The Journal of burn care & rehabilitation
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J Burn Care Rehabil · Nov 2000
The 2000 Moyer Award. The relevance of base deficits after burn injuries.
The relevance of an elevated base deficit (BD) during the fluid resuscitation of a thermally injured patient is not completely understood. After nonthermal trauma, early elevation of the BD represents insufficient cellular perfusion and is ultimately associated with a higher incidence of organ dysfunction and death. However, this relationship has not been completely examined after burn injuries. ⋯ Despite adequate resuscitation with good maintenance of urinary output, the patients in the group with a mean BD of less than -6 mmol/L had more florid systemic inflammatory response syndrome (P = .004), had more prevalent acute respiratory distress syndrome (P = .012), and experienced more severe multiple organ dysfunction (P < .001) compared with patients in the group with a mean BD of more than -6 mmol/L. The results suggest that abnormal elevation of the BD after burn injuries represents a malperfusion state, which may not be recognized if only "traditional" parameters, such as UO, are followed. Furthermore, this state appears to be related to the onset of more severe systemic inflammation and organ dysfunction.
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J Burn Care Rehabil · Sep 2000
Psychological principles of burn wound pain in children. II: Treatment applications.
The pain involved in acute burn care can be excruciating and intractable. Even the best pharmacologic pain control efforts often fail to adequately control pain, especially procedure-related pain, in pediatric patients with burn injuries. Nonpharmacologic interventions have been found to be effective in reducing pain in both children and adults and can be extremely important adjuvants to standard pharmacologic analgesia in the burn care setting. ⋯ Building on this theoretical framework, we now present a detailed discussion of the implementation of nonpharmacologic intervention strategies in the burn care setting. Because accurate measurement of discomfort is imperative for the development of interventions and for the evaluation of their efficacy, we begin with a brief review of pain measurement techniques. We follow this with suggestions for tailoring interventions to meet specific patient needs and conclude with a detailed and practical discussion of specific intervention techniques and the implementation of those techniques.
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J Burn Care Rehabil · Sep 2000
Application of a model to guide ethical decision making in burn treatment.
Ethical considerations in the decision to resuscitate and continue treatment of a massive burn injury are complex. As survival improves, the parameters we use in deciding to resuscitate are less clear. ⋯ Although there is no simple algorithm for decision making with ethical dilemmas, the systematic application of the decision-making model presented here that consists of 4 prioritized questions that address medical indications, patient preferences, quality-of-life issues, and contextual factors can focus the problem and define options. In addition, early use of a hospital bioethics committee is advocated to resolve conflict and to provide an acceptable forum for discussion.
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J Burn Care Rehabil · Jul 2000
Case Reports Randomized Controlled Trial Clinical TrialControlled clinical study of deep partial-thickness burns treated with frozen cultured human allogeneic epidermal sheets.
Numerous studies, many uncontrolled, have suggested that the application of freshly prepared human allogeneic epidermal cultures promotes faster re-epithelialization of skin donor sites and deep partial-thickness burns. We describe the results of a study of deep partial-thickness burns treated with such cultures preserved in the frozen state. The study was controlled, side-by-side comparative, and randomized. ⋯ For 5 of the patients with deep partial-thickness burns, the wounds treated with frozen cultures healed in a mean time of 5.6 days, whereas the control wounds healed in 12.2 days. More importantly, for the 4 other patients with deep partial-thickness burns, the wounds treated with the frozen cultures underwent complete re-epithelialization in a mean time of 4.2 days, but the control wounds were partially or mostly unhealed at up to 14 days. The results show that the frozen cultures not only accelerate the re-epithelialization of deep and superficial partial-thickness burns but also make it possible to heal such wounds that otherwise would not heal.
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Burn center verification requires the use of autopsy as one method of quality assurance in a burn center. Because of the decreasing rates of autopsies worldwide and improved diagnostic accuracy in our critical care units, we tested the hypothesis that autopsy diagnosis would not alter our clinical diagnosis. A chart review of all deaths (N = 94) that occurred during a 6-year period (1989-1994) was performed. ⋯ Five class I errors were found in 4 patients (4.5%), and 15 class II errors were found in 13 patients (14.7%). Although the rate of potentially serious errors was low (only 4.5% of the patients in this study) postmortem examinations revealed clinical diagnostic errors. The results of this study support the continued use of autopsies as a means of quality assurance, despite our ability to closely monitor our critically ill patients with burns.