bluuebunny/crossref_metadata_2025 huggingface dataset:
580 Regional Anesthesia for Autograft Donor Sites
Authors: Canady Kristina , Loyd Jacob M , Mueller Scott W , Gibson Cameron , Moorehead Brianna , Wiktor Arek J
Published: April 2024

Introduction

Pain control remains a significant problem in burn patients. To some extent, increased pain can be predicted during the first 24-48 hours following donor site placement and during donor site dressing takedowns. Our objective was to evaluate the utilization of regional anesthesia in the form of single shot nerve blocks (SSNB) on pain in the perioperative setting of a donor site placement and prior to a donor site takedown.

Methods

We performed a retrospective cohort study with prospective secondary survey examining SSNB effectiveness at our ABA verified burn center. Patients were candidates for SSNB if autograft donor sites were predicted to remain within femoral nerve sensory distribution zones. Opiate requirements 48 hours prior to and following SSNB as well as procedural requirements during the previous major wound care session or surgical case were collected. Procedural and overall opiate requirements were compared with and without a SSNB. Similar data were collected in a cohort of patients who did not receive a SSNB but otherwise would have qualified for one. A matched-pairs analysis compared each patient against themselves (pre-post). Surveys were administered to patients and staff on perceived effectiveness and pain scores.

Results

A total of 13 blocks were administered, 9 for a donor site take down. Patients were predominantly male (n=8) with a median (interquartile range) age of 44 (28.5, 58.5) and TBSA 3% (1.9, 6.8). SSNB was associated with less intra-patient procedural fentanyl and a trend in less midazolam requirements between matched groups, mean difference of 89.4mcg (p=0.049) and 0.62mg (p=0.055), respectively. Eleven patient and six staff surveys were completed. There were no significant differences in patient reported pain/effectiveness between matched groups (p=0.13). 4 patients reported zero pain, 2 had 50% or greater decrease. However, 4 patients reported increased pain/discomfort: 1 due to SSNB administration and 3 due to “heavy or numb sensation”, but not pain itself. Staff perception of pain control improved from agreed (83.3%) to strongly agreed (66.7%), p=0.04. Overall total opiate exposures were not different pre-post block at 0-24 or 24-48 hours, p=0.2 and p=0.14, respectively.

Conclusions

Utilization of regional anesthesia in a burn specific population may reduce the need for procedural opiates in anticipation of painful procedures. However, patient perceptions of pain/discomfort/numbness are varied, and education regarding expectations is warranted. Further research is needed to fully assess the effectiveness of SSNB for burn patients.

Applicability of Research to Practice

In selected patients, SSNB can be a useful adjunct to reduce procedural opiates.
583 Risk Factors Associated with Subtherapeutic Enoxaparin Levels in Burn Patients
Authors: Pinto Desiree , Lee Sophia , Johnson Cory , Halabi Rola A , Tejiram Shawn , Travis Taryn E , Moffatt Lauren T , Shupp Jeffrey W
Published: April 2024

Introduction

A hypermetabolic state develops after severe burn injury altering volume distribution, creatinine clearance (CrCl), and hepatic metabolism. This ultimately impacts pharmacokinetics of drugs, including enoxaparin, the standard prophylactic venous thromboembolism (VTE) anticoagulant. Understanding specific factors in burn patients that impact the pharmacokinetics of enoxaparin is necessary to reduce rates of VTE. This study aims to identify risk factors associated with subtherapeutic levels of enoxaparin, measured by peak anti-Xa levels, in burn patients.

Methods

Patients admitted to a regional burn center over a six-month period were included in this retrospective review. Patients on enoxaparin 40mg twice a day (BID) for VTE prophylaxis and had a peak anti-Xa level were included. Exclusion criteria included polytrauma, therapeutic anticoagulation or anti-platelet therapy, a history of chronic kidney disease, cirrhosis, coagulation disorder, heparin induced thrombocytopenia (HIT), or thrombocytopenia at admission. Patient demographics, burn injury characteristics, and lab values for peak anti-Xa levels and admission CrCl were obtained. For prophylactic enoxaparin, a therapeutic level is 0.2-0.4U/mL and a subtherapeutic level is < 0.2U/mL. Patients were separated into groups based on therapeutic or subtherapeutic levels. Differences between groups were evaluated using two-sample t-test or Wilcoxon rank-sum test.

Results

Both the subtherapeutic and therapeutic groups had 13 patients. No patient developed a symptomatic VTE within 31 days of discharge. There were no significant differences in gender, BMI (30.4 vs 31.6 kg/m2), presence of inhalation injury, or ICU length of stay (5 vs 3 days) between groups. Patients in the subtherapeutic group were significantly younger (38 vs 48 years), with a higher TBSA (22.6% vs 6%), and a higher CrCl at admission (134.2 vs 104.8 mg/dL). In the subtherapeutic group, the highest dose needed to reach a therapeutic level of enoxaparin was 60mg BID and the median final dose was 50mg BID.

Conclusions

A delay in initiation of VTE prophylaxis is associated with increased rates of VTE in burn patients, and a delay to therapeutic levels of VTE prophylaxis will likely lead to increased rates of VTE as well. Factors associated with a delay to therapeutic enoxaparin levels were age, %TBSA, and CrCl. A uniform standard dose of enoxaparin may not be effective for all burn patients.

Applicability of Research to Practice

Burn patients are a unique subgroup that require special consideration in every aspect of care, including VTE prophylaxis. Risk factors associated with subtherapeutic enoxaparin levels after burn injury need to be identified to guide the development of effective VTE prophylaxis guidelines.
587 Pharmacy Residents Have a Significant Impact on Process Improvement at Verified Burn Center
Authors: Lauzon Megan , Ko Caroline , Lau Sherman , Vargas Vina , Zaballero Lea , Karanas Yvonne L , Sheckter Clifford C
Published: April 2024

Introduction

Quality and process improvement are vital for burn centers to maintain patient safety, systematically review complications, and adopt new practices involving technology, medications, and staff development. The pharmacy is involved in every facet of burn care from the intensive care unit to the operating room. Pharmacy residents participate in quality and process improvement projects during their training, but little published data exists on how pharmacy residents contribute to overall process improvement in a verified burn center.

Methods

Postgraduate Year-Two (PGY2) pharmacy residents specializing in critical care rotate through the Burn Intensive Care Unit (BICU) for 6 weeks. In addition to patient monitoring, advising, and multidisciplinary rounding, pharmacy residents develop a process improvement project for the burn center. Projects are determined in collaboration with the burn unit director, nursing management, and senior ICU pharmacist; agreement is decided with a Delphi process. After drafting, the project is presented and approved by the county hospital’s critical care sub-committee. Following completed sign-off by stakeholders, the project is presented to the Pharmacy and Therapeutics committee for official approval. Pharmacy residents spearhead implementation of the projects by further building out the electronic medical record interface.

We reviewed all PGY-2 Pharmacy Resident led process improvement projects from 2020 to 2023. The primary end point was the total number of projects and their topics. Secondary outcomes included the number of stakeholders per project along with success of each project which was determined by utilization endpoints

Results

There were a total of five projects completed over the 3-year period including: 1) smoke inhalation nebulizer panel, 2) advanced opioid analgesia, 3) stress ulcer prophylaxis panel for major burn patients , 4) delirium prevention and management, and 5) ketamine infusion for pain management. Since implementation, the burn inhalation panel has been used in 4/4 patients with confirmed smoke inhalation injury, the advanced opioid analgesia in 10/11 patients, stress ulcer prophylaxis panel in 17/17 patients, and delirium prevention and management in 91/91 patients. The ketamine infusion for pain management was recently approved and not yet live in the electronic health record.

Conclusions

Pharmacy residents are an innovative and potentiality underutilized resource for the development and implementation of pertinent process improvement projects at burn centers.

Applicability of Research to Practice

Other burn centers may wish to consider the benefits of pharmacy residents within the burn unit for targeted quality and process improvement projects.
594 A Novel Sequential Compression Appliance to Reduce Scarring of the Face
Authors: Dwertman Michelle N , Huson Henry B
Published: April 2024

Introduction

A transparent facial orthosis (TFO) is crucial for managing scars in burn cases. However, TFOs are typically static and rigid, lacking adaptability to facial movements. Their effectiveness depends on the ability to conform to each patient's unique facial contours and applying the correct amount of pressure to scars. Crafting or modifying TFOs is a time-consuming, skilled, and costly process. To address these challenges, we've developed the flexible and adaptable Sequential Compression Appliance to Reduce Scarring (SCARS) mask in collaboration with a local prosthetic and orthotic lab. This innovation is seamless, allows natural facial movement, and can be easily customized by a trained burn therapist, providing effective scar management.

Methods

SCARS Mask Design: The SCARS mask consists of two key components: a rigid transparent outer layer akin to traditional TFOs and a pliable High Consistency Rubber (HCR) silicone layer. These can be used together or separately. The inner layer offers a minimum 20mmHg pressure displayed by the Kikuhime device and remains flexible to accommodate natural facial movements, including temporomandibular joint (TMJ) mobility. The silicone layer is elastic, able to conform to facial contours, and can be color-tinted to individual skin tones. The mask features multidirectional embedded harness attachments, is lighter in weight than traditional orthotics, and can be trimmed with scissors.

Process: To create the SCARS mask, FDA-approved Platinum Silicone HCR is merged, pigment tinted, and rolled to the desired thickness. The HCR silicone is heated and molded based on a 3D scan of their face.

Clinical Trials: Successful trials on three patients with severe facial burns who exhibit significant scarring and microstomia progression, provided valuable insights. The SCARS mask's performance was noted, confirming its effectiveness.

Measurement: Each individual was given Likert scale to rate their experience.

Results

In the trials involving three patients with severe facial burns:

Patient Preference: All patients unanimously preferred the SCARS mask over traditional TFOs, rating it five on the Likert scale.

Improved Eating and Mandibular Movement: Patients experienced significant improvements in eating comfort and mandibular movement while using the SCARS mask, with an average Likert scale rating of five.

Conclusions

The SCARS mask represents a significant advancement in the field of facial orthosis. Its innovative design, flexibility, adaptability, and customizable features offer a promising solution for individuals with burn-related facial scarring, enhancing both comfort and treatment effectiveness.

Applicability of Research to Practice

This pliable appliance enhances comfort and adherence in managing facial scar hypertrophy. Its customization, allowing color-tinting to match skin tones, and cost-effective modification make it a valuable tool for improving scar management outcomes of facial scarring.
600 A Meta-analysis of Expected In-patient Burn Mortality Rates
Authors: Elloso Margarita S , Tedesco Diana , Jeschke Marc G
Published: April 2024

Introduction

Improvements in burn care have significantly decreased burn-related mortality over the last several decades. However, a small percentage of patients admitted to burn centers still die from their burn injuries. There is a paucity of information as to the rate of burn deaths at specific time points. The purpose of this study was to determine an updated estimate of overall burn mortality as well as expected event rates within 30-, 60- and 90- days post-burn admission.

Methods

A search of the existing literature was conducted using PubMed and Google Scholar databases in December 2022. An additional search of relevant primary literature and review articles was performed. Title and abstract screening was performed, followed by full-text reviews. Studies related to burns including patients ≥ 16 y/o with sample sizes ≥ 250 reporting overall in-hospital mortality and mortality at 30-, 60- and/or 90- days post-admission were included in the analysis. Studies including pediatric populations in analyses and patients with non-burn etiologies were excluded. A secondary analysis of adult patients admitted to our burn centre between 2006-2021 were included.

Results

A total of selected 9 studies were included in the meta-analysis (4 retrospective, 1 prospective, 1 double-blind, randomized, placebo-controlled trial, and 1 Phase III, multi-center, open label, investigator-initiated, randomized trial) in addition to 2611 patients admitted to our burn centre. A total of 10,824 patients were included in our analysis.

The overall mortality rate of the included studies is 8.51%. By 60-days post-admission, the overall mortality rate of 6 studies was 7.51%. By 90-days post-admission, the overall mortality rate is 11.66%.

The expected mortality rate at 30 days is 6.62%, at 60 days 2.99%, and at 90 days 0.91%. The mortality rate within the first 30 days of admission is 6.6% (95% CI 6.3-6.9%). A decreasing trend in mortality is noted at 60 days of admission which is 1.64% (95% CI 1.4-2%), 90 days of admission 0.5% (95% CI 0.43-0.67%), and 120 days of admission 0.3% (95% CI 0.17-0.37%).

Conclusions

The meta-analysis shows a higher rate of mortality during the first 30 days of burn admission followed by a decreasing trend in mortality at 60- and 90-days post-admission.

Applicability of Research to Practice

Our findings suggest further inquiry into factors contributing to increased mortality within the first 30 days of hospital admission as well as the development of effective therapeutic strategies to decrease the rate of mortality.
700 Early Heart Rate Trend Predicts Burn Mortality
Authors: Biswas Arushi , Kuo Keith T , Rajagopalan Shanmuga Priya , Tsou Terrence , Lagziel Tomer , Subramanian Madhu , Cooney Carisa M M , Caffrey Julie A
Published: April 2024

Introduction

During post-burn hypermetabolism, tachycardia is considered a compensatory response to sustain cardiac output and oxygenation to essential organs. Although heart rate variability predicts mortality in burn patients, many centers lack access to non-invasive measurement methods. We hypothesized that heart rate trend in the first 48 hours of admission (measured via vital signs monitor) could predict mortality in burn patients.

Methods

We performed a retrospective review of 128 patients treated for burns with TBSA ≥ 20% at a single institution between 2016 and 2021. We extracted demographics, burn characteristics (e.g. location, mechanism, depth, presence of inhalation injury), complications (surgical and hospital-acquired), and hourly vital signs for the first 48 hours of admission. We performed bivariate analyses to determine associations between mortality within 90 days of discharge and patient and burn characteristics. We conducted multivariate regression to examine the associations between heart rate trends and 90-day post-discharge mortality, adjusting for confounding variables.

Results

Of 128 patients, 73% were male. Median age at time of burn was 52 (IQR, 38-66). Mean TBSA was 40%. The most common burn mechanism was flame (86%). 29 (23%) patients died within 90 days of discharge. Bivariate analysis demonstrated significant associations between mortality and age, TBSA, length of hospital stay, smoking status, whether patients had surgical intervention (e.g. excision, debridement), and number of follow-up visits. On average, patients who survived experienced a 20% increase in heart rate between the 1st and 48th hour of admission, compared to a 9% increase in patients who died. Multivariate regression, controlling for age, TBSA, inhalation injury, renal injury, and vasopressor usage on admission, demonstrated that heart rate trend in the first 48 hours of admission was a significant predictor of mortality within 90 days of discharge (p< 0.001).

Conclusions

Burn patients whose heart rate increased less than 20% in the first 48 hours of admission exhibit a higher mortality risk. This underscores the need for intensified clinical surveillance and intervention for such high-risk patients, optimizing outcomes.

Applicability of Research to Practice

The conclusion drawn from this study emphasizes the role of initial heart rate trends in recognizing burn patients at elevated mortality risk, serving as a guideline for clinicians in allocating attention and medical resources more efficiently.
702 Ethnicity Does Not Change Burn Resuscitation and Time to First Excision
Authors: Abdelfattah Kareem R , Coffey Rebecca , Faris Janie J , Clark Audra , Levi Benjamin
Published: April 2024

Introduction

Burn patients sustaining a greater than 20% total body surface area (TBSA) require a systematic approach for resuscitation as these patients have a large systemic inflammatory response causing large fluid shifts. Ethnicity has been shown to influence overall clinical outcome from burn injury, but differences in the initial resuscitation between ethnicities has not been explored. This study was to identify potential racial disparities that might exist during the initial resuscitation and time to first excision.

Methods

A convenience sample of all burn patients 14 years or older admitted to one burn center between 1/1/2020 and 12/31/2021 and require formal fluid resuscitation were included. Baseline demographics, burn data, past medical history, inhalation injury and mechanical ventilation (MV) were collected. Outcomes included hospital and ICU length of stay (LOS), duration of MV, total IV fluids (ml/kg/hr.), urine output (ml/kg/hr.), and hospital mortality. Nominal data was analyzed using fishers exact and Kruskal Wallis for continuous variables. A p value of < 0.05 was considered significant.

Results

A total of 109 subjects were included in analysis. See table 1

Conclusions

Burn outcomes have been shown to be influenced by ethnicity, although the causes of these inequities are unknown. This is the first study to evaluate the potential impact of multiple ethnicities on initial burn fluid resuscitation and time to first excision. No statistically significant difference in baseline demographics, LOS, duration of MV or overall hospital mortality were found. There appeared to be no disparities in burn resuscitation and time to first excision based on ethnicity, however further studies are needed.

Applicability of Research to Practice

Effects of health disparities on burn treatment can affect outcomes
717 Survival Benefit with a Topical Anti-inflammatory with Antimicrobial Properties in Patients with >15%; TBSA Burns
Authors: Dakin Myles H E , Kenny Tom D , Aspinall Richard
Published: April 2024

Introduction

Burn units acknowledge the challenges of burn-site infection including risk to graft survival and IL-6 mediated systemic inflammatory response, sepsis, concurrent multiple organ failure and death. The risk of repeated grafts, additional ICU time and mortality correlates highly with Pseudomonas spp infection. This risk is compounded by high levels of AMR species (up to 50%) in burns units. The mortality and economic burden are significant and likely to worsen without innovation as AMR becomes increasingly prevalent.

Methods

A novel drug, based on an endogenous immunomodulatory compound (a physiologic aqueous chlorine with the acronym PAC) has been shown to possess broad anti-IL6, anti-microbial and keratinocyte activation activity. In vitro studies confirm efficacy against pathogens including AMR species. The compound is not an antibiotic and is termed compound-PAC.

Over a 50 month period, a tertiary burns unit undertook a proof of concept, open label trial to assess the impact of the compound on survival in patients with confirmed Gram -ve bacterial infections in patient with >15% TBSA. Patients with Gram -ve infection entered the study arm of the trial. Aqueous compound-PAC was administered topically via both hydrotherapy showers and soaked dressings, on a 4-6 hourly basis. In the control arm, showering was performed with normal sterile saline at every dressing change.

Data recorded age, gender, depth of burn + TBSA affected, confirmed Pseudomonas infection, length of stay, and overall survival.

Results

Results from audit analysis (blinded to treatment) revealed compound-PAC could be used to manage confirmed Gram -ve infection of burn-sites; clearing colonization of the wounds without adverse effect and maintaining this with continued use. Such treatment was also effective against other bacterial pathogens. Comparison of survival data of patients with confirmed infection treated with compound-PAC (n = 46) against patients without infection and not receiving this treatment (n= 94), revealed that study arm treatment statistically significantly improved survival compared with normal gold standard of recommended clinical care HR = 0.459 (95% CI 0.282 – 0.750 – P< 0.002). In addition, in patients with >50% TBSA, the use of compound-PAC doubled survival vs. control treatment.

Conclusions

Odds ratio analysis concluded patients receiving the study compound had 5x increased probability of survival vs the current standard of care.

Applicability of Research to Practice

The compound has ability to integrate into standard of care as a wash-drench, with potential survival, wound-healing and health-economic benefits. Further, potential, benefit may be the reduction on failure of skin grafts with reduced requirement for surgeries. A separate investigation is exploring the potential for use in treating inhalation burns.
744 The Unhoused Burn Population: An Alarming Increase of Leaving Against Medical Advice and Unplanned Readmissions
Authors: Speiser Noah , Donohue Sean J , Pickering Trevor A , Pham Christopher H , Johnson Maxwell B , Gillenwater Justin , Yenikomshian Haig A
Published: April 2024

Introduction

Unhoused burn patients (UBP) have historically been more likely to leave against medical advice (AMA) and suffer worse health outcomes compared to the general population. The COVID-19 (CV) pandemic has created major strain on the healthcare system that has resulted in worse overall health outcomes in burn patients. Currently, there is sparse data on how UBP have fared since the start of CV. We sought to investigate how CV impacted treatment for UBP, specifically the rate of leaving AMA and unplanned readmissions.

Methods

We conducted a retrospective chart analysis of UBP admitted to a regional burn center from 2014 through 2022. March 2020 was used as the cutoff to separate the cohorts into pre-CV and CV patients. Outcomes studied included leaving AMA and readmission rates within 30 days. Data analysis included distributions of continuous variables using the Wilcoxon rank sum test and dichotomous variables using Pearson’s Chi-squared test.

Results

385 patients met inclusion criteria, of which 130 were placed in the pre-CV and 255 were placed in the CV group. UBP were significantly more likely to leave AMA during CV (19.2% vs. 6.2%, p< 0.001). These patients also experienced a significantly higher 30-day readmission rate during CV (11.8% vs. 4.6%, p< 0.05).

Conclusions

CV has changed the paradigm of many health systems and the approach to treating UBP is no exception. Our findings identify two alarming increases: the rate of leaving AMA and the readmission rate in this population. While the root of this is unclear, these factors represent the inadequate care being provided to this vulnerable patient population. Future research should identify the root causes of these factors and identify early interventions to mitigate them.

Applicability of Research to Practice

Leaving AMA is associated with worse health outcomes and understanding the driving force behind this increase can improve care for this population.
750 Discharge to Door Metrics: Collaboration Matters!
Authors: Granger Jenny , Bujanda-Sotelo Nora , Hockenberry Tiffany , Richey Karen J , Foster Kevin N
Published: April 2024

Introduction

Timely hospital discharges are an essential part of patient satisfaction and emergency department throughput. The discharge process for burn patients is complex and delays can be both frustrating and anxiety producing. In addition, delayed discharges affect the financial bottom line, patients that are discharged late in the day still require care but if not on unit when midnight strikes, hospitals are unable to charge for that inpatient day. Our institutional benchmark is ≤ 90 minutes from time of written discharge order to patient leaving the center. The purpose of this quality improvement (QI) project was to evaluate our center’s current status, identify process barriers, develop interventions, and decrease delayed discharges (DC).

Methods

This was a retrospective chart review examining the relationship between placement of the DC order and the following elements, terminal dressing change, rehabilitation clearance, pending care management/transportation needs, and discharge destination.

Results

A total of 96 charts were reviewed and 47% (n=45) of center DC exceeded 90 minutes, with an average time to DC of 3 hours 33 minutes. Of the 45 patients with delayed DC, only 17 (38%) had all elements of the DC process completed prior to the order being placed. Those who did not have all elements completed were split evenly between having 1-2 tasks pending. The most frequently uncompleted tasks were pending care management/transportation needs (47%), completion of terminal dressing change (33%) and rehabilitation clearance (13%). Patients with timely DC were more likely to have been DC home (78%) compared to untimely DC (62%). A multidisciplinary task force was formed, and the following interventions were initiated; formalization of daily Clinical Resource Leaders report to include estimated discharge date, discharge destination, status of family/support discharge teaching and targeted education for the ordering clinicians, nurses, rehabilitation and the care management team. Within 4 months of instituting these interventions, delayed DC dropped to 25% and at 6 months were down to 15%. These results have been sustained and over the past 10 months less than 10% of burn DC have exceeded the 90-minute benchmark.

Conclusions

Overwhelmingly, this QI project demonstrated the importance of a fully integrated, collaborative approach to timely discharges. Discharge planning begins on admission and is an ongoing process. Establishing an estimated date of discharge, ensuring teaching is done prior to the day of discharge, ensuring wound care is complete as well as all rehabilitation and care management needs are met, are essential to making sure the patient is ready for a safe and timely discharge.

Applicability of Research to Practice

Discharge collaboration increases patient satisfaction, decreases discharge times, improves hospital throughput, and improves the financial health of the organization.
751 Assessing Functional Outcomes in Pediatric Burn Acute Rehabilitation
Authors: Coakley Katie , Berry AnnMarie , Davis Allison
Published: April 2024

Introduction

Pediatric burn survivors experience difficulty returning to daily activities. Functional outcome measures are needed for therapists to use in acute care. At one burn center the Center for Appearance Research (CARe) Burn Scales Parent Quality of Life Form and Boston Activity Measure for Post Acute Care (AM-PAC) were used with the pediatric burn population.

Methods

Therapists used the AM-PAC with children 4-17. Therapists scored the child’s functional abilities at evaluation and discharge. The child’s ability to perform self-care was scored using the Daily Activity form and functional mobility was scored using the Basic Mobility form. Scores range from 6-24. Higher scores indicate greater independence. The AM-PAC was recently validated for use with the pediatric population, ages 4 and up. The project’s inclusion criteria were children 4 years and older with a burn injury, hospitalized for >4 days.

For children under 4, therapists used the CARe. This form has several subscales and uses a Likert scale for rating. This project focused on subscales 2, 3, and 5, which assess parent confidence with burn care, social concerns about their child’s injury or scars, and parental stress, respectively. Sessions targeted building parent confidence and parents were appropriately referred if they indicated stress and social concerns. The CARe was administered to parents/caregivers of children 0-3 years old with a burn injury who were hospitalized >4 days.

Results

For the AM-PAC, data was collected on 17 patients who met inclusion criteria from September 2022-September 2023. 8 patients were female and 9 were male. The average affected total body surface area was 8.5%. The average scores for the AM-PAC Basic Mobility at evaluation was 18 and at discharge was 19.3. The average scores for the AM-PAC Daily Activity at evaluation was 16.6 and at discharge was 17.8. 9 children demonstrated improvement.

For the CARe, data was collected on 12 patients who met inclusion criteria from September 2022-September 2023. The average age was 1.67 years old. The average score on the Confidence subscale was 26/35 at eval and the average score at discharge was 33.3/35. 10 patients demonstrated improvement from evaluation to discharge. Parents who reported social concerns and stress were referred to the unit Social Worker.

Conclusions

The AM-PAC and CARe are feasible and helpful tools to employ in acute burn rehabilitation for pediatric patients. They allow therapists working with these patients to evaluate and treat the functional needs of the child and caregivers.

Applicability of Research to Practice

This QI project adds to the body of knowledge about pediatric burn rehabilitation. More research is needed to evaluate the clinical utility of the AM-PAC and CARe. The presenters will continue to collect data and update the results prior to presentation if accepted.
753 Implementation of a QR-code-linked Instructional Video for Resting Hand Splint Application by Non-therapists
Authors: Terken Tonya S , Parker Kristine A , Carrougher Gretchen J , MacKenzie Paige L , Jason Dylan S , Pham Tam N
Published: April 2024

Introduction

Custom-made rigid orthotics such as a resting hand splints are a cornerstone of burn rehabilitation. Non-therapists are often asked to apply or reapply these specialized splints. Improper application not only reduces their efficacy but may also risk harm, such as pressure ulceration. This quality improvement project aims to improve resting hand splint application via a short instructional video accessible by QR code placed directly on the splint.

Methods

Phase I consisted of directly observing non-therapists in resting hand splint application, which informed the development of a < 2-minute video demonstrating correct application. Suboptimal techniques were compiled and rated on a 4-point error severity scale by 3 therapists. Phase II queried providers who reviewed the initial draft video and informed the team on finalizing the instructional video. Phase III determined video effectiveness: 1) by comparing application techniques before and after watching the video, and 2) by tracking of QR code usage.

Results

Phase I assessed 9 clinicians for splint application. All trials contained application errors, (mean 4 errors/trial, range 2-8, with 87% agreement between 2 trained observers). In Phase II, 8 clinicians evaluated the draft video: 100% reported that the content was clear; with ideal video length reported as < 2 to 5 minutes; and video speed and length were deemed “just right”. In Phase III, viewing the video resulted in fewer applications errors and shifted toward milder error types (Figure 1). Additional Phase III assessments are ongoing.

Conclusions

A short instructional video improves application accuracy by providers less familiar with resting hand splint application. A QR-code that links to a short instruction video is a useful strategy for delivery of just-in-time education for non-therapists.

Applicability of Research to Practice

Just-in-time instructional videos facilitate burn rehabilitation tasks for non-therapists. This strategy can potentially expand to patients and caregivers as well.
776 Use of Paraffin Wax During Occupational Therapy Treatment of Burn Survivors
Authors: Rainey Kristin
Published: April 2024

Introduction

Burn survivors face long and often painful rehabilitation after injury. Unfortunately, the severe pain from burn injuries can lead to chronic pain and stress-related disorders. Occupational therapists work with burn survivors to improve movement and reduce negative impacts of scars to increase independence with self-care tasks, return to work and hobbies, and facilitate social participation. Paraffin wax is used as a modality by occupational therapists to decrease pain and assist with soft issue mobilization. It is imperative to determine if paraffin is beneficial specifically for burn injuries to facilitate physiological and psychological recovery.

Methods

Low melting point paraffin wax at a temperature between 120-130 degrees without scent was chosen to prevent any burns or allergic reactions. Inclusion criteria was for subjects over the age of 18 years and all wounds on extremity being assessed must have been closed. Active range of motion (AROM) and passive range of motion (PROM) were assessed as well as pain score. The patient then washed the extremity with soap and water, dried, placed into the paraffin bath, dipped four times, then placed into a plastic liner and wrapped in a towel for 10 minutes. After the treatment was complete, ROM and pain were assessed and the patient was offered an opportunity to provide any feedback or comments.

Results

A total of 7 burn survivors were identified and chosen for participation in the study. All patients showed improvement of AROM and PROM measurements of the tested extremity. Pain was reduced with every patient by an average of 30%. Every patient reported less pain and better movement, subjectively. Most patients reported less fear or anxiety. 42% of patients felt like their scar was softer after the paraffin treatment. Unfortunately, the study has a limited trial size due to requirement of completely closed wounds with continued follow up by the patient in clinic. Many patients with closed wounds do not follow up in the clinic on a regular basis. Interestingly, women reported more psychological benefits and also more likely to report a plan to continue using paraffin at home, compared to the men. AROM and PROM improved consistently within each session after paraffin was used, however week to week improvement was more variable between patients. This could be due to varying compliance of each individual’s home exercise program.

Conclusions

Paraffin wax can be beneficial during occupational therapy for soft tissue mobilization of burn scars to increase range of motion and reduce pain and anxiety. Utilizing paraffin wax as a modality helps to reduce physiological and psychological barriers of traditional occupational therapy interventions and should be considered as an adjunct treatment.

Applicability of Research to Practice

While the use of paraffin has been studied for treating conditions such as arthritis, scleroderma, and stroke, there is limited research on the use of paraffin for treating burn scars.
788 Lower BMIs Are Correlated with Increased Risk of Graft Loss
Authors: Tran Vivie , Sauers Delaney A , Ugwa Destiny , Nanni Amber , Gabrilska Rebecca , Pang Alan , Griswold John A
Published: April 2024

Introduction

The relationship between obesity and burn injuries in the United States remains poorly understood. Skin grafts, frequently used for burn treatments, are considered successful when they effectively merge with the damaged tissue, relying heavily on restored blood flow in the affected area. Inadequate graft incorporation, known as "graft loss," is linked to unfavorable health outcomes. Obesity, characterized by a high body mass index (BMI), is a known condition that reduces peripheral blood flow. Our hypothesis posits that burn patients with higher BMIs are likely to experience lower rates of successful grafting.

Methods

We conducted a retrospective analysis based on a hypothesis, using a cohort of 193 burn patients from October 1, 2012, to October 1, 2022. Inclusion criteria encompassed patients who underwent grafting surgery for burns involving a total body surface area (TBSA) greater than 20%, while females who were pregnant or breastfeeding were excluded. All patients were carefully matched for age, comorbidities, and TBSA percentage. Our primary objective was to utilize the information collected to determine whether patients with higher BMIs exhibited significantly increased rates of graft loss. We employed logistic regression analysis to examine the relationship between BMI and various variables, including the number of surgeries, the presence of infections, graft success, and mortality rates.

Results

We accounted for age, comorbidities, and total body surface area (TBSA) percentage in our analysis. The range of BMIs varied from 17.56 (indicating underweight) to 47.26 (indicating morbid obesity), with an average BMI of 29.81 (classifying as overweight). Our findings revealed a notable link between lower BMIs and increased mortality among burn patients (p=0.0107). Furthermore, lower BMIs were significantly connected to patients requiring more than three grafting surgeries (p=0.0094).

Conclusions

Our study indicates that patients with lower BMIs face elevated mortality risks and are prone to needing multiple grafting surgeries for successful outcomes. This could stem from the fact that lower BMIs might leave the body malnourished and depleted, impacting overall healing. However, it's crucial to note that our study has limitations, including a relatively small sample size and limited geographical diversity.

Applicability of Research to Practice

Medical practitioners can assess surgical risks using BMI, especially for grafting surgeries. Patients with lower BMIs may be considered high-risk and require close post-surgical monitoring. Preoperative nutritional assessments and interventions, such as dietary changes and supplements, can optimize their nutritional status. After surgery, specialized postoperative care, like enhanced nutritional support, can aid healing. Prompt identification and management of signs of malnutrition can enhance recovery.
803 Evaluation of Burn Depth and Reactive Inflammation Using Perioperative Fluorescence Imaging
Authors: Junak Mary , Zajac Jocelyn C , Liu Aiping , Jupitz Sydney , Seets Trevor , Kawahara, Tisha , Uselmann Adam , Lin Christie , Nosanov Lauren B , Faucher Lee D , Gibson Angela
Published: April 2024

Introduction

Early determination of burn depth is essential for guiding proper treatment of burn injuries. The primary technique used to evaluate burn depth is visual assessment, relying heavily on subjective interpretation while risking over-excision. Second window indocyanine green (SWIG) is a novel method of delayed fluorescence imaging with possible utility in burn surgery, as indocyanine green (ICG) persists in burn wounds 24 hours after intravenous injection. The objective of this study is to correlate intraoperative SWIG florescence with burn depth as evaluated by lactate dehydrogenase (LDH) staining. Additionally, given inflammation is thought to impact the progression of a burn, we investigated the relationship between SWIG florescence signal and reactive inflammation.

Methods

Consented patients with indeterminate depth burns received a 5 mg/kg ICG infusion during their third daily burn care after admission or 24-hours prior to surgery. SWIG was performed 24 hours after ICG injection on a region of interest (ROI) during wound care or during burn excision. A full thickness skin biopsy was taken from the center of the ROI and processed for ICG microscopy and staining. Burn depths were scored using LDH-stained sections. To investigate the relationship between SWIG and inflammation, nude mice underwent a full thickness contact burn or received endotoxin to induce inflammation. Mice were injected with ICG at 5mg/kg and SWIG signal was captured at the non-burned control, burned, and inflamed ROIs 24 hours after injection. Signal-background ratio (SBR) was calculated using the ratio between the averaged ICG intensity in the burned or inflamed ROI and the control ROI. GraphPad Prism 8.0 was used for statistical analyses.

Results

There was no correlation between the raw SWIG fluorescence value of the ROI in vivo and burn depth as determined by LDH staining. Furthermore, when the fluorescence value of the ROI was normalized to the SWIG intensity of the overall image and the SWIG intensity of non-burn control skin, there was no correlation to burn depth. In mice, SWIG SBR was significantly higher in the burned region (3.2±0.5) compared to the endotoxin induced inflamed regions (1.6±0.1).

Conclusions

There is heterogeneity in the intraoperative fluorescence signal when compared to burn depth. This variability in fluorescence signal could be attributed to the effects of local inflammation on the burn wound microenvironment as animal studies have shown that ICG signal is present in non-burn inflamed tissue. Further studies are warranted to discern the role of inflammation on burn wound progression and fluorescence signal in humans.

Applicability of Research to Practice

This data supports the potential utility of perioperative ICG fluorescence imaging for guidance of surgical excision in patients with indeterminate depth burns.
807 The Effects of Fish Skin on Wound Healing in a Standardized Pre-clinical Model
Authors: Pignet Anna-Lisa , Hofmann Elisabeth , Hahn David , Fink Julia , Hecker Andrzej , Prevedel Manuel , Einsiedler Johanna , Carnieletto Martina , Kamolz Lars-Peter , Kotzbeck Petra
Published: April 2024

Introduction

Acellular fish skin grafts (FSG) have proven to be effective in acute and chronic wound healing, as well as in burns. However, the underlying mechanisms promoting healing are still unknown. The aim of this preclincal study was to investigate the effects of fish skin grafts on wound healing properties under standardized conditions in a full-thickness skin defect pig model.

Methods

FSGs were tested in a full-thickness skin defect (3 cm x 3 cm) pig model (n=9, male landrace pigs) and compared intra-individually to untreated control wounds. The experiment lasted for 21 days. Reapplication of the dressings was carried out after 9 days post wounding. Wound scoring, photo-documentation and non-invasive imaging were carried out 5, 9, 14 and 21 days post wounding. Tissue biopsies were sampled at the same time points and subjected to histologic (HE and Masson’s trichrome stains) and gene expression analysis of various cytokines.

Results

As soon as on day 5, wounds treated with FSG showed a thicker formation of new tissue compared to control wounds. Planiometry revealed lower residual wound areas of the wounds treated with FSG, especially on day 9 and 14 post wounding. Gene expression analysis revealed a higher upregulation of the pro (eg. IL-8) and anti-inflammatory markers (eg. IL-10) in the first days after wounding compared to the controls. In the later phases, there were no differences between the two groups. On day 21, control wounds showed severe signs of contraction, which were not observed in the wounds treated with FSG.

Conclusions

FSGs modulate the local immune response by upregulation of both, pro- and anti-inflammatory markers. Moreover, FSGs support wound healing due to the accelerated formation of new tissue and the prevention of wound contraction in a pre-clinical full thickness wound model.

Applicability of Research to Practice

The study gives insights into the mode of action of FSG and therefore aids at redefining the ideal clinical indications for the use of the product.
809 Isotonic Medium Treatment Improves Burn Wound Healing Potential in Larval Zebrafish and Human Skin Explants
Authors: Horn Adam , Zajac Jocelyn C , Hou Yiran , Pashaj Joana , Gibson Angela , Huttenlocher Anna
Published: April 2024

Introduction

Larval zebrafish have been widely adopted as a model to study tissue repair and regeneration. Due to their optical transparency, larval zebrafish are amenable to live imaging, which enables real-time investigation of early tissue dynamics following injury. Here, we utilized a previously developed method of burning larval zebrafish to investigate how epithelial tissue responds to injury. We find that aberrant keratinocyte dynamics and signaling contribute to long-term damage in burn wounded tissue, but treatment with isotonic medium limited overall tissue damage by targeting keratinocyte behavior. Finally, we assessed the utility of isotonic medium to treat human burns using an ex vivo skin culture model.

Methods

Intravital imaging of transgenic larval zebrafish was performed to identify how epithelial tissue responds to burn injury in real-time. To test the efficacy of isotonic medium for the treatment of burn injury in humans, cultured skin explants were treated topically with saline for 24 hours after burn using a previously developed method.

Results

Burn wounding of larval zebrafish expressing the photoconvertible protein Dendra in keratinocytes revealed the formation of burn wounding zones analogous to the Jackson’s zones of coagulation and stasis. Further investigation revealed that aberrant keratinocyte migration contributes to burn wound damage characterized by chronic oxidative stress. This resulted in loss of keratinocytes in the purported “zone of stasis” in zebrafish over time. Treatment with isotonic medium prevented keratinocyte migration and reduced overall tissue oxidation, protecting keratinocytes in the “zone of stasis” from clearance. Using human cultured skin explants, we tested the ability of topically applied isotonic medium (saline) to improve burn wound healing. Saline treated burn wounds showed reduced burn depth 6 and 14 days after injury compared to skin that was left untreated or treated with hypotonic solution (water).

Conclusions

Collectively, these results identify larval zebrafish as a useful tool in uncovering the underlying mechanisms of burn wound healing and suggest saline treatment could be a potential avenue to improve healing of human burn wounds.

Applicability of Research to Practice

Larval zebrafish provide a unique model to investigate mechanisms of burn wound healing and efficiently test potential drug-based treatments.
Chronic constipation and abdominal distension in a patient with adult Hirschprung’s disease and bilateral ovarian teratomas
Authors: Vo Jessica , Hayler Raymond , Tyler Alex , Verschuer Kurt
Published: April 2024

Hirschprung’s disease is a congenital disorder characterized by aganglionic bowel, usually diagnosed in infancy. Here, we present a unique case of Hirschprung’s disease diagnosed in a 29-year-old female with acute on chronic constipation. As part of her work up, a computerized tomography of her abdomen and pelvis revealed large, bilateral dermoid cysts. A diagnostic and therapeutic colonoscopy allowed manual disimpaction and decompression of her bowel, as well as biopsy attainment. Histopathology revealed absence of ganglionic cells on haematoxylin and eosin stain and calretinin immunostaining. This case underscores the diagnostic challenges of Adult Hirschprung’s disease and how this impacts patient quality of life, as well as the work up and management of concurrent causes abdominopelvic conditions.