Journal of burn care & research : official publication of the American Burn Association
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Randomized Controlled Trial Comparative Study
Prospective randomized controlled trial comparing two methods of securing skin grafts using negative pressure wound therapy: vacuum-assisted closure and gauze suction.
Negative pressure wound therapy (NPWT) has revolutionized the management of complicated wounds and has contributed an additional modality for securing split thickness skin grafts (STSG). The standard for NPWT is the vacuum-assisted closure (VAC) device. The authors' institution has accumulated experience using standard gauze sealed with an occlusive dressing and wall suction (GSUC) as their primary mode for NPWT. ⋯ The mean percent take in the GSUC group was 96.12% vs 96.21% in the VAC arm (P = .98). The use of NPWT in securing STSG is a useful method to promote adherence and healing. This study demonstrates that a low-cost, readily accessible system utilizing gauze dressings and wall suction (GSUC) results in comparable skin graft take in comparison to the VAC device.
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Enteral nutrition (EN) is commonly interrupted in burn patients for many reasons, which leads to discrepancies between prescribed and actual EN delivery. The magnitude and origin of these discrepancies have never been well documented among burn patients. The purpose of this study was to examine differences between prescribed and actual EN delivery and to identify the specific causes of EN interruption and to quantify these. ⋯ Other causes of discrepancies were physician- or nurse-directed interruptions (16% of time), planned extubation (7%), feed intolerance (11%), tube malfunction (2%), bedside procedures (2%), and dressing changes (3%). Enterally fed burn patients received significantly less nutrition than prescribed. Some of the causes for discrepancies between prescribed and received EN are unavoidable, but many are not, suggesting the need for careful review and possible alteration of existing EN practices.
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Review Case Reports
Methylene blue for burn-induced vasoplegia: case report and review of literature.
We report the use of a single dose of methylene blue in a patient with burn-induced vasoplegia refractory to fluids, vasopressors, and steroids. Administration of methylene blue allowed for cessation of epinephrine infusion within 2 hours of administration, and reduction in excessive fluid resuscitation. The patient's clinical course continued for 2 months and was complicated by severe acute respiratory distress syndrome, pneumonia, septic shock, poor skin graft adherence, renal failure requiring continuous renal replacement therapy, cutaneous mucormycosis, and ultimately, withdrawal of care and death. Despite the eventual outcome, this is the longest reported survival following methylene blue administration for vasoplegia secondary to burn injury.
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Patients with significant thermal injury are at a high risk for developing bacterial and fungal infections due to the loss of protective integument and often require lengthy treatment courses with anti-infective agents. Dosing of these agents in the burn population is challenging as these patients experience changes in their physiology around 48 hours postinjury. These changes include increased cardiac output, increased blood flow to the kidneys and liver, and decreased albumin production. ⋯ Currently, there are no guidelines describing the most ideal method of dosing anti-infectives in this population, and most studies that have been published include only a small number of patients. The purpose of this review is to summarize the existing literature regarding the pharmacokinetics and pharmacodynamics of antibiotics and antifungal agents in the burn population and to provide dosing suggestions whenever possible. Not all antibiotics and antifungal agents have been studied, and further research is needed in this area in order to provide optimal care for patients with thermal injury.
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Adrenal insufficiency (AI), whether etomidate-induced or secondary to critical illness-related corticosteroid insufficiency (CIRCI), is a common and under appreciated problem in the intensive care unit intensive care unit (ICU). However, AI is often difficult to identify and diagnose in the critically ill. The pathophysiology and ideal management of etomidate-induced AI and CIRCI, especially in burn patients, is unknown. ⋯ Among the critically ill, burn patients are at increased risk for developing adrenal insufficiency and the risk is greatest for elderly patients with large burns and inhalation injury. Both CIRCI and etomidate-induced AI are associated with high morbidity and mortality, therefore avoiding preventable causes of AI, such as choosing alternatives to etomidate for rapid sequence intubation (RSI) in the severely burn injured patient should be encouraged. Further research is indicated to investigate the biological relationship between AI and associated morbidity and mortality, whether etomidate-induced or secondary to critical illness; as well as how best to identify and diagnose patients with suspected adrenal insufficiency in the burn intensive care unit.