Topical petrolatum gel alone versus topical silver sulfadiazine with standard gauze dressings for the treatment of superficial partial thickness burns in adults: A randomized controlled trial

BackgroundNon-extensive superficial partial thickness burns constitute a major proportion of burns. Conventional treatment involves regular changing of absorptive dressings including the application of a topical antimicrobial, commonly silver sulfadiazine. A systematic review has found insufficient evidence to support or refute such antimicrobial prophylaxis. Another review compared silver sulfadiazine dressings with other occlusive and non-antimicrobial dressings and found insufficient evidence to guide practice. Other research has suggested that dressings with petrolatum gel are as effective as silver sulfadiazine.MethodsSingle-center, randomized, controlled parallel group trial comparing conventional silver sulfadiazine dressings with treatment with petrolatum gel alone. Consenting adults 18–45 years old with superficial partial thickness burns ≤10% total body surface area seen within 24 h of the injury were randomized to daily dressing either with petrolatum gel without top dressings or conventional silver sulfadiazine treatment with gauze dressings. Primary outcomes were blinded assessment of time to complete re-epithelialization, wound infection or allergic contact dermatitis. Secondary outcomes included assessment of ease, time and pain of dressing changes.Results26 patients were randomized to petrolatum and 24 to silver sulfadiazine dressings. Follow up data available for 19 in each group. Mean time to re-epithelialization was 6.2 days (SD 2.8) in the petrolatum group and 7.8 days (SD 2.1) in the silver sulfadiazine group (p = 0.050). No wound infection or dermatitis was observed in either group. Scores for adherence to wound, ease of dressing removal and time required to change dressings were significantly better in the petrolatum treatment arm (p < 0.01).ConclusionsPetrolatum gel without top dressings may be at least as effective as silver sulfadiazine gauze dressings with regard to time to re-epithelialization, and incidence of infection and allergic contact dermatitis. Petrolatum gel appears to be an effective, affordable and widely available alternative in the treatment of minor superficial partial thickness burns in adults.     

Prevalence and Risk Factors for Hypertrophic Scarring of Split Thickness Autograft Donor Sites in a Pediatric Burn Population

TitlePrevalence and Risk Factors for Hypertrophic Scarring of Split Thickness Autograft Donor Sites in a Pediatric Burn Population.ObjectiveThe split-thickness autograft remains a fundamental treatment for burn injuries; however, donor sites may remain hypersensitive, hyperemic, less pliable, and develop hypertrophic scarring. This study sought to assess the long-term scarring of donor sites after pediatric burns.MethodsA retrospective review of pediatric burn patients treated at a single institution (2010–2016) was performed. Primary outcomes were prevalence of donor site hypertrophic scarring, scarring time course, and risk factor assessment.Results237 pediatric burn patients were identified. Mean age at burn was 7 yrs., mean %TBSA was 26% with 17% being Full Thickness. Mean follow-up was 2.4 yrs. Hypertrophic scarring was observed in 152 (64%) patients with 81 (34%) patients having persistent hypertrophic scarring through long-term follow-up. Patient-specific risk factors for hypertrophic scarring were Hispanic ethnicity (P = 0.03), increased %TBSA (P = 0.03), %Full Thickness burn (P = 0.02) and total autograft amount (P = 0.03). Donor site factors for hypertrophic scarring were longer time to epithelialization (P < 0.0001), increased donor site harvest depth (P < 0.0001), autografts harvested in the acute burn setting (P = 0.008), and thigh donor site location (vs. all other sites; P < 0.0001). The scalp, arm, foot, and lower leg donor sites (vs. all other sites) were less likely to develop HTS (P < 0.0001, 0.02, 0.005, 0.002, respectively), along with a history of previous donor site harvest (P = 0.04).ConclusionsHypertrophic scarring is a prominent burden in donor site wounds of pediatric burn patients. Knowledge of pertinent risk factors can assist with guiding management and expectations.     

Predicting the effectiveness of virtual reality relaxation on pain and anxiety when added to PCA morphine in patients having burns dressings changes

BackgroundPain arising in burns sufferers is often severe and protracted. The prospect of a dressing change can heighten existing pain by impacting both physically and psychologically. In this trial we examined whether pre-procedural virtual reality guided relaxation added to patient controlled analgesia with morphine reduced pain severity during awake dressings changes in burns patients.MethodsWe conducted a prospective randomized clinical trial in all patients with burns necessitating admission to a tertiary burns referral centre. Eligible patients requiring awake dressings changes were randomly allocated to single use virtual reality relaxation plus intravenous morphine patient controlled analgesia (PCA) infusion or to intravenous morphine patient controlled analgesia infusion alone. Patients rated their worst pain intensity during the dressing change using a visual analogue scale. The primary outcome measure was presence of 30% or greater difference in pain intensity ratings between the groups in estimation of worst pain during the dressing change.FindingsOf 88 eligible and consenting patients having awake dressings changes, 43 were assigned to virtual reality relaxation plus intravenous morphine PCA infusion and 43 to morphine PCA infusion alone. The group receiving virtual reality relaxation plus morphine PCA infusion reported significantly higher pain intensities during the dressing change (mean = 7.3) compared with patients receiving morphine PCA alone (mean = 5.3) (p = 0.003) (95% CI 0.6–2.8).InterpretationThe addition of virtual reality guided relaxation to morphine PCA infusion in burns patients resulted in a significant increase in pain experienced during awake dressings changes. In the absence of a validated predictor for responsiveness to virtual reality relaxation such a therapy cannot be recommended for general use in burns patients having awake dressings changes.     

A randomized,double-blind,phase I clinical trial of fetal cell-based skin substitutes on healing of donor sites in burn patients

BackgroundDue to limited graft donor sites in extensive burns, re-harvesting of a single donor area is very common. Given the importance of fetal fibroblasts in accelerating fetal wound healing, fetal cell-based skin substitutes have emerged as a novel therapeutic modality for regenerating damaged skin. In this trial, we aimed to evaluate the safety, feasibility and potential efficacy of application of amniotic membranes seeded with fetal fibroblasts for accelerating donor sites healing in burn patients.MethodsIn this randomized, double-blind, phase I clinical trial, 10 patients with total burn surface area of 10–55% were enrolled. Three equal parts (10 × 10 cm) were selected in donor site of each patient and covered by Vaseline gauze (control group), amniotic membrane (AM group), or amniotic membrane seeded with fetal fibroblasts (AM-F group). Adverse events, pain intensity scores, and wound sizes were recorded on days 4, 8, 11, 14, and 20 post-treatment. Also, histological assessments were done on days 0 and 14 after the surgery.ResultsAll patients underwent surgery, and no adverse events occurred during the procedure and follow-up period. Significantly lower pain intensity and higher healing rates were observed in AM-F and AM groups compared to the control group. Moreover, mean complete re-epithelializatin in AM-F and AM groups were 10.1 ± 2.4 and 11.3 ± 2.9 days, showing that the healing process was significantly accelerated compared to the control group with mean closure time of 14.8 ± 1.6 days. Histological assessment showed lower inflammatory cells infiltration in AM-F and AM groups compared to control group.ConclusionsThis study indicated the safety of transplantation of amniotic membrane seeded with fetal fibroblasts for treatment of donor sites in burn patients; however, preliminary assessments showed no benefits for this therapeutic modality over amniotic membrane alone. Thus, to draw accurate conclusions, further trials in larger populations should be conducted.Level of Evidence: This study is assigned as level I.     

Impact of orally administered tramadol combined with self-selected music on adult outpatients with burns undergoing dressing change: A randomized controlled trial

ObjectiveTo investigate the effects of music and/or tramadol on pain and anxiety in burn outpatients undergoing dressing changes.DesignRandomized controlled trial.SettingBurns and Plastic Reconstruction Unit.ParticipantsPatients (N = 180) with burns on up to 10%–30% of the total body surface area (TBSA).InterventionsThe patients were randomly allocated to 4 equal-sized groups as follows: (1) tramadol group (TG), patients received 100 mg of tramadol orally 20 min before the dressing change; (2) music group (MG), patients listened to self-selected music during the dressing change; (3) music-plus-tramadol group (MTG), patients received tramadol and listened to self-selected music; and (4) control group (CG), patients received a routine dressing change only. All patients underwent the interventions once per day for 2 days.Main outcome measuresMcGill Pain Questionnaire Short Form (MPQ-SF) (primary outcome), McGill Pain Persian version of Burn Specific Pain Anxiety Scale (BSPAS) (primary outcome), and heart rate (HR) and overall patient satisfaction (secondary outcomes).ResultsThe results showed that music-plus-tramadol group (MTG) had better outcomes with respect to pain and anxiety management during dressing changes.ConclusionsIn comparison with music or tramadol alone, the integration of music and tramadol offers a secure and favorable treatment choice to relieve pain and anxiety, ultimately improving the satisfaction levels of burn outpatients during dressing changes.     

Betulin wound gel accelerated healing of superficial partial thickness burns: Results of a randomized,intra‐individually controlled,phase III trial with 12‐months follow‐up

ObjectiveAcceleration of wound healing promises advantages for patients and caregivers in reducing the burden of disease, avoiding complications such as wound infections, and improving the long-term outcome. However, medicines that can accelerate wound healing are lacking. The objective of this open, blindly evaluated, randomized, multicenter phase III study was to compare intra‐individually the efficacy and tolerability of Oleogel‐S10 with fatty gauze dressing versus Octenilin^® wound gel with fatty gauze dressing in accelerating the healing of superficial partial thickness burn wounds.MethodsAcute superficial partial thickness burn wounds in adults caused by fire, heat burn or scalding were divided into 2 halves and randomly assigned to treatment with Oleogel‐S10 or Octenilin^® wound gel. Photos for observer‐blinded analysis of wound healing were taken at each wound dressing change. Percentages of reepithelialization were assessed at defined intervals. Efficacy and tolerability were evaluated based on a 5‐point Likert scale.ResultsOf 61 patients that were enrolled, 57 received the allocated intervention and 48 completed treatment. The percentage of patients with earlier wound healing was significantly higher for Oleogel‐S10 (85.7%, n = 30) compared to Octenilin^® wound gel (14.3%, n = 5, p < 0.0001). The mean intra‐individual difference in time to wound closure was −1.0 day in favour of Oleogel‐S10 (−1.4, −0.6; 95% CI, p < 0.0001). Most investigators (87.0%) and patients (84.8%) evaluated the efficacy of Oleogel‐S10 to be ‘better’ or ‘much better’ than that of Octenilin^® wound gel. Long-term outcome 3 months and 12 months post injury was improved in some patients.ConclusionsOleogel‐S10 (Episalvan) significantly accelerated the healing of superficial partial thickness burn wounds. It was safe and well tolerated.     

Determination of efficacy of a novel alginate dressing in a lethal arterial injury model in swine

IntroductionAlginate is a biocompatible polysaccharide that is commonly used in the pharmaceutical, biomedical, cosmetic, and food industries. Though solid dressings composed of alginate can absorb water and promote wound healing, they are not effective hemostatic materials, particularly against massive hemorrhage. The purpose of this study is to attempt to increase the hemostatic capabilities of alginate by means of hydrophobic modification. Previous studies have illustrated that modifying a different polysaccharide, chitosan, in this way enhances its hemostatic efficacy as well as its adhesion to tissue. Here, it was hypothesized that modifying alginate with hydrophobic groups would demonstrate analogous effects.MethodsFifteen Yorkshire swine were randomized to receive hydrophobically-modified (hm) alginate lyophilized sponges (n = 5), unmodified alginate lyophilized sponges (n = 5), or standard Kerlix™ gauze dressing (n = 5) for hemostatic control. Following a splenectomy, arterial puncture (6 mm punch) of the femoral artery was made. Wounds were allowed to freely bleed for 30 s, at which time dressings were applied and compressed for 3 min in a randomized fashion. Fluid resuscitation was given to preserve the baseline mean arterial pressure. Wounds were monitored for 180 min after arterial puncture, and surviving animals were euthanized.ResultsBlood loss for the hm-alginate group was significantly less than the two control groups of (1) alginate and (2) Kerlix™ gauze (p = < 0.0001). Furthermore, 80% of hm-alginate sponges were able to sustain hemostasis for the full 180 min, whereas 0% of dressings from the control groups were able to achieve initial hemostasis.ConclusionsHm-alginate demonstrates a greatly superior efficacy, relative to unmodified alginate and Kerlix™ gauze dressings, in achieving hemostasis from a lethal femoral artery puncture in swine. This is a similar result as has been previously described when performing hydrophobic modification to chitosan. The current study further suggests that hydrophobic modification of a hydrophilic biopolymer backbone can significantly increase the hemostatic capabilities relative to the native biopolymer.     

Comparison of skin graft donor site management using oxidised regenerated cellulose (ORC)/collagen/silver-ORC with absorptive silicone adhesive border and transparent film dressing vs semi-occlusive dressings

Split-thickness skin grafts (STSG) are widely used in wound reconstruction. However, donor site wounds are created as a result. Traditionally, moist wound healing and transparent film dressings have been used to promote donor site wound healing. This retrospective study evaluated the use of oxidised regenerated cellulose (ORC)/collagen/silver-ORC dressing (ORC/C/Ag-ORC) with an absorptive silicone adhesive border dressing and transparent film dressing (treatment) compared with petrolatum-based gauze dressing (control) over donor site wounds. Patients underwent an STSG procedure between January and December 2020. Donor sites received treatment (n = 10) or control (n = 10) dressings. Dressing changes occurred as necessary. Time to epithelialisation, narcotic pain medication requirements, and the number of office/hospital visits were examined. Twenty patients were managed (9 males, 11 females, average age: 49.7 ± 13.9 y). Patient comorbidities included hypertension, diabetes, and hyperlipidemia. Wound types included traumatic and cancer excision. Time to epithelialisation was significantly reduced in the treatment group (11.1 ± 1.4 d vs 18 ± 2.4 d, P < 0.0001). The number of office visits for dressing changes was significantly lower in the treatment group (0.1 ± 0.3 vs 2 ± 0.7, P < 0.0001). No patients in the treatment group required a hospital visit, compared with 3 patients in the control group. One patient in the treatment group required narcotic pain medication, compared with 5 in the control group. In this patient population, the use of ORC/C/Ag-ORC, an absorptive silicone adhesive border dressing, and transparent film dressing resulted in a shorter time to epithelialisation and less analgesic requirement compared with petrolatum-based gauze dressing use.     

The effect of foot reflexology massage on burn-specific pain anxiety and sleep quality and quantity of patients hospitalized in the burn intensive care unit (ICU)

BackgroundBurn-specific pain anxiety and sleep disorders are common factors in burned patients that affect wound healing process, as well as the severity of burn pain. This study aimed to investigate the effect of foot reflexology massage on burn-specific pain anxiety and sleep condition of patients hospitalized in the burn ICU.MethodIn this randomized controlled clinical trial, 52 patients were assigned by permuted block randomization 1:1 to the intervention (n = 26) and control (n = 26) groups. The intervention group received 20 min of foot reflexology massage during 3 days on their third, fourth and fifth days of hospitalization and 15 min before changing wound dressings. Patients in the control group merely received routine care. The Burn-Specific Pain Anxiety Scale (BSPAS) was completed for three consecutive days before and after changing wound dressings, and St. Mary's Hospital Sleep Questionnaire (SMHSQ) was filled out for four consecutive days before changing wound dressings for patients in both groups. The data were analyzed by IBM SPSS 16 software, Chicago, independent t, Chi-square, Friedman, Mann–Whitney and Wilcoxon tests.FindingsWe found no significant difference between pain-anxiety in the two groups before the intervention. The trend of different days in each groups were compared with Friedman test and showed that pain anxiety (p < 0.001), sleep latency (p < 0.001), duration of the last day's sleep (p < 0.001) and satisfaction of the last night sleep (p < 0.001) had a significant difference. In addition, Mann–Whitney test results showed that there were significant differences between the two groups at different times in terms of the above variables (p < 0.05). The effect size was = 0.82 for pain anxiety between group after the intervention.ConclusionBased on the results, foot reflexology massage can effectively reduce pain anxiety levels and improve sleep quality and quantity of patients with burn injuries; therefore, this non- pharmacological therapeutic method is recommended to be used in the burn ICUs. (Clinical trial’s registration code: IRCT20110906007494N27)     

Feasibility of monomodal analgesia with IV alfentanil during burn dressing changes at bedside (in spontaneously breathing non-intubated patients)

Introduction

The severe pain related to repeated burn dressing changes at bedside is often difficult to manage. However these dressings can be performed at bedside on spontaneously breathing non-intubated patients using powerful intravenous opioids with a quick onset and a short duration of action such as alfentanil. The purpose of this study is to demonstrate the efficacy and safety of the protocol which is used in our burn unit for pain control during burn dressing changes.

Intraoperative liposomal bupivacaine for skin graft donor site analgesia: A retrospective cohort study

IntroductionBurn injury and reconstructive operations often result in severe pain, particularly at skin graft donor sites. Traditional local anesthetics administered intraoperatively control pain at donor sites, but the duration of action is short. Liposomal bupivacaine, a novel local anesthetic, can provide sustained-release analgesia for 72 h. The primary aim of this study was to describe the efficacy of liposomal bupivacaine for postoperative donor site pain control for patients undergoing skin graft procedures.MethodsA retrospective cohort study was performed on patients who received a donor site liposomal bupivacaine field block and was compared to a matched control. Patients rated donor site pain on post-operative day 0 and 1, and stated whether the donor or graft site was more painful.ResultsFifty-eight patients were included. Twenty-nine patients received liposomal bupivacaine. Eighty-six percent of patients in the treatment group rated donor site pain as three or less on postoperative day 0 and 1, compared to 3.4% in the control (p < 0.0001). Also, 76% of patients in the treatment group stated donor site pain was less than graft site pain, compared to 3.4% in the control (p < 0.0001).ConclusionPatients who received liposomal bupivacaine reported less postoperative donor site pain and found the donor site to be less bothersome without major complications. Liposomal bupivacaine may be a safe and promising agent for prolonging postoperative analgesia and minimizing donor site pain.     

Feasibility and impact of the implementation of a clinical scale-based sedation-analgesia protocol in severe burn patients undergoing mechanical ventilation. A before-after bi-center study

BackgroundSevere burn patients undergo prolonged administration of sedatives and analgesics for burn care. There are currently no guidelines for the dose adaptation of sedation-analgesia in severe burn patients.MethodsWe performed a before-after 2-center study to demonstrate the feasibility and efficacy of a sedation-analgesia scale-based protocol in severely burned patients receiving ≥24 h of invasive mechanical ventilation. Before the intervention, continuous infusion of hypnotic and morphine derivatives was continued. During the Intervention phase, general anesthesia was relayed from day 1 by RASS/BPS-titrated continuous infusion of hypnotic and morphine derivatives and with short half-life drugs adminstered for daily burn dressings. The primary outcome was the duration of invasive mechanical ventilation in the ICU.ResultsEighty-seven (46.2%) patients were included in the Control phase and 101 (53.7%) in the Intervention phase. The median burned cutaneous surface was 20% [11%–38%] and median ABSI was 7 [5–9]. The durations of hypnotic and opioid infusions were not statistically different between the 2 phases (8 days [2–24] vs. 6 days [2–17] (P = 0.3) and 17 days [4–32] vs. 8 days [3–23] (P = 0.06), respectively). The duration of mechanical ventilation was 14 days [3-29] in the Control phase and 7 days [2–24] in the Intervention phase (P = 0.7). When taking into account the competition between mortality and weaning from mechanical ventilation, we found no significant difference between the 2 phases (Gray test, P = 0.4). The time-series analysis showed no difference for the duration of mechanical ventilation in the Intervention phase (P = 0.6). Eighteen (20.7%) patients died in the Control phase, and 18 (18%) in the Intervention phase (P = 0.6).ConclusionScale-based lightening of continuous sedation-analgesia with repeated short general anesthesia for dressing is feasible in severe burn patients but failed to demonstrate a decrease in the duration of invasive mechanical ventilation.     

Prehospital use of hemostatic dressings in emergency medical services in the Netherlands: A prospective study of 66 cases

BackgroundUncontrolled haemorrhage is the leading cause of potentially preventable death in both civilian and military trauma patients. Animal studies and several case series have shown that hemostatic dressings reduce haemorrhage and might improve survival. One of these products is HemCon ChitoGauze^®. The objective of this study was to determine the effectiveness and safety of ChitoGauze in achieving hemostasis in massive traumatic bleeding in civilian emergency medical services.MethodsFrom June 2012 to December 2014, all ambulances of two emergency medical services in the Netherlands were equipped with ChitoGauze. The dressing was used according to protocol; if conventional treatment (gauze dressing with manual pressure) failed to control external traumatic bleeding or if conventional treatment was unlikely to achieve hemostasis. The ambulance personnel filled in an evaluation form after each use.ResultsA total of 66 patients were treated with ChitoGauze during the study period. Twenty-one patients were taking anticoagulants or suffered from a clotting disorder. The injuries were located in the extremities (n = 29), the head and face (n = 29), or the neck, thorax and groin (n = 8). In 46/66 patients, the use of ChitoGauze resulted in cessation of haemorrhage. In 13/66 patients, Chitogauze application reduced haemorrhage. ChitoGauze failed to control haemorrhage in 7/66 patients, whereby user error was a contributing factor in 3 of these failures. No side effects have been observed during treatment or transport of the patients and no adverse effects have been reported in discharge letters.ConclusionThis is the largest prospective study in civilian healthcare and the second largest case series with prehospital use of hemostatic dressings. It demonstrated that ChitoGauze is an effective and safe adjunct in the prehospital treatment of massive external traumatic haemorrhage.     

High-valve vapor-permeable film dressing versus fine mesh gauze dressing on skin graft donor areas in diabetic patients: a prospective randomized controlled trial

The use of split-thickness skin grafts (STSG) as a reconstructive technique in the diabetic foot is common. Studies on the ideal dressing for donor-site care have not included subjects such as diabetics who have wound-healing problems. The aim of this study was to determine the efficacy of high-valve water vapor transmission rate (WVTR) polyurethane film dressing in the management of the STSG donor site compared to the clinical standard fine mesh gauze dressing in diabetic patients. Twenty diabetic patients were observed for healing, scarring, and pain. Healing times were recorded. Pain was monitored using a visual analog pain scale and recorded. Scarring of the donor sites was assessed using the Vancouver scar scale 6 months after surgery. The WVTR dressing was found to be significantly better than mesh gauze dressing for the healing of STSG donor sites. Healing occurred more rapidly and with less pain. Moreover, it has some advantages of dry wound dressings such as ease of application and follow-up. Dressings should retain enough moisture to stimulate good healing and yet should not cause maceration to the surrounding skin, and also should not cause allergic reactions. In this study it was shown that high-valve WVTR polyurethane film dressing provided many qualities of the ideal split-thickness skin graft donor-site dressing.     

Effects of a projector-based hybrid virtual reality on pain in young children with burn injuries during hydrotherapy sessions: A within-subject randomized crossover trial

AimThe aim of this study was to examine the effect of a water-friendly Projector-Based Hybrid Virtual Reality (VR) dome environment combined with standard pharmacological treatment on pain in young children undergoing burn wound care in hydrotherapy.MethodsThis study was a prospective, within-subject crossover trial of 38 children aged 6 months to 7 years old (mean age = 1.8 years old). Each hydrotherapy procedure was divided into two equivalent wound care segments (No hybrid VR during one segment vs. Hybrid VR during the other segment, treatment order was randomized). Pain was measured using the 0–10 FLACC (Face, Legs, Activity, Cry Consolability scale) and the 0–10 NRS-obs (Numerical Rating Scale-obs).ResultsProjector-Based Hybrid VR significantly reduced procedural pain levels measured by the FLACC (p = 0.026) and significantly increased patients' comfort levels (p = 0.002). Patients' pain levels rated by the nurses using the NRS-obs were non-significant between both groups (p = 0.135). No side effects were reported.ConclusionProjector-Based Hybrid VR helped in reducing the pain related to hydrotherapy procedures in young children with burn wound injuries. This is the first study using virtual reality distraction with young children, and our findings are especially important because a large percentage of pediatric burn patients are very young. Additional research and development are recommended.Trial registrationClinicalTrials.gov, NCT02986464, registered on June 12, 2016.     

Rectal ketamine during paediatric burn wound dressing procedures: a randomised dose-finding study

BackgroundWorldwide, ketamine is used during paediatric procedures, but no recommendations are available regarding a suitable dose for rectal administration during procedures involving high levels of pain and/or anxiety such as burn wound dressing change.MethodsWe evaluated three different single doses of rectally administered racemic ketamine mixed with a fixed dose of 0.5 mg/kg of midazolam. In total, 90 children – aged 6 months to 4 years – were randomised 1:1:1 to receive 4 mg/kg (K-4 group), 6 mg/kg (K-6 group) or 8 mg/kg (K-8 group) of racemic ketamine for a maximum of three consecutive procedures. Primary outcome measure was procedural pain evaluated by Face, Legs, Activity, Cry, Consolability (FLACC) behavioural scale. Secondary outcome included feasibility and recovery time. Patient safety was evaluated using surrogate outcomes.ResultsIn total, 201 procedures in 90 children aged 19 ± 8 months were completed. The median maximum pain was FLACC 0 in all groups (p = 0.141). The feasibility was better for groups K-6 (p = 0.049) and K-8 (p = 0.027) compared with K-4, and the mean recovery time was the longest for group K-8 (36 ± 22 min) compared with groups K-4 (25 ± 15 min; p = 0.003) and K-6 (27 ± 20 min; p = 0.025). Median maximum sedation measured by the University of Michigan Sedation Scale (UMSS) was higher in group K-8 compared with group K-4 (p < 0.0001) and K-6 (p = 0.023). One child in group K-8 had a study drug-related serious adverse event — laryngospasm/airway obstruction. No rescue analgosedative medication was administered for group K-6.ConclusionsA rectally administered mixture of racemic ketamine (6 mg/kg) and midazolam (0.5 mg/kg) during paediatric burn dressing procedures with a duration of approximately 30 min provides optimal conditions regarding pain relief, feasibility, recovery time and patient safety, with no need for rescue analgosedative medication.     

Long term sensory function after minor partial thickness burn: A pilot study to determine if recovery is complete or incomplete

BackgroundAcute burn damages skin architecture, including nerve endings, altering sensation and influencing recovery of quality of life and participation. It is established that sensation is reduced in scars after deep burn. However, it is unclear if sensory deficits exist in mild scars. The aim of this trial was to determine if sensory deficits persist in mature scars after minor partial thickness burn.MethodsThis observational pilot involved 30 patients with ‘good quality’ scars (defined as VSS ≤5 at ≥6 months post-burn). Sensory function was compared in scars and site matched uninjured skin using von Frey filaments and two-point discrimination (2-PD). Multivariable regression was used to predict the influence of burn and confounders on sensory outcomes.ResultsBoth pressure and 2-PD distance were significantly greater in scar compared to uninjured sites, indicating reduced sensory function. For von Frey filaments, the median was 3.84 (IQR = 1) in scars and 3.22 (IQR = 1) for uninjured (p = 0.001). For 2-PD, the median was 3.9 cm (IQR = 1.8) for scars and 2.6 cm (IQR = 1.6) for control sites (p = 0.001).ConclusionMeasureable sensory deficits persist in mature, good quality burn scars. These deficits may influence long-term recovery after minor partial thickness burn.     

Closed incision negative pressure therapy decreases complications after periprosthetic fracture surgery around the hip and knee

IntroductionPeriprosthetic fractures (PPFXs) are becoming increasingly common following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Patients sustaining PPFXs face considerable perioperative morbidity, with relatively increased rates of surgical site infection. We sought to evaluate the efficacy of closed-incision negative-pressure wound therapy (ciNPT) in decreasing perioperative wound complications following lower extremity periprosthetic fracture surgery.MethodsWe performed a retrospective review of 69 consecutive patients who underwent surgery to address lower extremity periprosthetic fractures around hip or knee implants performed over a 6.5-year period. The population was divided into two groups based on the surgical dressing used at the conclusion of the procedure: (1) a sterile, antimicrobial hydrofiber dressing, or (2) ciNPT. There were no baseline demographic differences between the two groups. Rates of wound complications, surgical site infection, and reoperation related to the surgical site were compared between groups. Continuous variables were analyzed using a student’s t-test, and categorical variables using either chi-square or fisher’s exact test.ResultsPatients treated with ciNPT developed fewer wound complications (4% vs. 35%; p = 0.002), fewer deep infections (0% vs. 25%; p = 0.004), and underwent fewer reoperations related to the surgical site (4% vs. 25%; p = 0.021) compared to patients treated with standard of care.ConclusionsOur findings suggest that ciNPT may reduce wound complications, SSIs, and reoperations in patients undergoing lower extremity periprosthetic fracture surgery. This is the first study to investigate ciNPT as a treatment for periprosthetic fracture surgery, and has the potential to change the postoperative management of these patients.     

Using a clinical judgement model to understand the impact of validated pain assessment tools for burn clinicians and adult patients in the ICU: A multi-methods study

BackgroundIntensive care (ICU) patients’ burn pain is difficult to assess, communicate and address, risking chronic pain syndromes and psychological morbidity.AimsTo understand how the introduction of validated pain tools (Critical Care Pain Observation Tool [CPOT], Numerical Rating Scale [NRS], Pain Assessment in Advanced Dementia [PAINAD]) affected clinical judgement processes, analgesia/sedation administration and the experience of burn-injured patients.MethodsConsecutive chart review compared type and amount of analgesia/sedation administered, ventilation time and length of ICU/hospital stay between consecutive burn patients pre- and 6-months post-intervention (n = 70). Analysis of 36 qualitative interviews with ICU clinicians (n = 12) and burn-injured adults (n = 12) pre- and post-intervention was guided by Tanner's (2006) Clinical Judgement Model.ResultsOverall, there was a significant increase in morphine (P = 0.04) and propofol (P = 0.04) use and a trend towards increased paracetamol (P = 0.06) use post-intervention. There was a trend towards greater Midazolam use for TBSA < 20% (P = 0.06), and significantly increased propofol use for TBSA ≥ 20% (P = 0.03). Ventilation time and ICU/hospital length of stay were unchanged.Qualitative analysis revealed complex clinical judgement dependent on the context of the patient's situation, unit culture, background beliefs of clinicians and in knowing the patient. Whilst the CPOT and NRS enhanced analytic reasoning and pain advocacy, the PAINAD appeared redundant.ConclusionsEffective pain assessment, management and advocacy are assisted by evidence-based assessment practices.     

Cost Analysis of 48 Burn Patients in a Mass Casualty Explosion Treated at Chang Gung Memorial Hospital

IntroductionLittle is known about the costs of treating burn patients after a mass casualty event. A devastating Color Dust explosion that injured 499 patients occurred on June 27, 2015 in Taiwan. This study was performed to investigate the economic effects of treating burn patients at a single medical center after an explosion disaster.MethodsA detailed retrospective analysis on 48 patient expense records at Chang Gung Memorial Hospital after the Color Dust explosion was performed. Data were collected during the acute treatment period between June 27, 2015 and September 30, 2015. The distribution of cost drivers for the entire patient cohort (n = 48), patients with a percent total body surface area burn (%TBSA) ≥ 50 (n = 20), and those with %TBSA <50 (n = 28) were analyzed.ResultsThe total cost of 48 burn patients over the acute 3-month time period was $2,440,688, with a mean cost per patient of $50,848 ±36,438. Inpatient ward fees (30%), therapeutic treatment fees (22%), and medication fees (11%) were found to be the three highest cost drivers. The 20 patients with a %TBSA ≥50 consumed $1,559,300 (63.8%) of the total expenses, at an average cost of $77,965 ± 34,226 per patient. The 28 patients with a %TBSA <50 consumed $881,387 (36.1%) of care expenses, at an average cost of $31,478 ± 23,518 per patient.ConclusionsIn response to this mass casualty event, inpatient ward fees represented the largest expense. Hospitals can reduce this fee by ensuring wound dressing and skin substitute materials are regionally stocked and accessible. Medication fees may be higher than expected when treating a mass burn cohort. In preparation for a future event, hospitals should anticipate patients with a %TBSA ≥ 50 will contribute the majority of inpatient expenses.