Eur. Burn J., Volume 3, Issue 1 (March 2022) – 20 articles

Insufflation of epinephrine-containing solutions (clysis) has shown to decrease blood loss in burn surgery. Current delivery methods are associated with significant cost and may predispose burn patients to hypothermia. This was a proof-of-concept study to evaluate a novel surgeon-operated clysis delivery system. Our initial experience with a novel fluid management system is presented. Temperature, pressure, and volume of clysis was recorded. Patient and burn factors were evaluated and complications collected. Finally, a cost-effectiveness analysis was conducted. Thirty-seven consecutive cases comprising 22 adult patients (15/22, 68% male), with a mean age of 49 years (+/−19) were reviewed. The mean % total body surface area of all patients was 39 (+/−21.7). The mean temperature, pressure, and volume of administered clysis was 32.2 degrees Celsius (+/−4.4), 265.04 mmHg (+/−56.17), and 5805.8 mL (+/−4844.4), respectively. The mean dose of epinephrine administered was 14.5 mg (+/−12.1). The mean temperature variability was 1.1 °C (+/−1.2). The total mean of packed red blood cells (PRBC) transfused was 507.6 mL (+/−624.4). There were no recorded complications. We identified a cost savings of CAD 20,766 over the cases examined, compared to our conventional clysis delivery technique. This novel technique provides rapid and safe infiltration of warmed clysis in burn surgery. We were able to maintain intra-operative euthermia. In addition, this technique may be transfusion-sparing. The introduction of this method of clysis administration was associated with significant cost-savings. Future randomized study is necessary. Full article

The CARe Burn Scales are a suite of burn-specific PROMs for adults, children, young people, and parents affected by burns. This study aimed to determine the responsiveness and minimal important difference (MID) values of the Adult Form for use in adult burn care and research. Participants were recruited by 11 UK Burn Services. They completed online or paper versions of the CARe Burn Scale –Adult Form and a set of appropriate comparison validated measures and anchor questions at baseline (T1, up to 4 weeks post-burn), 3 months (T2), and 6 months post-burn (T3). A total of 269 participants took part at baseline and 226 (84%) were retained at the 6-month follow-up. Spearman’s correlation analysis and effect sizes based on Cohen’s d thresholds were reported and MID values calculated. MID values were created for all subscales and ranged from 4–15. The CARe Burn Scale–Adult Form is responsive to change over time and can therefore be used to reliably inform the management of adults’ burn injury treatment and recovery. It is freely available for clinical and research use. Full article

Presently, research assessments of burn scar management interventions focus on measures of scarring and scar features. However, qualitative research demonstrates that patients experience scarring and scar management therapies holistically. Patient-centred assessment should reflect this. An agreement is required regarding what to assess, which tools and measures to use and at what time points. Key issues include (1) whether and how burn- or scar-related quality-of-life measures could be included in the assessment of scar management interventions and how these are weighed against scar measures; (2) routine inclusion of the assessment of treatment burden (or treatment experience) in comparative research and (3) generating further understanding of the relationship between scar management and psychosocial adaptation, along with an assessment of this. A debate concerning a holistic and standardized evaluation of scar management interventions is needed to ensure that future evidence-based decisions are made in a patient-centred manner. Full article

Burn survivors are at risk for dissatisfaction with body image, relationships, and sexuality due to disfiguring changes secondary to the injury. This review compares available global data on BSHS-B psychosocial scores. Twenty-four studies were included in the final analysis encompassing 14 countries; significant differences were found in scores across all BSHS-B psychological sub-sections of affect, body image, interpersonal relationships, and sexuality. On the whole, psychological well-being after burn injury was lower in Asian and South Asian countries compared to Europe or the United States. This study provides information for providers in burn centers caring for patients from a variety of cultural contexts and begins to steer initiatives to remedy psychological inequities in global burn care. Full article

Burn patients are unique because their recovery requires prolonged hospital admissions, often complicated by a myriad of medical and surgical complications as well as psychological and emotional challenges. Religion and spirituality have been linked to improved health outcomes in other medical fields. Our scoping review aimed to examine the available literature for evidence of the impact of spirituality on burns, complex wounds, and critical care to shed more light on the relationship between spirituality and the conditions treated by multidisciplinary burn center teams. We performed three systematic reviews to examine the relationship between spirituality and these conditions. Searches were performed using MeSH terms utilizing four databases (MEDLINE via PubMed, Embase, Cochrane, Web of Science, and Scopus). A systematic and independent title/abstract screening was carried out by two independent reviewers and a full-text review was followed. Our review demonstrated a clear lack of overlap between study outcomes and lack of objective spirituality measurements. Most articles primarily focused on psychological outcomes, such as stress or mental health, instead of objective measures such as wound size or scar formation. We found a trend toward better psychological outcomes in patients with more spirituality, either pre-existing or interventional. To increase comparability and uniformity of outcomes, future studies would benefit from utilizing standardized spiritual assessment tools and objective wound metrics. Full article

Background: There is no consensus regarding the timing of surgery in children with smaller burn size, specifically in deep dermal burns. Delayed surgery has risks in terms of infection and delayed wound healing. Early surgery also risks the removal of potentially viable tissue. Our aim was to investigate the effect of the timing of surgical intervention on the size of the area operated on and the time to wound healing. Methods: A retrospective analysis for all children (<18 years) with burn size <20% body surface area (BSA%) during 2009–2020 who were operated on with a split-thickness skin graft. The patients were grouped by the timing of the first skin graft operation: early = operated on within 14 days of injury; delayed = operated on more than two weeks after injury. Results: A total of 84 patients were included in the study, 43 who had an early operation and 41 who had a delayed operation. There were no differences between the groups regarding burn size, or whether the burns were superficial or deep. The mean duration of healing time was seven days longer in the group with delayed operation (p = 0.001). The area operated on was somewhat larger (not significantly so) in the group who had early operation. Nine children had two skin graft operations, eight in the early group and one in the delayed group (p = 0.03). Conclusion: The patients who were operated on early had the advantage of a shorter healing time, but there was a higher rate of complementary operations and a tendency towards a larger burn excision. Full article

Burn injury is debilitating and among one of the most frequently occurring traumas. Critical care improvements have allowed for increasingly positive outcomes. However, infection, whether it be localized to the site of the wound or systemic in nature, remains a serious cause of morbidity and mortality. Immune suppression predisposes the burn population to the development of invasive infections; and this along with the possibility of inhalation injury puts them at a significant risk for mortality. Emerging multi-drug-resistant pathogens, including Staphylococcus aureus, Enterococcus, Pseudomonas, Acinetobacter, Enterobacter, and yeast spp., continue to complicate clinical care measures, requiring innovative therapies and antimicrobial treatment. Close monitoring of antimicrobial regimens, strict decontamination procedures, early burn eschar removal, adequate wound closure, proper nutritional maintenance, and management of shock and resuscitation all play a significant role in mitigating infection. Novel antimicrobial therapies such as ultraviolet light, cold plasma and topical antiseptics must continue to evolve in order to lower the burden of infection in burn. Full article

Disease Related Appetite Questionnaire (DRAQ) and Eating Symptom Questionnaire (ESQ) are used to assess nutrition impact symptoms, which are symptoms that can negatively affect the patients’ food intake. However, these questionnaires have not yet been adapted to the needs of patients recovering from burn injuries. Our aim was therefore to develop DRAQ and ESQ for assessments of nutrition impact symptoms after burn injury. A content validation index (I-CVI) for items included in DRAQ and ESQ, regarding their relevance for possible nutrition impact symptoms in a burn-injured patient (Likert scale 1–4), was performed by an expert review group. A clarity validation by expert and non-expert reviewers was carried out. Two of the eleven questions in DRAQ and eight of the fourteen questions in ESQ were not considered relevant and were therefore removed from the questionnaires. Five additional questions were added to DRAQ and two to ESQ. A high degree of consensus on relevance (scale-content validity index average, S-CVI/Ave, 0.86 for DRAQ-burn and 0.83 for ESQ-burn) was reached in the expert group. To conclude, it is suggested that we use developed forms of DRAQ and ESQ (DRAQ-burn and ESQ-burn) for the assessment of nutrition impact symptoms, specifically during the rehabilitation phase of burn-injured patients. Full article

This study examined the relations among burn stigma, quality of life, resilience, and life satisfaction, hypothesizing that higher stigma and lower burn-related quality of life would lead to lower life satisfaction; however, resilience would moderate this relation. A sample of 89 participants was recruited from an outpatient clinic of a burn center in a critical care hospital. Participants completed a battery of measures assessing these constructs. Results suggested that burn stigma was associated with reduced life satisfaction after accounting for other variables. Multiple regression models found that burn stigma predicted both affect and body image but not interpersonal relationship quality or sexuality. Interpersonal relationship quality, sexuality, affect, and body image all predicted life satisfaction. Both affect and body image partially accounted for the relation between stigma and life satisfaction, and resilience accounted for the relation between stigma and affect. Findings reinforce previous literature that has shown a relationship between stigma and life satisfaction but also emphasizes the role of resilience and burn-related quality of life. Individuals who experience a burn injury may have innate resilience abilities, which allow them to bounce back from stressors; thus, resilience can be a targeted strength to bootstrap in order to improve adjustment outcomes. Full article

A proxy-assessment of health-related quality of life (HRQL) may be an alternative for burn patients who are medically unable to self-report shortly after being admitted to the hospital. This study examined the patient–partner agreement on the recalled pre-injury HRQL of burn patients. In a multi-centre study of 117 patient–partner pairs, the recalled pre-burn HRQL was assessed with the EQ-5D-3L + Cognition during the acute phase following the burns. Agreement was evaluated with Kappa and ICC statistics. Burn severity and PTSD symptoms were assessed as potential predictors of disagreement. The results showed that pre-burn EQ-Index scores were similar to population norms, whereas the EQ Visual Analog Scale (EQ-VAS) scores of patients were significantly higher. Agreement varied across EQ-5D domains and, after adjusting for prevalence, was substantial to almost perfect. Average agreement on the EQ-Index and EQ-VAS was, respectively, substantial and moderate, but differences between partners were larger at lower levels of HRQL, and specifically in the pain/discomfort domain. Patient–partner differences could not be explained by the patient’s age or gender, number of surgeries, partner’s presence at the burn event, or post-traumatic stress disorder (PTSD) symptoms of either the patient or partner. In conclusion, patient–partner agreement is substantial and partner–proxy reports of pre-burn EQ-5D domains and EQ-Index scores may be used to complement or serve as a substitute for the patient’s assessment. Given the moderate agreement on the EQ-VAS, it may be less suited for proxy assessment. Full article

Many burn survivors have pre-existing psychiatric conditions or develop psychological or psychiatric symptoms over the course of their hospital stay. Patients often present with low mood and neurovegetative symptoms which can be conceptualized as demoralization, adjustment disorder, or major depressive disorder. We review the literature on these syndromes in burn survivors and present three cases that highlight the continuum of these syndromes for patients who present with symptoms of depression following a burn injury. We discuss the clinical challenges of differentiating these syndromes as well as psychotherapeutic and psychopharmacologic considerations and recommendations. Full article

Burn injuries are traumatic experiences that can detrimentally impact an individual’s psychological and emotional wellbeing. Despite this, some survivors adapt to psychosocial challenges better than others despite similar characteristics relating to the burn. Positive adaptation is known as resilience or posttraumatic growth, depending on the trajectory and process. This review aimed to describe the constructs of resiliency and growth within the burn injury context, examine the risk factors that inhibit resilience or growth after burn (barriers), the factors that promote resilience or growth after burn (enablers), and finally to assess the impact of interventions that have been tested that may facilitate resilience or growth after burn. This review was performed according to the recently updated Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. An electronic search was conducted in November 2021 on the databases PubMed, Medline (1966-present), Embase (1974-present), PsycINFO for English-language peer-reviewed academic articles. There were 33 studies included in the review. Findings were mixed for most studies; however, there were factors related to demographic information (age, gender), burn-specific characteristics (TBSA, time since burn), person-specific factors (personality, coping style), psychopathology (depression, PTSD), and psychosocial factors (social support, spirituality/religion, life purpose) that were evidenced to be related to resilience and growth. One qualitative study evaluated an intervention, and this study showed that a social camp for burn patients can promote resilience. This study has presented a variety of factors that inhibit or encourage resilience and growth, such as demographic, individual, and social factors. We also present suggestions on interventions that may be used to promote growth following this adverse event, such as improving social support, coping styles and deliberate positive introspection. Full article

Given the high rates of psychological distress after burn injury, thorough screening and assessment for psychosocial factors and psychiatric pathology should be routinely completed for individuals with burn injuries. Burn survivors experience unique psychosocial changes and injury sequelae, such as body image concerns, trauma-related pathology, and itching. Screening for these factors is integral to understanding how these may be contributing to psychological distress. Proactively identifying distress and psychiatric pathology is important to optimize physical and emotional outcomes. The aim of this manuscript is to summarize information about the available screening and assessment tools for psychological distress among burn survivors. Full article

Background: The optimal therapy for deep burn wounds is based on the early debridement of necrotic tissue followed by wound coverage to avoid a systemic inflammatory response and optimize scar-free healing. The outcomes are affected by available resources and underlying patient factors, which represent challenges in burn care and suboptimal outcomes. In this study, we aimed to determine optimal burn-wound management using enzymatic debridement (NexoBrid™, MediWound Germany GmbH, Rüsselsheim, Germany) and intact fish skin (Kerecis^® Omega3 Wound, Isafjordur, Iceland). Methods: In this retrospective case series, 12 patients with superficial or deep dermal burn wounds were treated with enzymatic debridement followed by fish skin, Suprathel^® (PolyMedics Innovations GmbH, Denkendorf, Germany), or a split-thickness skin graft (STSG). Patients’ outcomes regarding healing and scar quality were collected objectively and subjectively for 12 months after the burn injury. Results: Wounds treated with fish skin demonstrated accelerated wound healing, a significantly higher water-storage capacity, and better pain relief. Furthermore, improved functional and cosmetic outcomes, such as elasticity, skin thickness, and pigmentation, were demonstrated. The pain and itch expressed as POSAS scores (Patient and Observer Scar Assessment Scale) for fish skin decreased compared to those for wounds managed with an STSG or Suprathel. Importantly, fish skin-treated wounds had significantly improved sebum production and skin elasticity than those treated with Suprathel but showed no significant superiority compared to STSG-treated wounds. Conclusions: Enzymatic debridement in combination with intact fish skin grafts resulted in the faster healing of burn wounds and better functional and aesthetic outcomes than split-thickness skin grafts and Suprathel treatment. Full article

Although the hands constitute approximately 5% of the total body surface area (TBSA), the sequelae and subsequent functional outcomes following hand burns (HBs) significantly impact the quality of life for affected patients. HBs, which frequently accompany severe burns and are often neglected, deserve additional attention in the management of burns of this anatomical region, as they are responsible for a majority of postburn morbidity. In addition, many questions remain unanswered in almost every aspect of HB management. Moreover, recent articles suggest that the primary issue of optimal timing concerning skin closure for HBs, which seemed well answered, has been questioned, and even this fundamental question may require further investigation. Appropriate initial management of HBs commencing from the acute phase in children remains of great importance in optimizing functional outcomes and minimizing long-term scar formation. In this context, our primary purpose in this retrospective cohort study was to present the epidemiological characteristics of HBs in children as a whole and to discuss the incidence and mechanisms, in addition to the outcomes of superficial and deep HB acute-phase management modalities. During the 5-year study period, HBs were detected in 27% (n = 422) of 1580 hospitalized pediatric burn patients in the Adana Faculty of Medicine-University of Health Sciences (AFM-UHS) Burn Center. Movement and functional status of the hands were evaluated with a simple qualitative staging system adapted from the original scoring tools used by Stiefel et al., and Sheridan et al. Good, moderate, and poor scores in the study were graded as Category A, Category B, and Category C, respectively. According to the hand movement and function assessment categorization, 84% of the cases were observed as Category-A who had good/normal regular movements/functions of the hands/fingers, followed by Category-B and -C with percentages of 15 and 1, respectively, during the 5.8 ± 3.4 month follow-up period. Full article

Secondary infections of skin grafts pose a continuous problem in burn patients, very often leading to loss of transplanted skin grafts and making multiple surgical revisions necessary. We present a case report about persisting Pseudomonas aeruginosa infection in burn patients with known diabetes. The burn wounds in lower extremities required repeated debridements, multiple skin grafting attempts and finally an application of the dermal scaffold NovoSorb BTM. With these measures, we managed to undertake a successful reconstruction of infected burn defects and pre-vent an amputation. We concluded that the NovoSorb BTM could be seen as an additional promising tool in a burn surgery armamentarium. In cases where radical surgical wound decontamination is not possible without risking the loss of the limb, the application of NovoSorb BTM over a contaminated field can win extra time for topical infection treatment and additionally provide an excellent skin grafting ground. Full article

Central line-associated bloodstream infection (CLABSI) and catheter-related bloodstream infection (CLABSI with a positive catheter tip culture, CRBSI) are preventable causes of morbidity and mortality for severe adult burns patients. Routine central line changes as a CLABSI prevention strategy in burns patients is controversial due to the paucity of evidence to guide the appropriate timing of line changes. This study aimed to address this evidence gap by investigating risk factors associated with central line sepsis, including the duration of central line insertion, in a population of severe adult burns patients (burns involving ≥20% total body surface area (TBSA)) admitted to the Royal Brisbane and Women’s Hospital Intensive Care Unit over five years (2015–2019 inclusive). On multivariate analysis, central line duration and burn TBSA were identified as independent risk factors for CLABSI, with central line duration the most significant predictor (p = 0.0008; OR 1.177, 95% CI 1.072–1.299). No risk factor independently predicted CRBSI. CLABSI detection occurred a median of 8.5 days (IQR 6.0–11.0) post central line insertion. These findings suggest further research to assess the efficacy of routine line changes prior to the at-risk period of 6–11 days post central line insertion in reducing CLABSI in severe adult burns patients may be beneficial. Full article

Treating pain in burn patients with a history of opioid or drug abuse is challenging. There is no consensus on pain management for burn patients with a history of drug usage. Our aim was to study the association of previous drug addiction and the treatment of acute burn patients, focusing on daily morphine milligram equivalent (MME) requirements and outcomes. We compared patients with (group 1) and without (group 2) a drug addiction history who were admitted to an American Burn Association verified burn center using the Premier database from 2013 to 2018 (n = 3046). Primary outcome was daily MME usage. Secondary outcomes included mortality, expected mortality rate, length of stay (LOS), and number of surgeries. Linear regression was performed to predict MME usage. In total, 16.6% of patients had history of drug abuse. In unadjusted analysis, group 1 had more males (68.1% vs. 57.3%, p < 0.001) and was younger (median 47 vs. median 53, p < 0.001) compared to group 2. In the adjusted analysis, group 1 required 84.1 additional daily MME usage than group 2 (p < 0.01). Drug addiction was associated with an increased number of surgeries, LOS, and higher daily MME usage. Patients with a history of drug usage required almost 60 mg of additional oxycodone per day. Full article

Background: Thermal injuries represent a highly relevant epidemiologic problem with 11 million individuals affected globally each year, of which around 2.75 million are children. Different approaches to the conservative treatment of second-degree burns have been widely discussed in the existing literature. One method that has attracted increasing attention is the use of caprolactone dressings. This paper describes a study involving the therapeutic management of 2084 pediatric patients suffering from mixed superficial and deep dermal second-degree burns who received comprehensive expert treatment using caprolactone membranes at the pediatric hospital AUF DER BULT. Methods: A retrospective study was conducted to evaluate the frequency and effect of caprolactone membrane usage on children who were admitted to the pediatric hospital between 2002 and 2016 with mixed second-degree burns. The number of dressing changes under general anesthesia and the requirement for split thickness skin grafting were monitored and recorded. In addition, a cost comparison analysis of different treatment modalities was performed. Results: This retrospective study involved 2084 children who had been treated for mixed superficial and deep dermal burns between 2002 and 2016 using either caprolactone dressing (Suprathel^®) (study group; n = 1154) or an alternative dressing material (control group; n = 930). Of the patients in the study group, 91.74% (n = 1053) were treated conservatively compared to 76.05% of the control group patients, meaning that 8.26% (n = 101) of the study group patients required skin grafting, compared to 23.95% (n = 223) in the control group. Additionally, the number of procedures under general anesthesia per patient was found to be 54.3% lower among all patients treated with caprolactone dressing (1.75 procedures per patient) compared to the entire control group (3.22 procedures per patient). In the subgroups, patients treated conservatively with caprolactone dressing required 1.42 procedures per patient compared to 2.25 procedures per patient in patients with alternative wound treatment. When split thickness skin grafting was necessary, 1.2 times as many procedures were performed on patients with alternative dressing compared to those treated with caprolactone dressing. Finally, the cost per patient was considerably lower in the conservative therapy group in comparison to the group that consisted of patients undergoing operative therapy with split thickness skin grafting. Conclusions: Caprolactone dressings were found to be beneficial for children who reported with mixed superficial and deep dermal burns. Specifically, they reduced the need for skin transplantation, the number of dressing changes under general anesthesia, and the treatment costs. Full article