bluuebunny/crossref_metadata_2025_split huggingface dataset:
110 Pain Medication Prescription Patterns and the American Burn Association 2020 Guidelines on the Management of Acute Pain in the Adult Burn Patient
Authors: Ziolkowski Natalia , D’Abbondanza Josephine , Rehou Sarah , Shahrohki Shahriar 
Published: April 2021

Abstract

Introduction
In September 2020, the American Burn Association released new pain guidelines following a rigorous literature review and input from experts. These guidelines were last updated 14 years ago and represent a multitude of changes including increased importance for non-opioid pain medication use and non-pharmacologic adjuncts given the current opioid crisis. Specifically, the main recommendations were to use opioid medication sparingly and always with adjuncts; acetaminophen utilized in all patients; NSAID use depending on baseline comorbidities and kidney function; neuropathic pain therapy for those with such pain/refractory to standard therapy; and ketamine for procedural sedation/adjunct for opioid consumption. Further, nonpharmacologic treatments include cognitive-behavioural therapy (‘CBT’), hypnosis, and virtual reality should be considered. The objective of this study is to describe current pain medication prescription habits at one ABA-verified centre and how well they are in compliance with these new guidelines.

Methods
We conducted phase one of a quality improvement retrospective study of 514 patients admitted to an ABA-verified centre over a two-year period. Data included demographics and pain medication use which was compared against the new ABA American Burn Association 2020 Guidelines on the Management of Acute Pain in the Adult Burn Patient. Pain medication contraindications were defined using UpToDate Drug Information. Statistical analysis was descriptive in nature.

Results
422 patients were admitted for acute burns. 65.9% were male with an average age of 46.4 (st dev 17.6,range 15–96). Flame burns were most common(n=209,49.5%) with average TBSA of 11.9%(st dev 16.5,range 0–98%) and 54 inhalation injuries(12.8%) covering an average length of stay of 15.6 days in the burn centre (st dev 16.8,range 1–146 days). A total of 3549 pain medications were prescribed: 1792 opioid(50.5%) and 1757 non-opioid(49.5%). Of those admitted, 93.8% were prescribed opioids, 72.5% NSAIDs, 87.2% acetaminophen, 74.4% nerve pain medications, and 25.3% ketamine. Opioids were not prescribed in 26 patients(6.2%) and only prescribed in 29 patients(6.9%). Regarding adjuncts, 4(0.94%) had documented contraindications to NSAIDs and 3(0.71%) to acetaminophen. No referrals were completed for CBT. Virtual reality and hypnosis are not available at this centre.

Conclusions
This work represents the first known study examining compliance to the new pain guidelines in an ABA-verified burn centre. There is significant room for improvement for the use of adjuncts specifically NSAIDs and acetaminophen as both were under prescribed. In addition, nonpharmacologic treatments are largely not available or not used and may be an untapped resource for better pain control.
111 Burn Sepsis Screening Tool to Facilitate Diagnosis of Burn Sepsis
Authors: Libraro Kaitlyn , Bessey Palmer , Heffernan Jamie , Gallagher James 
Published: April 2021

Abstract

Introduction
Sepsis following critical burn injury is an ominous development that can lead to death. Most patients will manifest a systemic inflammatory response syndrome (SIRS), even without being septic. This may obscure the clinical recognition of developing sepsis and delay the initiation of effective treatment. We developed a burn sepsis screening tool (BSST) to facilitate the recognition of developing burn sepsis. The purpose of this study was to review the utility of that tool.

Methods
The BSST was based on several clinical signs, laboratory values, and changes in physiologic support modalities associated with sepsis. It consisted of nine parameters that could be scored as indicating or not indicating sepsis or not applicable. If three were positive, the patient was identified as septic, and a search for a septic source was undertaken and treatment initiated. The BSST was completed on patients judged to be critically ill during morning rounds over a period of nine months. The values were transcribed into a secure web database and analyzed using SAS 9.4.

Results
There were 593 individual encounters on 31 critically ill patients with burns and/or inhalation injury for which the BSST was completed. The mean age of the patients was 57 ± 4 years (Mean ± SEM), and the burn size was 24 ± 15 % TBSA. Eleven patients were women (36%) and 7 patients had inhalation injury (23%). The expected case fatality was 21 - 30% depending on the statistical model used. Six patients (19%) died. The length of stay was 64 ± 10 days and ranged from 3 to 267 days. A patient was judged to be septic in only 45 of the daily encounters (8.0 % ± 1.1). There were 21 instances of a new septic event made in 12 patients. Episode of sepsis separated by at least 5 days of no sepsis, were considered to be a new septic event. There was a substantial amount of data that was missing or not applicable. There were no significant differences in the septic parameters on days with new sepsis diagnosis when compared to the day prior, or compared to all encounters in patients that were never septic. Patients deteriorated acutely between BSST completions on only two occasions and both were stabilized.

Conclusions
The BSST was used consistently to help evaluate the daily status of critically ill burn injured patients. The expected case fatality of the group was moderately high, based on statistical models derived from the ABA Burn Registry. The observed outcome was as good as or better than predicted. Acute decompensation was rare. The BSST added daily administrative work to rounds, and the data recorded were often incomplete. Although the BSST did not demonstrate any single clinical feature that identified the transition from SIRS to sepsis, it did add structure and rigor to daily rounds. That contributed to the effectiveness of rounds, and it may have been responsible, in part, for the favorable outcomes.
120 A Survey of Burn Care Professionals to Characterize Patterns of Early Mobility in ICU Burn Patients
Authors: Higgins Lauren , Hines Danika , Murray Derek , Richey Karen J , Foster Kevin N 
Published: April 2021

Abstract

Introduction
Early mobility in intensive care unit (ICU) patients has been demonstrated effective in improving functional status, range of motion, preventing complications, and decreasing length of stay. There is limited data regarding the early mobilization of burn ICU patients. The purpose of this study was to survey burn care providers to better understand their experience with early mobilization and explore perceived barriers and contraindications.

Methods
An internet-based 21-item survey was distributed to burn professionals at North American burn centers and units. Descriptive statistics were performed.

Results
There were a total of 63 respondents. Most respondents were physical therapists (33%), occupational therapists (33%), or nurses (25%), with &gt;5 years of burn care experience (71%). Early mobility was characterized as both in bed and out of bed activities within 24 hours of ICU admission, up to any time during the course of mechanical ventilation or ICU stay. The majority of respondents (54%) indicated they mobilize patients on ventilators in bed and out of bed, while there was an even split on whether or not patients on vasopressor support were mobilized. Of those respondents (46%) who use the Richmond Agitation-Sedation Scale (RASS) to guide mobility, 14% mobilize patients with a RASS of -4 or -5 and 41% mobilize patients with a RASS of -3 to -2. The highest appropriate score for mobilization was +1 to +2 (76%). Hgb/Hct, line presence, ventilator mode, mental status, and vital signs were viewed as precautions to discuss with the medical team, rather than a contraindication to mobility. Respiratory rate &lt; 6 and presence of ECMO were the areas of most concern, with the majority respondents indicating they would likely hold mobility. Most respondents indicated that they would mobilize any burn ICU patients after discussion with the medical team if necessary. The majority of respondents (72%) indicated that they did not have an early mobilization protocol for burn ICU patients.

Conclusions
There is a paucity of evidence available for early mobility in burn ICU patients. This survey demonstrates a lack of consensus regarding what constitutes early mobility and when patients should be mobilized. A multi-center observational trial is needed to inform the development of an evidence-based mobility protocol.
128 Nonlinear Dynamic Analysis of Heart Rate Variability Can Detect Sepsis in Severe Burns
Authors: Zhu Min , Cummins Claire B , Radhakrishnan Ravi S 
Published: April 2021

Abstract

Introduction
Sepsis after burn injury affects 50–84% of adult patients and ~55% of pediatric patients. The diagnosis of sepsis in patients with severe burns is complicated by the overlap of clinical signs of post-burn hypermetabolic response with those of sepsis. Earlier detection of sepsis could lead to improved outcomes and decreased morbidity and mortality. Nonlinear dynamic (ND) analysis of heart rate variability (HRV) can identify non-random relationships between different HRV parameters by using a complex oscillogram. ND can be obtained even when heart rate recordings are weak or poor in quality, which is common in the setting of burns. We hypothesized that ND could detect differences in HRV after severe burns.

Methods
All patients enrolled during the study period at our institution with &gt;20% total body surface area (TBSA) burn were eligible for this study. High-definition heart rate monitoring was collected three times for each patient in five-minute intervals. The first collection occurred after patient ICU admission, and the third collection occurred 16–24 hours. Matlab was used to analyze heart rate using the following common ND methods: Correlation dimension (CD), detrended fluctuation (DF), largest Lyapunov exponent (LLE), approximate entropy (AE), fractal dimension (FD), Hurst exponent (HE), and recurrence quantification analysis (RQA). Additionally, several linear time-domain parameters were analyzed, including heart rate (R), RR interval (RR), SD1, and SD2.

Results
A total of six non-septic (NS) and four septic (S) patients were enrolled in the study. There were no significant differences between the two groups in age, sex, percent TBSA, or percent TBSA of third-degree burns. Two nonlinear parameters were significantly different between NS and S patients: AE and the density of recurrence points in RQA. AE was significantly lower in NS than S patients at all time points [(0.931±0.011 vs. 0.960±0.024, p=0.001); (0.923±0.019 vs. 0.959±0.025, p=0.008); (0.933±0.011 vs. 0.964±0.025, p=0.013)]. The density of recurrence points in RQA were significantly higher than in NS than S patients at all time points. [(90.4±40.2 vs. 41.4± 27.8, p=0.029), (102.2±39.4 vs. 40.1±22.9, p=0.008), (92.5±34.4 vs. 45.5±33.9, p=0.043)].

Conclusions
The two ND parameters AE and RQA, can be used to distinguish between patients with and without sepsis in the setting of severe burns.
129 Stimulating the Cholinergic Anti-inflammatory Pathway Alters Inflammatory Cell Mobilization after Burn Injury
Authors: Costantini Todd , Weaver Jessica , Eliceiri Brian 
Published: April 2021

Abstract

Introduction
Severe burn injury causes a systemic inflammatory response (SIRS) that is characterized by mobilization of inflammatory cells into the circulation and is associated with distant organ injury that can lead to significant morbidity and mortality. The cholinergic anti-inflammatory pathway, mediated by the vagus nerve, regulates the anti-inflammatory response to injury and infection. We have previously shown in models of burn injury that stimulating the vagus nerve may be a potential therapy aimed at limiting SIRS. Here, we hypothesized that stimulating the vagus nerve (VNS) would limit the SIRS response by altering the mobilization and trafficking of inflammatory cells after burn injury.

Methods
Wild type 10–12-week-old C57BL/6 mice were injured with a 30% total body surface area steam burn. A separate cohort of animals was treated with electrical stimulation of the cervical vagus nerve for 10 minutes immediately post-burn. Bone marrow, blood and lung tissue were collected 24 hours after burn injury. Flow cytometry of bone marrow was performed to measure Lineage- c-kit± Sca-1+ (LSK) hematopoietic stem cells (HSC), then further analyzed to quantify changes in Long-term (LT) HSC, short-term (ST) HSC, and Multipotential Progenitor (MPP) compartments. Bone marrow, blood and perfused lung tissue were analyzed by flow cytometry using a panel of myeloid cell markers.

Results
Severe burn injury decreased bone marrow LSK expression by 50% compared to sham, with LT-HSC and MPP expression decreasing to a greater degree than ST-HSCs. VNS did not alter burn-induced changes in any bone marrow HSC cell type. Burn injury was associated with increased mobilization of CD45+CD11b+ monocytes and CD11b+Ly6Chi inflammatory monocytes into the peripheral blood and lung, while increased CD11b+Ly6Clo patrolling monocytes and Gr1+Ly6C- neutrophils was seen in the lung only. VNS significantly prevented the burn-induced increase in CD45+ inflammatory cells, CD11b+Ly6Clo patrolling monocytes and Gr1+Ly6C- neutrophils in the lung (see Figure), reducing their expression to sham levels, despite only modest changes to myeloid cell expression in the blood.

Conclusions
VNS attenuates myeloid cell cell trafficking to the lung after severe burn injury despite having no effect on emergency myelopoiesis in the bone marrow. Further studies are needed to define the mechanism by which the cholinergic anti-inflammatory pathway attenuates the SIRS response to burn.
138 Evaluation of Healing Outcomes Combining Negative Pressure Wound Therapy with Autologous Skin Cell Suspension and Meshed Autografts: Pre-Clinical and Clinical Evidence
Authors: Carney Bonnie C , Moffatt Lauren T , Travis Taryn E , Nisar Saira , Keyloun John W , Prindeze Nicholas , Oliver Mary , Kirkpatrick Liam , Johnson Laura S , Shupp Jeffrey W 
Published: April 2021

Abstract

Introduction
Negative pressure wound therapy (NPWT) is an option for securing meshed split thickness skin grafts (mSTSGs) after burn excision to optimize skin graft adherence, working by minimizing disruption by shear forces and promoting the continual removal of wound bed drainage. Recently, the use of autologous skin cell suspension (ASCS) has been approved for use in treating full-thickness burn injuries in conjunction with mSTSGs. Limited data exists regarding the impact of NPWT on healing outcomes when the cellular suspension is utilized. It was hypothesized that NPWT in conjunction with ASCS+mSTSGs would aid in skin graft adherence without compromise to healing outcomes.

Methods
In this study, a Duroc pig model of burn, excision, mSTSG, ASCS + NPWT was used (n=2), where each animal had 2 sets of paired burns. Four wounds received mSTSG+ASCS+NPWT through post-operative day 3, and 4 wounds received mSTSG+ACSC+ traditional ASCS dressings. Percent re-epithelialization was measured using digital planimetry and Image J. Graft-adherence was evaluated using a scale with blinded reviewers (0=no graft loss, 4= &gt;50% graft loss). Histological architecture, pigmentation, elasticity, and blood perfusion and blood vessel density were assessed at multiple time points through 2 weeks. After the evaluation of its effectiveness in animal models, the same surgical technique, including NPWT, was used in patients with full-thickness burns (n=9), and wound healing trajectories were described.

Results
In the Duroc pig study, all wounds healed within 14 days with minimal scar pathology and no significant differences in percent re-epithelialization between NPWT and non-NPWT wounds were observed (61.09 ± 9.01 and 61.15 ± 0.82% at Day 7). Additionally, no differences were detected for pigmentation, perfusion, or blood vessel density. Overall, the non-NPWT group had higher amounts of graft loss (1.0 ± 1.41 vs. 0 ± 0). NPWT-treated wounds had significantly improved elasticity (NPWT=109.5 ± 21.23 vs. non-NPWT=177.5 ± 35.4, p&lt; 0.05). There were no differences in histological architecture between treatment groups. Patients had a median age of 53 (37–69), and median TBSA of 12.5 (8–18) resulting primarily from scald burns (67%). There were no reported morbidities, and all wounds were re-epithelialized within an expected time period. The use of NPWT promoted graft adherence, and was useful as a bolster dressing in wounds that crossed joints.

Conclusions
These data suggest the positive attributes of the cellular suspension delivered are retained following the application of NPWT. Re-epithelialization, revascularization, and repigmentation are not adversely impacted.
507 Burn Survivor Perspectives On a “Virtual” Survivor Retreat
Authors: Yelvington Miranda L , Wilkinson Gretta E 
Published: April 2021

Abstract

Introduction
The social distancing restrictions mandated by the COVID-19 pandemic have directly impacted burn survivor support groups. Around the country, Pediatric Camps and Adult Support groups have been canceled or moved to an alternate format. While these alternative methods provide much-needed support and interaction for burn survivor groups, it is unknown how they compare to traditional, in-person support programs. In November 2020, our facility will replace our traditional Adult Burn Survivor Retreat with an entirely virtual, synchronous retreat. The retreat will feature many of the sessions and experiences from the in-person retreat but will be lacking the face-to-face contact that is so valued by our Adult Survivor Group. Educational sessions will be provided by adult psychologists and social workers, burn therapists and nurses. An adult burn survivor will provide the keynote address. Adult burn survivors, who have participated in prior year’s retreats, will be invited to participate in a comparison feedback survey.

Methods
Participants in the Virtual Adult Survivor Retreat will complete a post-retreat survey, comparing the virtual retreat experience to the traditional in-person retreat format. Likert scale questions will address participation level, benefit of retreat, specific feedback for sessions and ease of ability for survivors to interact with peers. In addition, the survey will seek to identify barriers of the virtual format as a means of providing needed survivor support.

Results
Survey results will be analyzed, and trends will be reported. Statistically significant results can be further explored to guide future virtual events.

Conclusions
Virtual events utilizing video platforms have become commonplace in the era of COVID-19, however, this format is still new, and the benefits have not been fully explored. Evidence has shown a direct benefit to survivors participating in support services. In an attempt to fill the gap left by the cancelation of in-person events, our facility is hosting a synchronous virtual retreat for adult burn survivors. Retreat evaluation and data comparing the virtual event to prior in-person events will be analyzed and reported.
509 Use of a burn sepsis screening protocol results in lower antibiotic usage rates
Authors: Jastram Charles W , Carter Jeffrey E , Bilbe Sarah , Vu Catherine , Phelan Herb A 
Published: April 2021

Abstract

Introduction
Antibiotic stewardship is widely recognized as being a necessary component of modern hospital care but remains difficult to put into practice particularly on burn services where the risk of infection is known to be higher than the general hospital population. Our burn service instituted a protocol for sepsis screening triggers and antibiotic usage, becoming the only unit in our hospital to do so. In-house quality metrics have shown this protocol to be successful in reducing utilization.

Methods
With the opening of our burn unit in April 2018, a burn sepsis screening protocol was put in place (see accompanying image). Briefly, the first level of screening consists of threshold hemodynamic and physiologic parameters. If these are met the pathway leads to drawing of basic laboratory tests plus lactate and procalcitonin. Group A findings consist of either Serum Lactic Acid &gt;2.2mmol/Lor Procalcitonin &gt;0.69ng/ml, and Group B findings consist of: Platelets &lt; 100,000/mmorGlucose &gt;150 mg/dL or New Insulin Requirement. If one finding from each of groups A and B are present, antibiotics are started, and a source work up is initiated. De-identified aggregate data on antibiotic usage are routinely tracked as a quality metric by our hospital’s Infection Control Committee. The results from calendar year 2019 are presented here for all antibiotics, vancomycin usage, and beta-lactam usage. One-way Analysis of Variance with Tukey’s post-hoc testing was used to analyze the differences in intravenous antibiotic usage rates between the Burn Intensive Care Unit (BICU), the Trauma ICU (TICU), and the remainder of the hospital.

Results
The BICU used significantly fewer IV antibiotics than the TICU across all examined parameters and fewer than the remainder of the hospital for all antibiotics and vancomycin usage. Data is presented as antibiotic days/1000 patient days.

Conclusions
Initiation of a formal protocol for sepsis screening and IV antibiotic initiation significantly lowers antibiotic utilization. Future work will focus on this protocol’s impact on clinical outcomes.