Limb Salvage through Intermediary Wound Coverage with Acellular Dermal Matrix Template after Persistent Pseudomonas Aeruginosa Infection in a Burn Patient

Secondary infections of skin grafts pose a continuous problem in burn patients, very often leading to loss of transplanted skin grafts and making multiple surgical revisions necessary. We present a case report about persisting Pseudomonas aeruginosa infection in burn patients with known diabetes. The burn wounds in lower extremities required repeated debridements, multiple skin grafting attempts and finally an application of the dermal scaffold NovoSorb BTM. With these measures, we managed to undertake a successful reconstruction of infected burn defects and pre-vent an amputation. We concluded that the NovoSorb BTM could be seen as an additional promising tool in a burn surgery armamentarium. In cases where radical surgical wound decontamination is not possible without risking the loss of the limb, the application of NovoSorb BTM over a contaminated field can win extra time for topical infection treatment and additionally provide an excellent skin grafting ground.

Effect of Central Line Duration and Other Risk Factors on Central Line-Associated Bloodstream Infection in Severe Adult Burns Patients at a Large Tertiary Referral Burns Centre: A 5-Year Retrospective Study

Central line-associated bloodstream infection (CLABSI) and catheter-related bloodstream infection (CLABSI with a positive catheter tip culture, CRBSI) are preventable causes of morbidity and mortality for severe adult burns patients. Routine central line changes as a CLABSI prevention strategy in burns patients is controversial due to the paucity of evidence to guide the appropriate timing of line changes. This study aimed to address this evidence gap by investigating risk factors associated with central line sepsis, including the duration of central line insertion, in a population of severe adult burns patients (burns involving ≥20% total body surface area (TBSA)) admitted to the Royal Brisbane and Women’s Hospital Intensive Care Unit over five years (2015–2019 inclusive). On multivariate analysis, central line duration and burn TBSA were identified as independent risk factors for CLABSI, with central line duration the most significant predictor (p = 0.0008; OR 1.177, 95% CI 1.072–1.299). No risk factor independently predicted CRBSI. CLABSI detection occurred a median of 8.5 days (IQR 6.0–11.0) post central line insertion. These findings suggest further research to assess the efficacy of routine line changes prior to the at-risk period of 6–11 days post central line insertion in reducing CLABSI in severe adult burns patients may be beneficial.

Acute Burn Treatment and History of Drug and Alcohol Addiction: Treatment Outcomes and Opioid Use

Treating pain in burn patients with a history of opioid or drug abuse is challenging. There is no consensus on pain management for burn patients with a history of drug usage. Our aim was to study the association of previous drug addiction and the treatment of acute burn patients, focusing on daily morphine milligram equivalent (MME) requirements and outcomes. We compared patients with (group 1) and without (group 2) a drug addiction history who were admitted to an American Burn Association verified burn center using the Premier database from 2013 to 2018 (n = 3046). Primary outcome was daily MME usage. Secondary outcomes included mortality, expected mortality rate, length of stay (LOS), and number of surgeries. Linear regression was performed to predict MME usage. In total, 16.6% of patients had history of drug abuse. In unadjusted analysis, group 1 had more males (68.1% vs. 57.3%, p < 0.001) and was younger (median 47 vs. median 53, p < 0.001) compared to group 2. In the adjusted analysis, group 1 required 84.1 additional daily MME usage than group 2 (p < 0.01). Drug addiction was associated with an increased number of surgeries, LOS, and higher daily MME usage. Patients with a history of drug usage required almost 60 mg of additional oxycodone per day.

Paradigm Shift in Treatment Strategies for Second-Degree Burns Using a Caprolactone Dressing (Suprathel®)? A 15-Year Pediatric Burn Center Experience in 2084 Patients

Background: Thermal injuries represent a highly relevant epidemiologic problem with 11 million individuals affected globally each year, of which around 2.75 million are children. Different approaches to the conservative treatment of second-degree burns have been widely discussed in the existing literature. One method that has attracted increasing attention is the use of caprolactone dressings. This paper describes a study involving the therapeutic management of 2084 pediatric patients suffering from mixed superficial and deep dermal second-degree burns who received comprehensive expert treatment using caprolactone membranes at the pediatric hospital AUF DER BULT. Methods: A retrospective study was conducted to evaluate the frequency and effect of caprolactone membrane usage on children who were admitted to the pediatric hospital between 2002 and 2016 with mixed second-degree burns. The number of dressing changes under general anesthesia and the requirement for split thickness skin grafting were monitored and recorded. In addition, a cost comparison analysis of different treatment modalities was performed. Results: This retrospective study involved 2084 children who had been treated for mixed superficial and deep dermal burns between 2002 and 2016 using either caprolactone dressing (Suprathel®) (study group; n = 1154) or an alternative dressing material (control group; n = 930). Of the patients in the study group, 91.74% (n = 1053) were treated conservatively compared to 76.05% of the control group patients, meaning that 8.26% (n = 101) of the study group patients required skin grafting, compared to 23.95% (n = 223) in the control group. Additionally, the number of procedures under general anesthesia per patient was found to be 54.3% lower among all patients treated with caprolactone dressing (1.75 procedures per patient) compared to the entire control group (3.22 procedures per patient). In the subgroups, patients treated conservatively with caprolactone dressing required 1.42 procedures per patient compared to 2.25 procedures per patient in patients with alternative wound treatment. When split thickness skin grafting was necessary, 1.2 times as many procedures were performed on patients with alternative dressing compared to those treated with caprolactone dressing. Finally, the cost per patient was considerably lower in the conservative therapy group in comparison to the group that consisted of patients undergoing operative therapy with split thickness skin grafting. Conclusions: Caprolactone dressings were found to be beneficial for children who reported with mixed superficial and deep dermal burns. Specifically, they reduced the need for skin transplantation, the number of dressing changes under general anesthesia, and the treatment costs.

A Review of Burn Patients Requiring Extracorporeal Membrane Oxygenation at a Burns Facility

Respiratory compromise is a recognised sequelae of major burn injuries, and in rare instances requires extracorporeal membrane oxygenation (ECMO). Over a ten-year period, our hospital trust, an ECMO centre and burns facility, had five major burn patients requiring ECMO, whose burn injuries would normally be managed at trusts with higher levels of burn care. Three patients (60%) survived to hospital discharge, one (20%) died at our trust, and one patient died after repatriation. All patients required regular, time-intensive dressing changes from our specialist nursing team, beyond their regular duties. This review presents these patients, as well as a review of the literature on the use of ECMO in burn injury patients. A formal review of the overlap between the networks that cater to ECMO and burn patients is recommended.

Accuracy of Image-Based Automated Diagnosis in the Identification and Classification of Acute Burn Injuries. A Systematic Review

Although they are a common type of injury worldwide, burns are challenging to diagnose, not least by untrained point-of-care clinicians. Given their visual nature, developments in artificial intelligence (AI) have sparked growing interest in the automated diagnosis of burns. This review aims to appraise the state of evidence thus far, with a focus on the identification and severity classification of acute burns. Three publicly available electronic databases were searched to identify peer-reviewed studies on the automated diagnosis of acute burns, published in English since 2005. From the 20 identified, three were excluded on the grounds that they concerned animals, older burns or lacked peer review. The remaining 17 studies, from nine different countries, were classified into three AI generations, considering the type of algorithms developed and the images used. Whereas the algorithms for burn identification have not gained much in accuracy across generations, those for severity classification improved substantially (from 66.2% to 96.4%), not least in the latest generation (n = 8). Those eight studies were further assessed for methodological bias and results applicability, using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. This highlighted the feasibility nature of the studies and their detrimental dependence on online databases of poorly documented images, at the expense of a substantial risk for patient selection and limited applicability in the clinical setting. In moving past the pilot stage, future development work would benefit from greater input from clinicians, who could contribute essential point-of-care knowledge and perspectives.

Testing the Responsiveness of and Defining Minimal Important Difference (MID) Values for the CARe Burn Scales: Patient-Reported Outcome Measures to Assess Quality of Life for Children and Young People Affected by Burn Injuries, and Their Parents/Caregivers

The CARe Burn Scales are a portfolio of burn-specific PROMs for people affected by burns, including a Child Form (for children < 8 years (parent-proxy)), a Young Person Form (for young people aged 8–17 years), an Adult Form, and a Parent Form (for parents/carers of children aged 0–17 years). This study aimed to determine the responsiveness and minimal important difference (MID) values of the three scales developed for use in paediatric burn services and research. Participants were recruited by 15 UK Burn Services. Participants completed the appropriate CARe Burn Scale and a set of appropriate comparison validated measures, at three time points: 4 weeks (T1), 3 months (T2) and 6 months (T3) post-burn injury. Spearman’s correlation analysis and effect sizes based on Cohen’s d thresholds were reported and MID values were calculated. At baseline, 250 participants completed the Child Form, 69 completed the Young Person Form, and 320 completed the Parent Form. A total of 85–92% of participants were retained at follow up. The tested CARe Burn Scales were all responsive to change over time. MID values were created for all subscales and ranged from 2 to 11 for the Child Form, 3 to 14 for the Young Person Form and 3 to 10 for the Parent Form. The CARe Burn Scales for children, young people and parents are responsive to change over time. The scales are freely available for clinical and research use.

Imaging Techniques Used for Wound Healing Assessment: A Systematic Review Part 1 Chronic Wounds

Background: chronic wounds are complex to manage and require an objective assessment for diagnosis and prognosis purposes. Therefore, this article aims to provide an overview of available noninvasive imaging techniques for chronic wound healing described in the literature. Methods: a systematic literature review using electronic databases was performed with appropriate “Mesh” terms. The primary outcome was the validity and reliability of the instrument, whilst the secondary outcome was its feasibility, such as speed of assessment, ease of use and cost of the tool. All studies underwent quality assessment of diagnostic accuracy studies (QUADAS) to ensure the quality of the data. Results: 44 articles were identified evaluating six wound assessment modalities. Most studies (n = 9) reported on a two-dimensional device with a mean error ranging from 1.9–5.1% and an inter/intra rater correlation over 0.9 with a high ICC (>95%). The average QUADAS score was 13, with the lowest being 9 and the highest being 14. Conclusion: this review collectively evaluates objective, reliable, quantitative, and innovative tools to assess wound healing objectively. The most superior wound measuring device was two dimensional. However, hyperspectral imaging had strong potential but required further development in its technology and future clinic validation studies.

Pain Management in Geriatric Burn Patients: A Scoping Review of Strategies and Key Issues

The effect of poorly treated pain is well documented in the literature. To offer support for the development of geriatric-specific pain management protocols, this review sought to scope the literature to identify what has been accomplished in geriatric burn pain management and offer suggestions. Arksey and O’Malley’s scoping review methodology was employed with extensive database and grey literature searches. A narrative synthesis was employed to analyse the evidence. The PRISMA extension guidelines for scoping reviews were followed in reporting this review. Sixteen evidence types comprising eleven reviews, two retrospective studies, two book chapters, and one practice guideline were retained in the review. The two retrospective studies emerged from the United States. The review findings suggest that though a plethora of generic pain assessment tools exist, they are yet to be validated in the older adult burn population. Pain management strategies involved the use of pharmacological agents (mainly opioids), but no outcome regarding pain relief was reported. Key issues identified include cautious use of opioids, oversedation concerns, and varied complexities associated with pain management. Though the literature remains largely unexplored, the complexities associated with geriatric burn pain management suggest a need for a multidisciplinary approach. More prospective studies are also needed to evaluate both pharmacological and non-pharmacological interventions in the geriatric burn population.

Diagnosis and Management of Invasive Fungal Wound Infections in Burn Patients

Invasive fungal wound infection (FWI) after burn injury, while uncommon, is associated with significant morbidity and mortality. There are numerous risk factors for FWI, including large burn size and incomplete excision of burn wounds. FWI can be challenging to diagnose. Close attention to changes in the physical examination and, in particular, to the appearance of burn wounds leads the burn team to be suspicious of FWI. Once FWI is suspected, histopathological evaluation of an incisional biopsy provides definitive diagnosis, while tissue culture enables identification of the causative organism to the species level and facilitates targeted antifungal therapy. Management of FWI focuses largely on aggressive surgical intervention, in addition to adjunctive systemic and topical antifungals and nonpharmacologic therapies. Treatment of FWI involves a multifaceted approach, which requires expertise from the entire multidisciplinary burn team.