Burns open : an international open access journal for burn injuries最新文献

Introduction

The COVID-19 pandemic resulted in unprecedented changes to healthcare services. Non-emergent, out-patient care was either discontinued, greatly reduced, or switched to telehealth during the first wave of the pandemic. Here, we describe an American Burn Association (ABA) verified Burn Center’s experience with telehealth services during and after the COVID-19 emergency.

Material and methods

In this retrospective study, all patients who underwent out-patient care at a large academic hospital’s ABA Burn Center between March 2018 and March 2023 were identified from the electronic medical record system. Descriptive analysis was carried out to delineate trends in outpatient in-person and telehealth services during the COVID-19 pandemic. The travel distance saved from the introduction of telehealth was determined.

Results

During the study period, 3471 patients underwent a total of 7444 out-patient visits for burn care. There were no telehealth visits prior to the onset of the COVID-19 pandemic. In the first year of the COVID-19 pandemic, 14.9% of all out-patient visits were conducted with telehealth. This decreased to 8.3% and 6.8% of all out-patient care in the second and third years of the pandemic, respectively. The average round trip travel distance saved was 123 miles (2.8–––2312 miles). No complications were reported specific to receiving telehealth care.

Conclusions

Telehealth is a feasible option for out-patient burn care in selected patients and reduces travel for patients. Further studies are needed to assess patient and clinician satisfaction, clinical outcomes, and the economic impact of telehealth utilization to help guide appropriateness of use.

Resourceful surgical planning for coverage of large burns has led to refinement of early innovative procedures including meshed split thickness skin grafts (STSG), MEEK procedure, and use of cultured epidermal autografts (CEAs). The use of STSG remains standard of care for burn wound coverage; however, manual expansion of STSG is limited due to shortcomings with expansion rates greater than 4:1. The MEEK micrografting method is a method of preparing skin grafts with a device instead of manually with an autograft mesher, allowing reliable expansion rates of autografts up to 9:1. Although the CEA indication for use includes both with and without STSG, use of meshed STSG placed under CEA has been reported to minimize shear forces and hasten graft take. The purpose of this study was to evaluate success of graft take in patients receiving MEEK and CEA for wound coverage in extensive burns at a single burn center experienced in the use of both MEEK and CEA. Data in 15 patients who received both MEEK and CEA for the treatment of large burns (mean total body surface area [TBSA] of 66%) demonstrated a high rate of successful engraftment (87%), and an overall 73% survival rate.

Background

Infection is a leading cause of death in burn patients and increasing antimicrobial resistance has made management difficult. Antibiograms are a useful tool to guide empiric treatment of infections, however, inappropriate prescribing may influence resistance. The objective of this study is to describe trends in antibiotic susceptibilities and use in a Canadian burn population pre- (PrA) and post-introduction (PoA) of antibiograms.

Methods

We performed a retrospective review of patients admitted to an ABA-verified Burn Centre for two years pre- (2013–2014) and post-introduction (2016–2017) of institutional antibiograms receiving empiric broad-spectrum antibiotics (meropenem, piperacillin-tazobactam, and/or vancomycin).

Results

A total of 864 patients were admitted during the study period with 257 patients PrA and 239 patients PoA included. Average age, % total body surface area (%TBSA), and length of stay were similar between cohorts. Administration of empiric meropenem increased (43.2 % vs. 56.8 %) and piperacillin-tazobactam decreased (60.6 % vs. 39.4 %), which was significant (p = 0.002). There was a significant decrease in the overall use of empiric antibiotics (p = 0.002) and sepsis (p = 0.008) since the inception of antibiograms. There was no significant difference in use of targeted antibiotics pre- or post-antibiogram introduction.

Conclusions

Our study demonstrates that since the introduction of antibiograms, there has been a decrease in overall use of empiric antibiotics, a significant decrease in administration of piperacillin-tazobactam, and improvement in sepsis rates. However, these antibiotics were not routinely targeted to the appropriate organism and therefore may contribute to multi-drug resistant organisms in a burn population.

According to WHO, a burn is a type of tissue injury that may be caused by thermal, electric, radioactive, or chemical agents. Burns represent a critical public health concern worldwide, particularly in developing countries that experience a disproportionately high incidence of burn injuries and mortality rates. Accurate and comprehensive statistics regarding the causes of mortality and their associated factors are crucial for informed healthcare decision-making. Unfortunately, there is a notable scarcity of studies that specifically address these issues, and a significant disparity exists between clinically diagnosed causes of death and postmortem findings. This study aims to determine the causes of mortality among patients admitted to the Burns Center to improve healthcare provision and reduce the mortality rate of burn patients. This retrospective cohort study involved 262 patients, comprising 58 % (n = 152) males and 42 % (n = 110) females. The mean age of males was 34.5 years (std = 13.9) while for males was 31.9 years (std = 13.2). The data was retrieved from patients' files and autopsy reports collected from the burns centre. The chi-square test and T-test were used to identify any correlation between the variables. The causes of mortality included sepsis (48.9, n = 128), hypovolemic shock (27.5, n = 72), renal failure (22.9, n = 60), and cardiac failure (0.8, n = 2). Significant associations were observed between the causes of mortality and factors such as age, total body surface area affected (TBSA), inhalational injury, and etiology of burns (p-value < 0.05. However, no significant associations were found with gender or the degree of burns (p-value > 0.05). Our study illustrates sepsis/multiple organ failure (MOF) as the most common cause of death in burn patients, along with highlighting the risk factors having a strong correlation with the causes of mortality in individuals with burn injuries.

We report a case in which burn wound conversion occurred in a patient with concomitant COVID-19 pneumonia. To our knowledge, this is the first report to present sequential clinical photographs in a case of burn with COVID-19. Abundant oxygenation with huge head room, massive fluid resuscitation, and anticoagulation therapy may be required in COVID-19 patients even with a narrower surface of burn.

Background

Toxic epidermal necrolysis (TEN) is the most severe form of drug eruption, necessitating intensive care management in several cases. Although guidelines have been established for diagnosing and treating skin symptoms, few studies have reported on the intensive care management and prognosis of TEN. This study aimed to investigate intensive care for various types of organ failure associated with TEN and their prognoses.

Methods

This retrospective, descriptive, single-center study included patients admitted to our intensive care unit (ICU) for treatment of TEN over a 10-year period. We investigated the participants’ characteristics, organ failure and management, duration of ICU and hospital stay, and prognosis, through the electronic medical and ICU progress records.

Results

This study enrolled eight patients. Most patients presented with multiple organ failure, and in-hospital mortality was 50%. The median SOFA score at ICU admission was 9.5, and the median maximum SOFA score during ICU stay was 16.0. All patients underwent mechanical ventilation. Renal replacement therapy was administered to five patients. The median length of stay in the ICU was 31.5 days, and the median duration of hospitalization was 87 days. Survivors required long-term hospitalization, and only one patient was discharged home.

Conclusions

Most TEN patients admitted to the ICU had multiple organ failure, and poor short- and long-term prognoses.

Background

Acute thermal burns can be severe injuries potentially requiring hospitalization and may even lead to limb amputation or permanent disability if not properly addressed. Primary burn reconstruction using flaps has been shown to be an effective method that optimizes tissue preservation, minimizes limb morbidity, and allows for early mobility. Previous studies have demonstrated the dependence of flap survival on several factors such as wound size, location, and specific tissue requirements (weight-bearing vs non-weight-bearing). Proper selection of soft tissue coverage for a wound defect is vital in ensuring adequate healing and recovery. Our objective was to identify whether the choice of flap leads to differences in near-term survival and postoperative complications in patients undergoing burn reconstruction for thermal hand injuries.

Methods

Retrospective review was performed of our single institution burn database to identify patients who underwent primary soft tissue reconstruction for thermal hand burns between September 2014 and March 2022. All patients had wound defects with significant depth not amendable to skin grafting alone for coverage. Medical records were reviewed for demographics, injury specifics, treatment details, and post-operative outcomes.

Results

Of all patients admitted to our institution over an 8-year period for burn-related injuries, we identified 17 patients requiring 28 local or regional flaps for reconstruction. All but one flap survived a minimum of two weeks post-operatively with a success rate of 96%. Complications included partial necrosis in 1 flap, full necrosis in the failed flap, dehiscence in 2 flaps, and hematoma in 1 flap. One patient developed a donor site hematoma requiring evacuation, and another developed flap cellulitis treated with IV antibiotics.

Conclusion

Local, regional, and distant flaps can reliably be used to salvage exposed tendons and neurovasculature in deep thermal hand burns. Flap success and subsequent outcomes rely heavily on the initial wound and extent of soft tissue injury, with flap type and timing acting as secondary predictors.

Background

Accurate burn injury documentation is crucial for management. The four crucial elements of burn injury documentation are location, etiology, degree, and total body surface area. In our emergency room (ER), ER physicians primarily provide initial care. We aim to evaluate their assessment of the 4 Crucial Elements and their correlation to in-house care or discharge.

Methods

A retrospective ER charts study was conducted using ICD-9 codes for burn injury. Every tenth file was retrieved for detailed review, and burns' characteristics and management were examined. Chi-squared test was used on the data for analysis.

Results

We examined 301 patient files. Location was always stated. Only 43% had a complete description. Etiology was missing in 7%, burn degree in 18.5%, and TBSA in 67.5% of files. Patients with full descriptions had a statistically significant higher admission rate than those with partial documentation (P < 0.035), indicating a relationship between full documentation and the need for admission.

Conclusions

The study found incomplete documentation of burn injuries by non-burn physicians in the ER, leading to an impact on patient care decisions. There is a need for education and training to improve documentation quality, and the inclusion of burn-care rotations in medical education and residency programs.