The Journal of burn care & rehabilitation
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A concerted effort to decrease resource usage and length of stay without sacrificing quality of care was undertaken over a 2-year period in a high-census Burn Center. Through a series of changes in practice, substantial decreases in the costs of several high-usage items were tracked. During this period the average length of stay also was decreased. ⋯ During this period there was no significant change in the patient population as measured by total body surface area percentage burn and acuity level. With the exception of significant improvement in the infection rate, there was no substantial change in indicators of quality care as measured by readmission, morbidity, and posthospital would healing progression. This cost-reduction program showed that costs can be reduced without diminishing quality of care; in some respects quality of care improved due to the practice changes that were implemented.
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J Burn Care Rehabil · May 1997
Prolonged use of propranolol safely decreases cardiac work in burned children.
Propranolol has been shown to be effective for as long as 5 days in massively burned children to reduce heart rate and cardiac work. This article describes the use of propranolol given for 10 days to burned children to test whether the drug remains effective and safe in reducing heart rate and cardiac work for longer periods. We prospectively studied 22 children, 1 to 10 years of age with burns covering > or = 40% of their total body surface area. ⋯ No hypotension, hypothermia, azotemia, hyperglycemia or hypoglycemia, arrhythmia, bronchospasm, or peripheral ischemia was noted during or after treatment. Whereas propranolol lowered heart rate more per milligram per kilogram body weight when given intravenously, both routes were safe and effective. From these data, we conclude that propranolol can be given to decrease the work of the heart safely and effectively for > or = 10 days.
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J Burn Care Rehabil · May 1997
Pressure-controlled ventilation for the long-range aeromedical transport of patients with burns.
Pressure-controlled ventilation is used to treat smoke inhalation injury to achieve adequate oxygenation and ventilation at lower peak inspiratory pressures. A portable pressure-controlled time-cycled transport ventilator permits this modality to be used in the field. We have examined the safety and efficacy of this ventilator for aeromedical transfer of thermally injured patients. ⋯ The study group was transported a total of 86,889 miles without in-flight morbidity, mortality, or failure of ventilation. Arterial blood gas analysis at conclusion of flight demonstrated an arterial pH > or = 7.35 in 85% of the patients, an arterial partial pressure of carbon dioxide < or = 45 torr in 97%, and an arterial partial pressure of oxygen > or = 70 torr in 99%. Pressure-controlled ventilation performed by an experienced transport team with this ventilator is safe and effective for the long-range aeromedical transfer of intubated patients with burns.
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J Burn Care Rehabil · May 1997
Excessive liver oxidant stress causes mortality in response to burn injury combined with endotoxin and is prevented with antioxidants.
We studied the effect of the oral administration of a water-soluble antioxidant solution containing ascorbic acid, glutathione, and a precursor for glutathione synthesis, N-Acetyl-L-cysteine, on liver antioxidant activity, liver cell energetics, and mortality in rats in response to a 20% third-degree burn injury challenged 5 days later with an intraperitoneal injection of 30 mg/kg endotoxin. Rats with burns were fluid-resuscitated with subcutaneous Ringer's lactate solution according to the Parkland formula (4 cc/kg/%burn). Rats challenged with endotoxin 5 days after burn were given an additional 100 ml/kg of subcutaneous Ringer's lactate solution immediately after the injection of endotoxin. ⋯ The addition of endotoxin further decreases liver antioxidant defenses, liver energy charge potential, and markedly increases mortality. Antioxidants, given post-burn, restored antioxidant defenses, attenuated the altered cell energetics, and prevented mortality, indicating oxidants to be the cause of mortality. This data also suggests that a critical value of decreases in antioxidant defenses and ATP exists, resulting in mortality.
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Age, burn size, inhalation injury, and comorbid diseases are important factors in predicting survival of patients with burn injuries. These same factors are important in attempting to objectively define the point when burn care is futile. We reviewed the records of 3301 patients admitted to our Burn Center between January 1, 1986, and December 31, 1994. ⋯ Seventy patients died at a later date. A do-not-resuscitate with comfort-measures-only order was written on 33 patients (26.7%). We have developed objective criteria that include age, extent of burn, presence of inhalation injury, and major organ dysfunction to be applied in the determination of futility of further therapy, either at the time of admission or when patients develop progressive multi-organ system failure during the hospital course.