clinic to improve the care of burn patients. Prior research has focused on the importance of OT in treatment of the burn patient, however no research was found in regard to the benefit of hiring a therapist specifically for an outpatient burn setting. This information is crucial for hospital administration to determine the need of having a burn-dedicated therapist. Specialized training in wound care, splinting, measuring and assessing for custom compression garments, and burn-specific evidence-based practice is required for a therapist to be competent in a burn center. Having a specialized burn therapist available is vital for the optimal care of the burn outpatient. This study analyzes the benefits of having an OT dedicated to the burn clinic compared to an OT being staffed for both the inpatient and outpatient needs.

Methods

A retrospective chart review was performed for 6 months prior to hiring a full time OT in the clinic to 6 months after.

Results

Preliminary data taken from October 2021 to present indicate a growth in OT services provided in the burn clinic from an average of 0.64 patients and 2.44 billed productive units per day to 3.9 patients and 12.4 units per day. At over 500% increase in just 3 months of hiring a full time OT, the data indicates that adding a burn therapist in the clinic increases number of patients seen. Productive units billed by the therapist also increased over 400%. Data regarding the amount of revenue are pending.

Conclusions

Having a dedicated burn therapist in an outpatient clinic increases the number of patients receiving necessary OT services and subsequently improves financial reimbursement.

Applicability of Research to Practice

Consistent availability of the OT, increased understanding of the role, purpose, and value of OT for the burn patient, increased communication with providers, and higher efficiency due to proximity to patients and providers result in increased use of OT services. Hiring a dedicated burn therapist in an outpatient setting should be considered by burn centers to increase number of patients seen and increase productive billable units by OT within the burn clinic.
751 Burn Therapy Certified Therapists Representation within Burn Society Leadership
Authors: O'Neil Audrey , Murray Derek , Warthman Renee
Published: May 2023

Introduction

The American Burn Association (ABA) Burn Therapist Certification (BT-C) program, developed in 2018, derived from an organizational desire to promote vetted quality burn care across the interprofessional team. Leadership positions within organizations, are responsible for formulating policy, developing education, and providing oversite to ensure the success of the association. A previous study examining interdisciplinary representation within burn society leadership for the ABA and International Society of Burn Injuries, found that rehabilitation representation within governance positions was 7% and 9% within committee memberships. In a 2022 Letter to the Editor, therapists described limited center support as a barrier for obtaining BT-C. This study aims to examine BT-C member involvement within ABA society leadership.

Methods

Official ABA society and membership websites were accessed to identify BT-C recipients who currently hold positions within society governance and committee memberships. ABA Special Interest Group (SIG) membership was also examined. The Journal of Burn Care and Research (JBCR) website was accessed to identify BT-C recipients on the editorial board. BT-C members were compared to other therapist involvement.

Results

Of 32 qualified BT-C therapists, 26 continue their ABA memberships. BT-C therapists hold 3 Governance positions (Board membership and current ABA President) and maintain 36 of the available 77 committee positions (47%). Excluding the BT-C Committee from data collection, BT-C therapists make up 44% (n=23) of therapist committee positions within the ABA. BT-C therapists hold a combined 46 SIG memberships. The JBCR currently lists 2 therapists on the editorial board, both of whom are BT-C.

Conclusions

Despite representing a fraction of the burn therapy community, BT-C therapists continue to be leaders within the burn field by participation in ABA membership, governance, and committee memberships. Current BT-C therapists serve to establish standards in research published within the JBCR. Professional and academic societies depend on qualified leaders to set standards of burn care. Promoting BT-C within individual burn centers may stimulate leadership within the center and burn professional organizations.

Applicability of Research to Practice

Definitive evidence supporting the benefits of BT-C to individuals and organizations is needed to overcome current barriers to certification.
752 Burn Rehab Guidelines Following Application of Cultured Epithelial Autografts For Closure of Large Burn Wounds
Authors: Sabbatini Sarah , Hill David
Published: May 2023

Introduction

As the use of CEA by burn surgeons becomes more widespread, the existence of an experienced and dedicated burn therapy team, educated in post-operative care and treatment of CEA, is essential to short and long-term success of patients post-CEA, and their ability to achieve and maintain maximum functional status. Early mobilization of patients is an important aspect of treatment in the BICU, and has demonstrated a positive effect on patient outcomes throughout the continuum of care. However, postoperative treatment practices following application of CEA vary across burn centers, depending on experience and perceptions of CEA fragility and expense.

The objective of this case series is to review one burn center’s therapy treatment plan before and after CEA application, and short and long-term outcomes in response to early implementation of therapy interventions. The hypothesis is early mobilization of patients after CEA can be achieved without negative consequence of graft loss.

Methods

This single-center, retrospective case series utilized electronic chart review to assess patients admitted between Apr '15 and Apr '20 who received CEA. Demographics, injury characteristics, surgical procedures collected. Therapy interventions and outcomes also collected, including postoperative therapy treatment plans, functional status at and following discharge, and occurrence of graft loss and contracture formation. Data collected analyzed with descriptive statistics.

Results

8 patients met inclusion criteria for the case series. Median post-operative day for initiating positioning techniques post CEA application was POD0 (0,0); POD6.5 (3.75,7) for active, passive elongation; POD12 (11,15) for out of bed mobilization, functional mobility training; POD25 (17.75,25) for return to treatment in therapy clinic. All 8 patients demonstrated 0% occurence of graft loss and 0% contracture formation; none of the patients required reconstructive surgical procedures as a result of decreased joint mobility. In addition, 6 out of the 8 patients were admitted to the burn-specific inpatient rehab program, and all achieved a functional status of independent community locomotor upon discharge, including return to work and leisure activity.

Conclusions

Early implementation of therapy interventions by burn therapists trained in post-op treatment of CEA resulted in optimal short and long-term functional patient outcomes following closure with CEA. Early mobilization of patients in the BICU post-CEA did not result in any graft loss related to therapy treatment, despite the increased risk for shearing due to the physiological structure of CEA. 75% of patients reviewed in this case series achieved functional mobility skills required for independent living upon discharge, as well as return to work or leisure activities, after receiving treatment in a burn-specific inpatient rehabilitation facility within the burn center.

Applicability of Research to Practice

n/a
754 A Longitudinal Study of Compression Therapy in Pediatric Burn Patients
Authors: Tran Sinh , Han Syra , Saade Daoud Maria , Gupta Deepak
Published: May 2023

Introduction

Compression Therapy is crucial to managing and preventing hypertrophic scarring. The pediatric population can be especially at risk for hypertrophic scarring due to rapid growth periods and/or discomfort which interferes with compliance. Our previous practice was for pediatric patients to be scheduled every 6 -12 months like the adult burn population. To address this issue, we hypothesized pediatric patients would benefit from more frequent follow up visits. We arbitrarily determined to follow our pediatric patients every 3-4 months for garment remeasuring to improve proper garment fit, efficacy and compliance.

Methods

A longitudinal study was conducted to determine whether 3–4 month interval check-ups would improve compliance of garment wearing and presumably efficacy of overall management of hypertrophic scarring. Data was collected between June 2020 – December 2021 (1 ½ years). The data was manually retrieved from our Electronic Medical Record.

Results

Prior to June 2021, children were routinely scheduled in the Burn Clinic at intervals between six and twelve months for scar checks (same as adults). Children were not able to participate in long term compression therapy for the entire interval for several reasons including growth, size changes, garment failure, expired insurance authorization, and possibly lack of knowledge.

We decided to schedule consistent follow-up of pediatric patients every 3-4 months, to ensure consistent remeasuring of garments was completed.

Pre intervention results noted that only 35% of patients had a 2nd garment remeasured as compared to our post intervention results which showed that 88% of patients successfully had a 2nd garment remeasured.

Conclusions

Our data suggests that short interval follow up with pediatric burn patients for scar management has led to improved rates of compression therapy compliance and presumably efficacy.

Applicability of Research to Practice

We have continued the practice of short term follow up in pediatric burn patients for scar management and our data has also provided opportunities to reinforce education with patients and their families. We have found that with better understanding, our patients and families are motivated to seek out and comply with longitudinal care.
757 Diabetes Mellitus Associated with Worse Outcomes in Stevens-Johnson Syndrome and Related Diseases
Authors: Chandran Keshav , Ozhathil Deepak
Published: May 2023

Introduction

Stevens-Johnson Syndrome(SJS),toxic epidermal necrolysis(TEN), and SJS/TEN Overlap Syndrome are on the same spectrum of severe blistering skin diseases affecting mucosal surfaces of the body.They have an immunological etiology and are caused by toxins, drugs, or infectious agents. The mortality rate for patients with these conditions ishigh, but there is limited research on the outcomes for those patients with additional comorbidities.This study investigates the association of inflammatory conditions such as diabetes mellitus, obesity, and tobacco usage have on the outcomes of patients with SJS or related disease. It was predicted that each of these comorbidities would be associated with higher rates of mortality and disease complications.

Methods

This study is a retrospective observational cohort study using the TriNetX Research Network, which provides deidentified electronic medical data from health care organizations all over the world. TriNetX was used to perform a search and analysis for patients with SJS, SJS-TEN Overlap Syndrome, and TEN as well diabetes mellitus(DM), tobacco usage(TU), or overweight/obesity status.A fourth, control cohort of patients without any comorbidities was also included. In total, 8,962 patients were included in the study: 6,348patientsin the control group;426 patients in the TU group; 1,186 patients in the DMgroup, and 1,002 patients in the Obesity group. Outcomes measured were rate and incidence of pneumonia, sepsis, and endotracheal intubation. Outcome variables from each of the four cohorts were analyzed with a total of six unique comparisons. Statistical analyses used included measure of association, Kaplan-Meyer Survival Curve, and measure of incidence.

Results

Compared to the control group, the DM group had a mortality rate14.3% higher(CI 95%, 11.8% -16.9%), pneumonia rate7.6% higher (CI 95%, 5.4%-9.9%), sepsis rate 4.7% higher (CI 95%, 6.9%-11.4%), and endotracheal intubation rate of 1.9% higher (CI 95%, 0.8%-3.0%). Furthermore,compared to the Obesity group, the DM group had a mortality rate 11.6% higher (CI 95%, 8.5%-14.8%)and sepsis rate 4.7% higher (CI 95%, 1.7%-7.6%). Compared to the TU group, the DM group had a mortality rate 12.4%higher(CI 95%, 8.5%-16.3%)and sepsis rate 8.1% higher (CI 95% 4.7%-11.6%). Besides this data on the DM group, the Obesity group showed statistically significant worse outcomes as well. Compared to the control group, the Obesity group showed a mortality rate 2.7% higher (CI 95%, 0.5%-4.9%), pneumonia rate 5% higher (CI 95%, 2.7%-7.3%), sepsis rate 4.5% higher (CI 95%, 2.3%-6.6%), and intubation rate of 2.1% higher (CI 95%, 0.8%-3.4%).

Conclusions

Diabetes mellitus is associated with worse outcomes for patients with SJS, SJS-TEN overlaps, or TEN compared to obesity and tobacco usage.

Applicability of Research to Practice

This data argues the importance of examining a patient’s past medical history when evaluating their prognosis for SJS, SJS-TEN overlaps or TEN.
758 Correlation between initial and diagnostic bronchoalveolar lavage isolates among patients with inhalation injury and pneumonia
Authors: Gaskins Devin , Coston Taylor , Arbabi Saman , McClellan John , West T Eoin , Stewart Barclay , Bailey Austin
Published: May 2023

Introduction

Inhalation injury is associated with increased risk of pneumonia. Bronchoscopy with bronchoalveolar lavage (BAL) is commonly used to diagnose and grade inhalation injury while obtaining a microbiological sample. It has been shown that a quarter of patients with inhalation injury have a single bacteria isolated from initial BAL within 12-48 hours of injury. The clinical significance of this and role of antibiotics in this setting are unknown. We investigated the incidence that bacteria isolated during a pneumonia episode were previously isolated on surveillance BAL among patients with inhalation injury.

Methods

Among patients with inhalation injury admitted to a large ABA-verified burn center from 2009-2022, microbiological isolates from initial BAL and subsequent culture obtained during a pneumonia episode (BAL, sputum), were extracted from medical records. Abbreviated injury severity score (AIS) was used to grade inhalation injury. Hospital-acquired pneumonia (HAP) was defined using CDC PNU1 criteria, and ventilator-associated pneumonia (VAP) was defined using PNU2 criteria with BAL cutoff >10,000 colony forming units (CFU).

Results

Two-hundred forty-eight patients with inhalation injury who underwent bronchoscopy for airway inspection and surveillance BAL within 48 hours of injury were included in the analysis. Of the 111 who had a bacterial isolate from initial BAL, 23 (21%) subsequently developed HAP or VAP during the hospitalization. Median (IQR) days between bronchoscopy and pneumonia diagnosis was six (2-8.5). In three of the 11 VAP cases (27%), the organisms identified at pneumonia diagnosis matched the organisms identified on initial BAL. Antibiotic use on admission was not associated with re-culture of initial BAL organism during a subsequent pneumonia episode (p=0.071).

Conclusions

Among patients with inhalation injury and bacteria isolated on surveillance BAL, 21% developed pneumonia during their hospital stay, usually with different bacteria than those isolated at initial bronchoscopy. There was no association between empiric antibiotic use and incidence of initial BAL organisms re-cultured during subsequent pneumonia episode.

Applicability of Research to Practice

Findings suggest initial BAL isolates cannot guide empiric coverage of pneumonia for patients with inhalation injury. This remains an important area of future research.
759 Comparing Burn Model System and ABA Registries: Differences in Sample Demographics and Burn Characteristics
Authors: Bamer Alyssa , Humbert Andrew , McMullen Kara , Carrougher Gretchen , Stewart Barclay , Gibran Nicole , Kowalske Karen , Schneider Jeffrey , Solis Kyra Jeanine , Suman-Vejas oscar , Yenikomshian Haig , Amtmann Dagmar
Published: May 2023

Introduction

The Burn Model System (BMS) collects longitudinal data on burn survivors. This provides a unique resource for the burn research community, however, as patients are only enrolled in select sites across the United States, it is important to examine how similar the BMS participants’ demographics and burn characteristics are compared to the broader burn community. The purpose of this study was to compare burn survivors in the BMS to those in the American Burn Association’s (ABA) National Burn Registry (NBR).

Methods

Demographic (age, sex, and race/ethnicity), injury (total burn surface area, etiology, presence of inhalation injury), and treatment (length of acute hospital stay, ventilator days) characteristics (as categorical variables) were compared between the BMS and ABA NBR for those with acute burn injuries from 2009 to 2014 who survived to hospital discharge. Differences and 95% confidence intervals were calculated for each category for adult and pediatric participants. Due to the large sample size and high power to detect non-meaningful differences, clinical significance was determined with the following criteria: a difference of >10% was major, 5-10% was minor, and < 5% was inconsequential.

Results

A total of 1,080 BMS (765 adult; 315 pediatric) and 111,270 ABA NBR (77,528 adult; 33,742 pediatric) burn survivors were analyzed. Among adults, no notable differences were present for demographic characteristics. However, adults in the BMS had lower rates of injuries caused by scalding, higher rates of burn size over 15%, hospital stays more than 7 days, and any ventilator use. Similar trends were seen in children, however, BMS pediatric participants tended to be older, identified more frequently as Hispanic, and had higher rates of inhalation injury compared to the ABA NBR.

Conclusions

Differences in demographic characteristics were inconsequential between the BMS and ABA NBR among adults. As expected, given the BMS inclusion criteria, BMS participants had more severe burns on average. Among children, major differences existed in many demographic, injury, and treatment characteristics. In part, these differences can be attributed to the difference in enrollment criteria between the databases and the over-representation of children from a single BMS site. Expanding the number of BMS centers and standardization of variables to allow for matching on inclusion criteria may improve the ability to compare the BMS with other samples.

Applicability of Research to Practice

Due to differences in inclusion criteria, the BMS and ABA NBR differ in many patient characteristics.
767 Tracking Changes in Pain Ratings between Admission to Discharge at a Regional Burn Center
Authors: Smith Lisa , Khan Iman , Lagziel Tomer , Cox Carrie , Caffrey Julie , Lerman Sheera
Published: May 2023

Introduction

The complex nature of burn pain has debilitating effects on burn patients’ physiological and psychological wellbeing. Characterized by its overwhelming intensity and extensive duration, burn pain involves inflammatory and neuropathic components. These pain responses vary in depth, severity, and sensation during and after the healing process. Despite best efforts, burn pain remains a widespread challenge for providers to effectively predict and address.

Methods

A retrospective chart review of 442 patients admitted to the Burn Center for treatment of burn injuries between January 2015 and February 2022 was conducted. Charts of patients age >18 and length of stay >4 days were included in the analysis. Mean age on admission was 50.13±17 years and 34% of the sample were female. Data on clinical and demographic factors was extracted electronically and manually from patients’ electronic medical records. Numerical pain scale ratings documented by nursing were averaged for the first and last 48 hours of patients’ hospital stay. Linear regression analysis was performed to assess significant predictors of pain prior to discharge.

Results

We controlled for TBSA, length of stay, gender and psychiatric diagnosis and discovered that pain within the first 48 hours of admission and age were statistically significant predictors of average pain prior to discharge. Specifically, younger age was associated with increased pain ratings. When comparing average pain levels between the first and last 48 hours, 22% reported an increase of more than 1 point in their pain, 42% had no difference in average pain ratings, and 36% reported a decrease of more than 1 point. Prior to discharge, 36% of the sample reported pain higher than 6 and 17% reported pain greater than 7.

Conclusions

Heightened pain is challenging in burn injuries even prior to discharge, especially for younger patients and those who report initial high levels of pain. For many burn survivors, pain remains the same or worsens from admission to discharge, putting them at risk for negative outcomes such as chronic pain, PTSD, suicidality, sleep disturbances, and reduced function. Future research is needed to determine if early intervention can serve to mitigate these risks and improve long term recovery and quality of life.

Applicability of Research to Practice

Patients at risk for increased pain upon discharge can be identified by understanding the factors contributing to this phenomenon during early treatment. Early, targeted, evidence-based interventions during treatment and following discharge will allow effective management of pain. Younger patients and patients with higher initial pain should be closely monitored and given multimodal pain interventions, thereby enhancing their comfort and overall recovery process.
768 Intraoperative Use of Intravenous Methadone and Post-Operative Opioid Requirements in Adult Burn Patients
Authors: LaChapelle Christopher , Ringqvist Jenny , Pham David , Shukla Vrinda , O'Connor Caitlin , Wu Braden , Ambardekar Aditee
Published: May 2023

Introduction

Post-operative pain management can be a significant challenge in patients undergoing burn excision. Standard pharmacologic pain management strategies include both opioid and non-opioid medications. Given the national overuse of opioids and the associated negative repercussions, it is prudent that we find ways manage pain with fewer or no opioids. We hypothesize that intraoperative administration of intravenous methadone will reduce the total morphine milligram equivalents (MME) used in the 36 hours following surgery.

Methods

This is a retrospective single-center cohort study of adult burn patients who underwent a first excision of full thickness burn between January 2019 through January 2021. The exposure group received intraoperative methadone while the control group did not. The primary outcome was total MME utilized in the 36 hours following surgery. Secondary outcomes included average pain score and post-anesthesia care unit (PACU) total MME utilized. Chi squared tests were used for statistical analysis of categorical variables and unpaired t-tests were used for continuous variables.

Results

The control group contained 35 subjects and the methadone group contained 19 subjects who did not differ in baseline characteristics. The average burned total body surface area (TBSA) was 9% in the control group and 18% in the methadone group (t(53)=-3.9, p < 0.01). Intraoperative narcotic requirements did differ between groups due to intravenous methadone utilization in the intervention group (t(53)=-15, p < 0.01). In the early post-operative period, the methadone group received 155 MME while the control group received 137 MME (t(53)=-0.36, p = 0.72). While in the PACU, patients in the methadone group received 5 MME while the control group received 12 MME (t(53)=1.60, p=0.12). Patient pain scores did not differ significantly between the groups (t(53)=-0.15, p=0.88).

Conclusions

Intraoperative utilization of methadone for burn surgery did not affect post-operative opioid usage in the first 36 hours or post-operative pain scores in a statistically significant manner. We acknowledge the data set is not large enough to power the study to detect a significant difference; additional data collection is ongoing to include several hundred subjects. Confounding variables such as different multimodal pain regimen techniques, % TBSA, extent of surgical excision, and history of opioid tolerance may exist within this data set. Further analysis is warranted to adequately power this study and account for potential confounding variables.

Applicability of Research to Practice

Intraoperative use of intravenous methadone may reduce use of opioid medications in the early post-operative period.
774 Providing Essential Burn Reconstructive Surgery in Resource-Limited Environments Using a Cleft Organization
Authors: Collier Zachary , Tapia Maria Fernanda , Bustamante Atenas , Daradkeh Heba , Celie Karel-Bart , Magee III William , Gillenwater Justin , Amarin Marzouq
Published: May 2023

Introduction

Cleft non-governmental organizations (NGOs) collaborate with multidisciplinary teams of healthcare professionals to provide safe and effective cleft surgery in resource limited environments. Unfortunately, other significantly disabling conditions like burns, which require similarly multidisciplinary reconstructive interventions, often lack the same degree of local and international support. Therefore, cleft NGOs are well positioned to support essential reconstructive burn care through sustainable service delivery models like those developed for cleft care.

Methods

An NGO with experience delivering global cleft care established a collaborative effort in COUNTRY between local and international burn experts from to provide burn care. Preoperative screening was performed by a local burn surgeon to identify patients. Virtual conferences were held bi-weekly to discuss candidates and operative planning. Following 3 months or preparation, a 5-day surgical program with a mixed team of COUNTRY and international volunteers was held. Patient demographics, interventions, and outcomes were monitored to determine efficacy of this Cleft NGO at delivering essential burn reconstruction.

Results

Of the 52 burn patients who were screened, 32 were surgical candidates, and 20 received a total of 26 surgeries during the 5-day program. Average age was 17 ± 16 years with 65% (13) females and 25% (5) refugees. Most had scald (65%) or flame (30%) burns from household accidents with average age at burn of 8 ± 12 years. Random pattern flaps were used in all cases. Only 1 patient required supplementary skin grafting. Seven patients had multiple operative sites that were addressed with a 2-team approach. No perioperative complications occurred. All patients were followed-up by the in-country team between 7 and 42 days. Five patients presented with minor complications - 5 flaps with partial necrosis and 2 partial dehiscence. None required surgical intervention.

Conclusions

Cleft NGOs have the resources and experience that allows them to implement impactful surgical programs for other conditions that are critically lacking access to essential reconstructive care.

Applicability of Research to Practice

Cleft NGOs can provide safe and effective burn surgery through collaborative local and international efforts aimed at sustainability and capacity building.
776 Importance of Adequate Nutrition Support in Severely Burned Patients
Authors: Stone Amanda
Published: May 2023

Introduction

The importance of optimal nutrition for burned patients has been well established through research. Provision of adequate nutrition is believed to improve healing outcomes, reduce complications and overall length of stay for burned patients. Enteral Nutrition (EN) support is the favored method of feeding for a severely burned patient, however timing of initiation of feeding and ability to meet estimated nutritional needs throughout a hospital stay still needs to be further established. The objective of this study was to evaluate not only the timing of initiation of EN for severely burned patients, but also the adequacy of the nutritional provisions the patients received.

Methods

Patients admitted to a Regional Burn Center with a burn ≥20% TBSA, intubated and started on EN support were eligible for the inclusion in this retrospective review. Specific variables that were assessed included time for burn team to consult Registered Dietitian (RD), time from consult until RD assessed patient, time from admission to initiation per order, total tube feed volume (in mL) actually infused per RN documentation, and percentage of EN received compared to order.

Results

Forty-two patients were included in this retrospective review. All patients had EN initiated within 24 hours of admission. Out of twenty-five patients that specific EN initiation time (by the minute) was able to be identified, the average time for EN to start was 9.5 hours. Average time for enteral nutrition to reach RD recommended goal rate was 26.2 hours, with 59% of patients reaching goal rate in ≤24 hours. Average amount of EN formula (in mL) patients actually received compared to what was ordered was 80.9%. Some complications observed for those patients whose EN did not reach goal rate in ≤24 hours or those who received a lower percentage of EN formula included difficulties with GI tolerance, high residuals, and incidence of ileus. However, these complications were only seen in 19% of patients included in the study.

Conclusions

The average time for initiation of EN support was within the SCCM/ASPEN guidelines for the critically ill patient. Additionally, more than half the patients reached the RD recommended EN goal rate in ≤24 hours. The investigator found that early initiation of EN and aggressive advancement to goal, as tolerated, to be safe.

Applicability of Research to Practice

A standard of practice for timing of EN initiation and advancing to goal would be beneficial, with possibility of reaching EN goal rates faster helping to increase the provisions of total EN received during admission and therefore closer meeting estimated nutritional needs. The effects of adequate nutrition in relation to overall burn healing / graft acceptance, complications, length of stay and mortality all warrant further studies prior to implementation of early EN/aggressive advancement to goal into practice.
777 Food Swamps, Food Deserts, and Wound Healing in Burn Patients at an Urban Academic Center
Authors: Donovan Brienne , Wiese Daniel , Wu Jingwei , Rae Lisa , Anderson Jeffrey , Henry Kevin
Published: May 2023

Introduction

Many victims of burn injury live in food deserts or food swamps. Food deserts are low-income areas with minimal or no access to nutritious foods while food swamps are areas with much greater access to unhealthy, high-calorie foods. We examined the relationship between residency in a food swamp or food desert by census tract and wound healing.

Methods

We performed a retrospective review of burn patients who underwent split-thickness skin grafting at an ABA verified urban academic burn center between September 2018 and August 2022. Inclusion criteria were burn area less than 20% total body surface area (TBSA), age ≥ 18, and single operation for split-thickness skin grafting. Patient residential locations were used in conjunction with Modified Retail Food Environment Index (mREFI) data to classify residency in food deserts and food swamps. The primary outcome was time to donor site healing. Time-to-event Cox proportional regression analysis was performed to evaluate risk factors for poor wound healing.

Results

A total of 238 patients were included in the study, of whom 110 (46.2%) were female and 128 (53.8%) were male. Mean age was 48, BMI was 28.5, TBSA 3.7, and average days to donor site healing was 26. In categorizing residency by mREFI data, 45 (18.9%) individuals had good access, 11 (4.6%) resided in food deserts, and 182 (76.5%) resided in food swamps. Although time to healing was longer on average in the food desert (25.8 days) and food swamp (26.4 days) groups compared to the group with good access to food within ½ mile (22.9 days), this difference was not statistically significant. Not having diabetes was found to be associated with shorter time to wound healing (HR=1.68, 95% CI [1.15, 2.47], p=0.007). Living in a good access area was associated with faster wound healing (compared to swamp: HR=1.23, 95% CI [0.86, 1.75], compare to desert: HR=1.06, 95% CI [0.51, 2.20]), however this association was not statistically significant.

Conclusions

Residency in a food swamp or food desert does not significantly influence time to healing in burn injured patients. However, not having diabetes was associated with a shorter time to wound healing. This is the first study to compare residency in food deserts or food swamps by census tract level data with time to wound healing in an urban burn population.

Applicability of Research to Practice

Wound healing is a complex and important process known to be affected by malnutrition. Our data contributes to the current body of literature on nutrition and wound healing.