Abstract
Introduction
Blood transfusions after major burn injury are common due to operative losses, blood sampling, and burn physiology. Burn patients lose an estimated 2% blood volume per percent ...burn excised, making large burn excisions a major source of blood loss. While a massive transfusion protocol improves outcomes in adult trauma patients, there remains a paucity of literature examining its effect in the critically ill pediatric population. The purpose of this study was to prospectively examine the outcomes of major pediatric burns receiving a 1:1 vs 4:1 red blood cell (RBC) to fresh frozen plasma (FFP) transfusion strategy during massive burn excision.
Methods
Children with >20% total body surface area (TBSA) 2nd and 3rd degree burns were randomized to a 1:1 or 4:1 RBC/FFP transfusion ratio during burn excision. Parameters measured included patient demographics, burn size, Pediatric Risk of Mortality (PRISM) scores, Pediatric Logistic Organ Dysfunction (PELOD) scores, clinical laboratory values, and total blood products transfused during operative interventions and hospitalization. Blood stream infections (BSI), urinary tract infections (UTI), and pneumonia (PNU), were documented using the burn consensus guidelines for infection.
Results
A total of 68 children were randomized into two groups (34 patients in the 1:1 group and 34 patients in the 4:1 group). Mean age (7.4 ± 5.5 v 8.2 ± 5.3 years), TBSA (39% ± 16 v 43% ± 24), and PRISM scores (9.5 ± 6 v 11 ± 6) did not significantly differ between groups. Estimated blood loss also did not significantly differ between groups (453 cc v 450 cc, p = 0.42). No significant differences were noted in ventilatory days (5 v 9, p = 0.47) or overall length of stay (57 v 60, p = 0.24). An equal number of infections were identified in both populations (24 patients each). Although no differences were identified in blood stream infections (20 v 18, p = 0.46), a higher number of pneumonias were documented in the 4:1 group (68 v 116, p = 0.08). On multivariate analysis, significantly higher TBSA (p < 0.001) and PRISM scores (p < 0.05) were identified in the 4:1 group when controlling for infection count.
Conclusions
No significant differences were identified in outcomes between a 1:1 and 4:1 massive transfusion strategy as measured by overall ventilator days, length of stay, or rates of infection. These findings would suggest noninferiority to either transfusion practice based on outcomes. Further work will be necessary to fully elucidate these results.
Applicability of Research to Practice
This work is an interim analysis of an ongoing study that suggests higher transfusion requirements may occur in higher risk patients such as those with larger TBSA burn sizes or mortality scores.
Abstract
Introduction
Pain management is critical for burn care with opioids serving as first line analgesics. Opioid dosing remains challenging in burn patients, especially in pediatrics, due to the ...immense interpatient variability in efficacy. Burn patients experience greater variability due to the impact of burn related comorbidities impacting opioid metabolism. This is exacerbated in children where developmental and physiological differences nullify dosing extrapolated from adult-data. A better understanding of the range of variability in the pharmacokinetics (PK) and pharmacodynamics (PD) of opioids in pediatric burn patients is warranted to optimize dosing. The goal of the present study is to characterize the variability in fentanyl PK in pediatric burn patients and identify significant covariates.
Methods
Patients with ≥ 10% total body surface area (TBSA) requiring intravenous fentanyl during routine wound care were enrolled in the study. Patient demographics, fentanyl dosing and other clinical data were recorded. Serial blood samples were collected at approximately 5, 30, 60, 120, and 240 minutes post fentanyl administration. Serum fentanyl concentrations were quantified using tandem liquid chromatography mass spectrometry (LC-MS/MS). Population PK analysis with Monolix software was used to estimate clearance (CL) and volume of distribution (Vd) parameters.
Results
Fourteen patients, 1.2 to 17 yrs old, with TBSA ranging from 10 to 50.5% were enrolled. A two-compartment PK model with weight as a covariate best described the fentanyl profiles for the overall population. The population CL and intercompartmental clearance (Q) were 7.19 and 2.16 L/hr, respectively, and the Vd1 and Vd2 were 4.01 and 25.1 L, respectively. Individual patient parameter estimates had extensive variability with some patient data poorly fitting the model. There was no significant correlation between CL and TBSA identified in these patients.
Conclusions
This study confirmed the high variability associated with fentanyl PK in pediatric burn patients. While some of these pediatric patients CL values were similar to the CL of non-burned pediatric patients reported literature, others were more in the range of CL reported for critically ill and elderly adults. Further research is needed with a larger number of patients to extensively investigate the impact of burns, genetic polymorphisms and other factors on opioid PK/PD and patient outcomes.
Applicability of Research to Practice
There is a vital need to better understand the variability in opioid PK to improve dosing regimens. Data obtained from this study informs clinicians that individualized opioid dosing in patients is warranted and further research is needed to understand the factors associated with opioid PK and PD variability.
Abstract
Introduction
There is a recent clinical trend toward “early mobility” of burn survivors yet there have been few studies to investigate or describe the components of an early mobility program ...with the burn population. A clinician may “mobilize” a burn survivor by providing range of motion (ROM) to a limb or by facilitating out of bed ambulation (OOB) or both. These interventions have different effects on patient physiology and local skin graft integrity therefore, it is essential we understand what burn clinicians mean by “mobility”. This study evaluates post-operative ROM and OOB practices with burn patients and investigates the influence of graft type and graft location on clinical decision making.
Methods
Specific mobility practices differentiating between ROM and OOB therapies were investigated using an electronically distributed SSL secure survey with 32 questions. Data specific to graft type (split thickness non-mesh (STSG), mesh (STSG-M) and full thickness (FTSG)) and to body location of graft placement was also collected.
Results
Responses were received from 96 clinicians who reported an average of 15.7 years of experience working in mostly verified burn centers (74%). Results demonstrated that 86% of clinicians report different practices for ROM and OOB mobilization with burn survivors. OOB occurred significantly earlier than ROM after skin grafting for patients with all types of grafts placed above the waist and on the feet (Table). For grafts between the knees and waist and on lower legs, OOB and ROM occurred at similar times, except for FTSG to lower legs. There was greater variability in practice for OOB than ROM (CV .71 v.5, p≤0.05) with OOB occurring on different post-operative days depending on graft location (p≤0.05).
Conclusions
Post-operative OOB mobility practices are quite varied with the burn population and influenced by the location and type of skin grafts. ROM is less varied, however in many cases, it occurs significantly later than OOB.
Applicability of Research to Practice
The results of this study establish an understanding of current practice that can help facilitate appropriate interventions and research that may optimize outcome for the burn survivor.
Abstract
Introduction
Cervical spine injuries (CI) carry significant morbidity and mortality; hence, cervical spine immobilization is used frequently in trauma patients, including burns. Cervical ...collars are not without associated morbidity of pressure ulcers, pain, and increased intracranial pressure. Minimal literature exists on cervical spine injuries in burn patients, including the appropriate criteria for placement and removal of collars.
Methods
The National Trauma Data Bank was queried from 2007 to 2012 to identify all burned patients with and without cervical spine injuries. Characteristics collected included age, gender, mechanism of injury, Injury Severity Score, mortality, length of stay, days in intensive care, and ventilator days. Records without documented length of stay values were excluded. Chi-squared tests were used for binomial variables and the Wilcoxon rank sum test for interval variables.
Results
A total of 94,964 patients were identified with burn injuries. The prevalence of cervical injury (CI) was 0.79% (n=745). The average age of patients with CI was higher than those without (40.5 vs 32.0 years). Male patients were the majority in both groups (71.5% with CI vs 68.8%). Presence of CI varied with mechanism of injury. CI was most common following blunt trauma and falls, however was uncommon with fire/flame, hot object/substance, and explosions (Table 1). Patients with CI had significantly worse injuries and outcomes. The Injury Severity Score was higher in those with CI (median 22.0 vs 1.0, Z 43.4, p<0.001). Patients with CI had higher mortality (10.3% vs 2.9% p<0.0001), higher total length of stay (median 12.0 vs 2.0, Z 25.2, p<0.0001), intensive care unit length of stay (median 4.0 vs 0.0, Z =28.0, p<0.001), and ventilator days (median 1.0 vs 0.0, Z 30.8, p<0.0001).
Conclusions
Cervical spine injuries are uncommon in burn patients, however are associated with significantly higher mortality and worse outcomes. Presence of cervical injury varies based on the mechanism.
Applicability of Research to Practice
Results can be used to determine criteria for placement and removal of collars in trauma patients with burns.
Table 1.
Percent of Cervical Injury By Mechanism
Fire/Flame
Hot Object/Substance
Blunt Trauma
Explosion
Fall
Other, specified
0.0008
0.0003
8.2
0.15
6.3
0.009
Abstract
Introduction
Treatment of lower extremity burn injuries in adults with diabetes can be complex. Due to diabetes related factors lower extremity burn wound healing may be impaired and many ...patients are at risk for poor burn wound healing leading to amputations. We hypothesize that chronic diabetes related risk factors such as peripheral neuropathy and poor glucose control increases the risk of poor burn wound healing leading to amputations.
Methods
After obtaining regulatory approval from our local institutional review board, we performed a 11 year retrospective review of all adult burn patients admitted to our burn unit with lower extremity burn injuries. We collected and analyzed the following data: age, TBSA, diabetic medications, length of stay, admission blood glucose, hemoglobin A1c level on admission, renal function, and need for amputation.
Results
A total of 113 patients were included in this study. Patients were divided into two groups; patients who had an amputation (AMP) during their hospitalization, and those who did not (no-AMP). There was no difference in age between the AMP (53 ± 12 years) and the no-AMP (58 ± 14 years) groups. There was also no difference in TBSA between AMP (4(IQR8)%)and no-AMP (2.23(IQR2)%). There was also no difference in the type of medication used by the patients for diabetic control, admission renal function, or admission blood sugar. The AMP group had more neuropathy (88% vs. 49%, p<0.05). The AMP group also had higher admission hemoglobin A1c levels (10 ± 2.4 % vs. 8.6 ± 2.5%, p<0.05)). Using multivariate regression analysis modeling to determine the risk of needing an amputation, neuropathy was an independent risk factor (Odds Ratio 11.5 (CI 1.6–80)).
Conclusions
Patients with diabetic neuropathy are likely at a higher risk of poor burn wound healing leading to amputations. More research is needed to determine other factors that may better inform diabetic patients and treating physicians about the risks of poor burn wound healing and amputations.
Applicability of Research to Practice
Treatment complication assessment for diabetic burn patients with lower extremity injuries.
Abstract
Introduction
Blood transfusion is often required in burn injury management. Several factors, including burn size, have been associated with the need for blood transfusion. However, the ...impact of inhalation injury, which is associated with adverse outcomes in burns, on blood transfusion has had limited study. The purpose of this study was to delineate the impact of inhalation injury on pediatric burn patients’ blood transfusion rates and outcomes.
Methods
A retrospective study was conducted for all pediatric burn cases that required blood transfusion from November 2005 to May 2017 at our burn center. Patients were assigned into two groups: inhalation injury and non-inhalation injury groups. Patient demographics, total body surface area (TBSA) burn, blood transfusions and outcomes were reviewed.
Results
A total of 460 patients with burn injury receiving blood transfusion were included. Median patient age was 6.00 (IQR 2.59, 12.2) years in the inhalation group vs 5.35 (IQR 2.1, 11.4) years in non-inhalation group. The inhalation group had longer ICU stay (26 vs. 16days, respectively; P<0.001), higher ratio of ICU stay per TBSA (0.8 vs. 0.58, respectively; P<0.001), longer mechanical ventilation duration (18 vs. 4 days, respectively; P<0.001), higher ratio of mechanical ventilation duration per TBSA (0.56 vs. 0.12, respectively; P<0.001) and higher mortality rate (0.24 vs. 0.03, respectively; P<0.001). The median number of blood products transfusion, including RBC, FFP, platelets and Cryoprecipitate, and the ratio of blood products transfusion per percentage TBSA were noted to be significantly higher in inhalation injury group (See Table 1). A multivariate linear regression analysis was run to predict the amount of RBC transfusion from inhalation, age and TBSA. Inhalation Injury independently associated with more RBC transfusion per percentage TBSA (P<0.05).
Conclusions
Inhalation injury increases blood transfusion needs in pediatric burn patients. Further study is indicated to determine if this discrepancy is due to burn injury extent or the pathophysiologic changes associated with inhalation injury.
Applicability of Research to Practice
This result would be helpful to form burn blood transfusion practice.
Table 1
Blood products transfusion in the inhalation injury and non-inhalation injury groups
Inhalation injury group (n=89)
Non-inhalation injury group (n=371)
P value
RBC (units)
10 (4,21)
4 (2,9)
< 0.001
RBC/TBSA
0.24 (0.15, 0.36)
0.15 (0.08, 0.26)
< 0.001
FFP (units)
3 (1, 9)
1 (0, 3)
< 0.001
FFP/TBSA
0.08 (0.03, 0.15)
0.03 (0, 0.08)
< 0.001
Platelets (units)
0 (0, 2)
0 (0, 0)
< 0.001
Platelets/TBSA
0 (0, 0.04)
0 (0, 0)
< 0.001
Cryoprecipitate (units)
0 (0, 0)
0 (0, 0)
0.01
Cryoprecipitate/TBSA
0 (0, 0)
0 (0, 0)
0.01
* RBC: Red blood cell, FFP: Fresh Frozen Plasma, TBSA: Total body surface area
Abstract
Introduction
Maintaining a clean, non-occlusive dressing that protects the site from infection for pediatric burn patients can be challenging. The aim of this study was to create a ...consistent and universal dressing for all central and arterial lines in or near wounds that are not amenable to an occlusive dressing.
Methods
We mobilized a team to create a new central line care policy and develop a prepackaged non-occlusive kit for central line care. The kit included all the items needed to clean the site. Existing staff were trained one on one to follow the new policy using the non-occlusive kits. All new staff members were trained at new employee orientation. We compared central line associated blood stream infection rates (CLABSI) the year prior to establishment of the protocol with the subsequent year (allowing for a 6 month training window).
Results
In 2015 we admitted 46 children with 33.4% TBSA compared to the ensuing year 48 children with 33% TBSA with central lines. In the year of 2015 there were 4 CLABSI with a total line days of 1346. In 2016–17 we had 3 CLABSI with total line days of 3355 (2121 in the second half of 2016 and 1234 in 2017).
Conclusions
Using the non-occlusive dressing change kits provided consistent universal central line care for all central lines in or near wounds that cannot maintain an occlusive dressing and likely contributed to decreased CLABSI rates.
Applicability of Research to Practice
Creating consistent and universal central line care using prepackaged non-occlusive central kits.
Abstract
Introduction
The effect of socioeconomic status on healthcare outcomes has been well established. However, little work has been done to assess this impact on burn patients. The aim of the ...study is to evaluate outcomes of burn patients in the setting of poverty levels.
Methods
Demographic data and outcomes were collected for patients aged 50 years or older who were admitted to the Burn Intensive Care Unit in 2015. State Census Bureau data was used to determine the percentage below poverty level based on patient’s home zip codes. Statistical analysis was then performed using univariate analysis followed by logistic regression to assess the effects of pertinent demographic data, including poverty level, on mortality. A p-value ≤ 0.05 was deemed significant.
Results
There were 489 patients included. The table shows the results of a univariate analysis analyzing factors and outcomes as related to poverty level ≤20% compared poverty level >20%. This showed statistically significant increased mortality for patients with poverty level >20%. There were also differences in burn types between the two poverty level groups. There was no significant difference in regards to age, gender, presence of inhalational injury or TBSA. Using clinically significant demographic data from hospital presentation, multivariate analysis was run on mortality to determine effect of poverty level. The results of this analysis are also shown in the table. The analysis showed that in patients who died, they were significantly more likely to be older, have inhalational injury, have higher TBSA and be from areas with poverty level > 20%.
Conclusions
Poverty level was associated with burn type as patients from more impoverished areas were more likely to suffer flame burns. These patients were also associated with increased mortality. When multivariate analysis was performed, patients who died were 5 times more likely to be from areas with poverty level >20%. Age, presence of inhalational injury and TBSA burn were also significant factors associated with mortality.
Applicability of Research to Practice
Understanding the interplay of socioeconomic factors and outcomes can assist physicians to make predict clinical course and perhaps alter management with these relationships in mind.
PDF
