Foster, Kevin N

Introduction Burn center patients present not only with burn injuries but also necrotizing infections, purpura fulminans, frostbite, toxic epidermal necrolysis, chronic wounds, and trauma. Burn surgeons are often faced with the need to amputate when limb salvage is no longer a viable option. The purpose of this study was to determine factors which predispose patients to extremity amputations. Methods: This retrospective registry review (2000-2019) compared patients who required upper extremity amputations with those who did not. Cases were pair-matched by age, sex, percent total body surface area (%TBSA), and type/location of injury to control for possible confounding variables. Results: There were 77 upper extremity amputee patients (APs) and 77 pair-matched non-amputees (NAPs) with the median age 45- and 43-years, %TBSA 21 and 10, respectively; second and third degree burn injuries were similar in the 2 groups. The AP group had longer hospitalizations (median 40 vs 15 days) P < .0001, with more intensive care unit days (median 28 vs 18 days). APs presented with significantly more cardiac, renal, and pulmonary comorbidities, acquired infections (61 [64%] vs 35 [36%]), escharotomies, and fasciotomies than the NAP, P < .0001. Mortality was similar (AP 14 [18.2%] vs NAP 9 [11.7%]), P = .26. Conclusions: Escharotomies, fasciotomies, sepsis, pneumonia, wound, and urinary tract infections contributed to prolonged hospitalizations and increased risk for upper extremity amputations in the AP group.

Abstract Introduction Enoxaparin, a low molecular weight heparin, has been proven to safely and effectively prevent venous thromboembolism (VTE) in acutely ill patients. Burn patients may be particularly vulnerable to the occurrence of a VTE due to prolonged immobility, frequent operating room procedures, and low flow states. Treatment of acute VTE is associated with a direct medical cost of $12000-$15000 and subsequent complications increase costs to $18000 to $23000 per case. Current institutional protocol for initiation of enoxaparin an all burn adult patients is 40 mg administered subcutaneously every 12 hours. Anti-Xa levels are used to monitor anticoagulation prophylaxis, with 0.3–0.5 U/mL recognized as the prophylactic range. Doses are subsequently modified in 10 mg increments to achieve goal prophylaxis anti-Xa levels. The purpose of this study was to evaluate current practice (CP) and assess if the implementation of a published enoxaparin dosing algorithm could minimize delay in achieving anticoagulation prophylaxis. Methods A retrospective chart review was performed of 94 adult burn patients. The doses and time required to reach goal prophylaxis anti-Xa levels using current practice (CP) were compared to the predicted algorithm dose (AD). The number of dose adjustments and the number of days needed for adjustments for CP were documented. Charges related for laboratory determinations and medication administration were calculated. Results Of the 94 patients reviewed, the average age was 47 years, the majority were male (74%), mean actual weight 92 kilograms and mean TBSA 15.7%. The most common mechanism of injury was flash/flame (63%) with 18% suffering an inhalation injury. On average, using CP, it took 9.3 days to get to goal prophylaxis anti-Xa levels, with a mean of 2.86 anti-Xa lab tests needed and an average prophylactic dose of 55.5 mg. A total of 360 labs draws were performed and 74% were timed correctly. The CP average starting dose was lower than the AD 40 mg versus 45 mg (p &lt; .0001). If the algorithm had been used the number of dosing adjustments would have been 25% less. The algorithm overestimated the starting dose in only 2.1% of the population. The average charges until goal was met for enoxaparin were $2,933 and $787 for anti-Xa levels. Conclusions This study demonstrates increased clinical efficacy and cost-effectiveness for an algorithm driven enoxaparin dosing regimen for burn patients. Prospective study with larger patient numbers is warranted.

Abstract Introduction Burn and traumatic limb injuries with exposed bone/tendon typically require surgical flaps or amputations for healing. Some burn patients are not candidates for these invasive techniques. Placental amniotic membrane has been used as a wound dressing for more than 100 years and may offer an alternative to flaps and/or amputations. Processed dehydrated human amnion/chorion membrane (dHACM), from human placental tissue, contains type 1 human collagen as well as non-viable cells and 285 identified regulatory proteins including growth factors, chemokines, cytokines, metalloproteinases, and other tissue growth and inflammatory mediators. dHACM has been successfully used as a dressing for wound ulcers, burns, donor sites, & surgical debridement. This study reports the use of dHCAM as a limb salvage tool in four patients with severe injuries. Methods This is a retrospective case series of patients suffering severe lower extremity injury with bone/tendon exposure that had applied dHACM/dHCM over or packed (depending on wound depth), then covered with 3% bismuth tribromophenate petrolatum dressing & glycerol/ hydroxyethylcellulose lubricant. Negative pressure wound therapy (NPWT) was initiated; wound re-evaluation occurred in seven days. dHACM/dHCM was reapplied if required (bone still exposed). Results There were 3 males and 1 female with three burns and one NSTI. The mean±sd (median) age was 58±23 (61) years; % total burn surface area 3±3 (2); length of hospital stay 48±30 (40) days; number of tangential excisions & debridements 6.5±1 (6.5); days from admission to product application 49±47 (34) and discharge 24±19 (19) days; negative pressure wound therapy (NPWT) 53±6 (56) days. All four patients continued treatment upon discharge with clinic visits and home NPWT. All recovered with good results and no complications. Treatment may be continued with NPWT therapy at home or in a skilled nursing facility. Patients healed after two to three dHACM/dHCM applications and did not require leg or foot amputations. Conclusions In select limb salvage cases, dHACM/HCM may be a promising alternative to extremity amputations, tissue transfer flaps or other techniques for secondary intention healing of wounds with bone/tendon exposure.