Wounds

CHICAGO — Patients with diabetes have an increased risk for foot burns, and once a burn occurs the morbidity and mortality are quite high, Dr. David Greenhalgh said at the annual meeting of the American Burn Association.

A patient might sustain a foot burn without being aware of the injury because of impaired sensation in the feet. Insensate feet lead to prolonged exposure and deeper burns. Walking on hot surfaces, soaking in hot water, and even car heaters can cause foot burns.

"You don't feel the pain after soaking your feet for a half-hour, and that leads to the problem," he said. "This is a duration-of-contact problem."

The neurovascular changes associated with diabetes might also lead to impaired burn wound healing. Impaired healing leads to higher graft loss and an increased risk of amputation, said Dr. Greenhalgh, professor and chief of burn surgery, University of California Davis Medical Center, Sacramento.

Dr. Greenhalgh described his own experiences treating small foot burn cases, including a patient with insensate feet who had been admitted for walking on hot asphalt, which resulted in transmetatarsal and below-knee amputations.

Another patient with insensate feet returned home from a walk over hot rocks at a river bed to discover blood oozing from his feet. After lengthy treatment, four of the patient's toes were amputated.

"This is not only a disease that leaves a scar, but a disease that won't heal," he said. "These are high-risk patients and once you have a wound, it can lead to a cascade of events.

"One minute you've got a patient with ulcers between the toes, the next you're sticking a hemostat up their foot draining pus out of their plantar, and then you're doing a below-the-knee amputation," said Dr. Greenhalgh.

He reported on a chart review of 27 patients, mean age 52 years, with diabetes who sustained foot burns from January 2000 to December 2005.

Of these, 22 (81%) had burns resulting from insensate feet. In 16 patients, including 15 with insensate burns, the patients were unaware of their feet having been injured, he said.

Burns were caused by soaking feet in hot water (7), putting feet near a heater or a radiator (6), walking on a hot surface (2), having contact with a heating pad (1), and being exposed to other sources (11).

Most (93%) of the patients were male, 16 were taking insulin, and 6 were diagnosed as having insulin-dependent diabetes.

Mean burn size was 4.7% of total body surface area (range 0.5%-15%), and 69% were full-thickness burns. Despite the small burn size, the mean length of hospital stay was 10 days (range 1-25) and 11 days for the insensate burns.

Skin grafting was required in 14 patients (52%). Five patients needed to be regrafted at least once, and one patient required four grafting procedures. Six patients required readmission, and three patients underwent amputations.

There were 16 complications, with 11 episodes of infections, mostly cellulitis. Three patients died.

"All diabetic patients should be taught about the risk of foot burns," Dr. Greenhalgh concluded.

"All patients with loss of sensation should never be exposed to heated water, heating pads, or heaters, or walk outside with bare feet," he said.

An audience member remarked that she's treated several burn injuries among her patients as a result of home treatment of chronic diabetic foot ulcers. Dr. Greenhalgh said he has not observed this, but said it is possible with extended foot soaks, as it takes just 6-8 hours at 43.5° C or 109° F to create a superficial burn.

A minor foot burn in a diabetes patient could lead to below-the-knee amputation. Courtesy Dr. David Greenhalgh

CHICAGO — Patients with diabetes have an increased risk for foot burns, and once a burn occurs the morbidity and mortality are quite high, Dr. David Greenhalgh said at the annual meeting of the American Burn Association.

A patient might sustain a foot burn without being aware of the injury because of impaired sensation in the feet. Insensate feet lead to prolonged exposure and deeper burns. Walking on hot surfaces, soaking in hot water, and even car heaters can cause foot burns.

"You don't feel the pain after soaking your feet for a half-hour, and that leads to the problem," he said. "This is a duration-of-contact problem."

The neurovascular changes associated with diabetes might also lead to impaired burn wound healing. Impaired healing leads to higher graft loss and an increased risk of amputation, said Dr. Greenhalgh, professor and chief of burn surgery, University of California Davis Medical Center, Sacramento.

Dr. Greenhalgh described his own experiences treating small foot burn cases, including a patient with insensate feet who had been admitted for walking on hot asphalt, which resulted in transmetatarsal and below-knee amputations.

Another patient with insensate feet returned home from a walk over hot rocks at a river bed to discover blood oozing from his feet. After lengthy treatment, four of the patient's toes were amputated.

"This is not only a disease that leaves a scar, but a disease that won't heal," he said. "These are high-risk patients and once you have a wound, it can lead to a cascade of events.

"One minute you've got a patient with ulcers between the toes, the next you're sticking a hemostat up their foot draining pus out of their plantar, and then you're doing a below-the-knee amputation," said Dr. Greenhalgh.

He reported on a chart review of 27 patients, mean age 52 years, with diabetes who sustained foot burns from January 2000 to December 2005.

Of these, 22 (81%) had burns resulting from insensate feet. In 16 patients, including 15 with insensate burns, the patients were unaware of their feet having been injured, he said.

Burns were caused by soaking feet in hot water (7), putting feet near a heater or a radiator (6), walking on a hot surface (2), having contact with a heating pad (1), and being exposed to other sources (11).

Most (93%) of the patients were male, 16 were taking insulin, and 6 were diagnosed as having insulin-dependent diabetes.

Mean burn size was 4.7% of total body surface area (range 0.5%-15%), and 69% were full-thickness burns. Despite the small burn size, the mean length of hospital stay was 10 days (range 1-25) and 11 days for the insensate burns.

Skin grafting was required in 14 patients (52%). Five patients needed to be regrafted at least once, and one patient required four grafting procedures. Six patients required readmission, and three patients underwent amputations.

There were 16 complications, with 11 episodes of infections, mostly cellulitis. Three patients died.

"All diabetic patients should be taught about the risk of foot burns," Dr. Greenhalgh concluded.

"All patients with loss of sensation should never be exposed to heated water, heating pads, or heaters, or walk outside with bare feet," he said.

An audience member remarked that she's treated several burn injuries among her patients as a result of home treatment of chronic diabetic foot ulcers. Dr. Greenhalgh said he has not observed this, but said it is possible with extended foot soaks, as it takes just 6-8 hours at 43.5° C or 109° F to create a superficial burn.

A minor foot burn in a diabetes patient could lead to below-the-knee amputation. Courtesy Dr. David Greenhalgh

CHICAGO — Patients with diabetes have an increased risk for foot burns, and once a burn occurs the morbidity and mortality are quite high, Dr. David Greenhalgh said at the annual meeting of the American Burn Association.

A patient might sustain a foot burn without being aware of the injury because of impaired sensation in the feet. Insensate feet lead to prolonged exposure and deeper burns. Walking on hot surfaces, soaking in hot water, and even car heaters can cause foot burns.

"You don't feel the pain after soaking your feet for a half-hour, and that leads to the problem," he said. "This is a duration-of-contact problem."

The neurovascular changes associated with diabetes might also lead to impaired burn wound healing. Impaired healing leads to higher graft loss and an increased risk of amputation, said Dr. Greenhalgh, professor and chief of burn surgery, University of California Davis Medical Center, Sacramento.

Dr. Greenhalgh described his own experiences treating small foot burn cases, including a patient with insensate feet who had been admitted for walking on hot asphalt, which resulted in transmetatarsal and below-knee amputations.

Another patient with insensate feet returned home from a walk over hot rocks at a river bed to discover blood oozing from his feet. After lengthy treatment, four of the patient's toes were amputated.

"This is not only a disease that leaves a scar, but a disease that won't heal," he said. "These are high-risk patients and once you have a wound, it can lead to a cascade of events.

"One minute you've got a patient with ulcers between the toes, the next you're sticking a hemostat up their foot draining pus out of their plantar, and then you're doing a below-the-knee amputation," said Dr. Greenhalgh.

He reported on a chart review of 27 patients, mean age 52 years, with diabetes who sustained foot burns from January 2000 to December 2005.

Of these, 22 (81%) had burns resulting from insensate feet. In 16 patients, including 15 with insensate burns, the patients were unaware of their feet having been injured, he said.

Burns were caused by soaking feet in hot water (7), putting feet near a heater or a radiator (6), walking on a hot surface (2), having contact with a heating pad (1), and being exposed to other sources (11).

Most (93%) of the patients were male, 16 were taking insulin, and 6 were diagnosed as having insulin-dependent diabetes.

Mean burn size was 4.7% of total body surface area (range 0.5%-15%), and 69% were full-thickness burns. Despite the small burn size, the mean length of hospital stay was 10 days (range 1-25) and 11 days for the insensate burns.

Skin grafting was required in 14 patients (52%). Five patients needed to be regrafted at least once, and one patient required four grafting procedures. Six patients required readmission, and three patients underwent amputations.

There were 16 complications, with 11 episodes of infections, mostly cellulitis. Three patients died.

"All diabetic patients should be taught about the risk of foot burns," Dr. Greenhalgh concluded.

"All patients with loss of sensation should never be exposed to heated water, heating pads, or heaters, or walk outside with bare feet," he said.

An audience member remarked that she's treated several burn injuries among her patients as a result of home treatment of chronic diabetic foot ulcers. Dr. Greenhalgh said he has not observed this, but said it is possible with extended foot soaks, as it takes just 6-8 hours at 43.5° C or 109° F to create a superficial burn.

A minor foot burn in a diabetes patient could lead to below-the-knee amputation. Courtesy Dr. David Greenhalgh

CHICAGO — The use of topical mafenide acetate on burn wounds was associated with a higher incidence of fungal infection than was silver sulfadiazine in a retrospective analysis of 111 patients.

The chart review was initiated after physicians at the regional burn center of Miami Valley Hospital, Dayton, Ohio, observed more fungal infections after replacing the application of saline soaks for 24 hours followed by silver sulfadiazine 1% cream (Silvadene) with only the application of mafenide acetate 5% solution (Sulfamylon) as the topical antibiotic of choice for initial antimicrobial therapy.

The change in burn wound treatment protocol was made in 2002 in an effort to improve patient outcomes, and has since been reversed, according to research coordinator Ryan Shapiro, on behalf principal investigator Dr. R. Michael Johnson, at the annual meeting of the American Burn Association.

From 1998 to 2006, 42 patients were treated twice daily with silver sulfadiazine, and 69 with mafenide acetate solution. The silver sulfadiazine group was significantly younger than the mafenide acetate group (mean age, 38 vs. 48 years), less likely to have a central line (16 vs. 43 patients), and more likely to have shorter ICU stays (4 vs. 10 days) and shorter total hospital stays (23.5 vs. 34 days).

Nonsignificant differences between the silver sulfadiazine and mafenide acetate groups included mean total body surface area burned (27% vs. 29%), inhalation injury (14 vs. 25 patients), and mortality (6 vs. 13 patients).

Univariate analysis showed that patients receiving mafenide acetate solution had twice the rate of burn infection or systemic fungal infection (48%) than did patients receiving silver sulfadiazine (24%), reported the investigators, who disclosed no relevant conflicts of interest.

Patients receiving mafenide acetate also had four times the rate of systemic fungal infections (27.5%) than did patients receiving silver sulfadiazine (7%). Both outcomes were statistically significant.

Significant predictors of fungal infection on univariate analysis included age, length of ICU stay, total length of stay, presence of a central line, and use of mafenide acetate.

However, in multivariate logistic regression analysis, only length of ICU stay and total length of stay remained as independent predictors of fungal infection, according to Dr. Johnson, chief of plastic surgery at Miami Valley Hospital, and colleagues.

The overall higher fungal infection rate in the series was higher than expected, and could be the result of an increase in the age of patients being treated rather than the choice of topical antibiotic, the investigators noted.

Although the protocol was changed back to using silver sulfadiazine cream in 2006, mafenide acetate is still used in the burn unit at the physician's discretion, they indicated.

Audience member Dr. Debra A. Reilly, director of the burn center and a surgeon at the University of Nebraska Medical Center in Omaha, recounted similar problems with mafenide acetate and fungal infections, but cautioned the audience not to discard the drug, calling it a "very useful product" with a long track record.

Dr. Reilly suggested adding the antifungal nystatin, with the caveat that it must be combined with mafenide acetate suspension and not mafenide acetate solution.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO — The use of topical mafenide acetate on burn wounds was associated with a higher incidence of fungal infection than was silver sulfadiazine in a retrospective analysis of 111 patients.

The chart review was initiated after physicians at the regional burn center of Miami Valley Hospital, Dayton, Ohio, observed more fungal infections after replacing the application of saline soaks for 24 hours followed by silver sulfadiazine 1% cream (Silvadene) with only the application of mafenide acetate 5% solution (Sulfamylon) as the topical antibiotic of choice for initial antimicrobial therapy.

The change in burn wound treatment protocol was made in 2002 in an effort to improve patient outcomes, and has since been reversed, according to research coordinator Ryan Shapiro, on behalf principal investigator Dr. R. Michael Johnson, at the annual meeting of the American Burn Association.

From 1998 to 2006, 42 patients were treated twice daily with silver sulfadiazine, and 69 with mafenide acetate solution. The silver sulfadiazine group was significantly younger than the mafenide acetate group (mean age, 38 vs. 48 years), less likely to have a central line (16 vs. 43 patients), and more likely to have shorter ICU stays (4 vs. 10 days) and shorter total hospital stays (23.5 vs. 34 days).

Nonsignificant differences between the silver sulfadiazine and mafenide acetate groups included mean total body surface area burned (27% vs. 29%), inhalation injury (14 vs. 25 patients), and mortality (6 vs. 13 patients).

Univariate analysis showed that patients receiving mafenide acetate solution had twice the rate of burn infection or systemic fungal infection (48%) than did patients receiving silver sulfadiazine (24%), reported the investigators, who disclosed no relevant conflicts of interest.

Patients receiving mafenide acetate also had four times the rate of systemic fungal infections (27.5%) than did patients receiving silver sulfadiazine (7%). Both outcomes were statistically significant.

Significant predictors of fungal infection on univariate analysis included age, length of ICU stay, total length of stay, presence of a central line, and use of mafenide acetate.

However, in multivariate logistic regression analysis, only length of ICU stay and total length of stay remained as independent predictors of fungal infection, according to Dr. Johnson, chief of plastic surgery at Miami Valley Hospital, and colleagues.

The overall higher fungal infection rate in the series was higher than expected, and could be the result of an increase in the age of patients being treated rather than the choice of topical antibiotic, the investigators noted.

Although the protocol was changed back to using silver sulfadiazine cream in 2006, mafenide acetate is still used in the burn unit at the physician's discretion, they indicated.

Audience member Dr. Debra A. Reilly, director of the burn center and a surgeon at the University of Nebraska Medical Center in Omaha, recounted similar problems with mafenide acetate and fungal infections, but cautioned the audience not to discard the drug, calling it a "very useful product" with a long track record.

Dr. Reilly suggested adding the antifungal nystatin, with the caveat that it must be combined with mafenide acetate suspension and not mafenide acetate solution.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO — The use of topical mafenide acetate on burn wounds was associated with a higher incidence of fungal infection than was silver sulfadiazine in a retrospective analysis of 111 patients.

The chart review was initiated after physicians at the regional burn center of Miami Valley Hospital, Dayton, Ohio, observed more fungal infections after replacing the application of saline soaks for 24 hours followed by silver sulfadiazine 1% cream (Silvadene) with only the application of mafenide acetate 5% solution (Sulfamylon) as the topical antibiotic of choice for initial antimicrobial therapy.

The change in burn wound treatment protocol was made in 2002 in an effort to improve patient outcomes, and has since been reversed, according to research coordinator Ryan Shapiro, on behalf principal investigator Dr. R. Michael Johnson, at the annual meeting of the American Burn Association.

From 1998 to 2006, 42 patients were treated twice daily with silver sulfadiazine, and 69 with mafenide acetate solution. The silver sulfadiazine group was significantly younger than the mafenide acetate group (mean age, 38 vs. 48 years), less likely to have a central line (16 vs. 43 patients), and more likely to have shorter ICU stays (4 vs. 10 days) and shorter total hospital stays (23.5 vs. 34 days).

Nonsignificant differences between the silver sulfadiazine and mafenide acetate groups included mean total body surface area burned (27% vs. 29%), inhalation injury (14 vs. 25 patients), and mortality (6 vs. 13 patients).

Univariate analysis showed that patients receiving mafenide acetate solution had twice the rate of burn infection or systemic fungal infection (48%) than did patients receiving silver sulfadiazine (24%), reported the investigators, who disclosed no relevant conflicts of interest.

Patients receiving mafenide acetate also had four times the rate of systemic fungal infections (27.5%) than did patients receiving silver sulfadiazine (7%). Both outcomes were statistically significant.

Significant predictors of fungal infection on univariate analysis included age, length of ICU stay, total length of stay, presence of a central line, and use of mafenide acetate.

However, in multivariate logistic regression analysis, only length of ICU stay and total length of stay remained as independent predictors of fungal infection, according to Dr. Johnson, chief of plastic surgery at Miami Valley Hospital, and colleagues.

The overall higher fungal infection rate in the series was higher than expected, and could be the result of an increase in the age of patients being treated rather than the choice of topical antibiotic, the investigators noted.

Although the protocol was changed back to using silver sulfadiazine cream in 2006, mafenide acetate is still used in the burn unit at the physician's discretion, they indicated.

Audience member Dr. Debra A. Reilly, director of the burn center and a surgeon at the University of Nebraska Medical Center in Omaha, recounted similar problems with mafenide acetate and fungal infections, but cautioned the audience not to discard the drug, calling it a "very useful product" with a long track record.

Dr. Reilly suggested adding the antifungal nystatin, with the caveat that it must be combined with mafenide acetate suspension and not mafenide acetate solution.

ELSEVIER GLOBAL MEDICAL NEWS

WASHINGTON — Thrombolytic therapy has resulted in limb salvage among 18 patients with severe frostbite treated at one Minnesota hospital in the last few years.

Thrombolytic therapy has been available for management of frostbite for 10 years and has the potential to reduce amputations, but its use has not extended to the rural northern areas where most cases of frostbite occur.

Severe frostbite results in ischemia and blistering with subsequent demarcation and loss of tissue. Prostaglandins and other chemical mediators are released locally, resulting in intense spasm and blistering. Arterial thrombosis results from injury to endothelial cells that retract to expose subintimal collagen, subsequently triggering acute thrombosis after rewarming, according to Dr. George R. Edmonson of St. Paul (Minn.) Radiology.

Traditional treatment has simply been to rewarm the affected extremity, wait to see how much tissue recovers, then amputate the rest, but over the last couple of decades, investigators have been experimenting with intra-arterial infusion of various thrombolytic and vasodilating agents to dissolve clots and relieve arterial spasm in attempts to preserve more tissue.

At the annual meeting of the Society of Interventional Radiology, Dr. Edmonson described the process used at Regions Hospital, also in St. Paul. Patients are admitted to the burn unit, where the the affected limb is assessed. Diagnostic arteriography is done to assess small vessel occlusion and loss of "distal tuft blush" at the tips of digits. Catheters are positioned for simultaneous infusion of treatment drugs into each affected limb.

Since the mid-1990s, Dr. Edmonson and his associates have been treating frostbite of the extremities with a variety of combined antithrombotic, antiplatelet, and vasodilating agents. Initially, they used urokinase along with heparin and papaverine, then switched to reteplase, and now have moved to using tenecteplase (TNK) because of its superior plasma stability and higher fibrin specificity compared with reteplase, he explained.

During three unusually mild Minnesota winters, six patients aged 18-65 years with severe frostbite who were at risk for amputation were treated for up to 72 hours with intra-arterial TNK infusions at 0.25 mg/hour per limb with coaxial papaverine at 30 mg/hour per limb and intravenous heparin at 500 mcg/hour.

Of the six patients, three who had 16 involved digits responded well and required no amputations. The other three (6 limbs, 30 digits) had incomplete angiographic responses. Of those, two (4 limbs, 20 involved digits) improved following TNK infusion but then developed infections and required partial amputations. One patient—who needed intubation for alcohol withdrawal—failed to respond and lost 8 fingers, but his thumbs were saved.

Those patients were compared with surviving patients (aged 14-77 years) of 12 treated with the same protocol using various doses of reteplase and papaverine over a 2-year period. Six of the patients recovered with no amputations, four had lost 31 digits at 45 days, and two had amputations but more distally than would have been anticipated without treatment.

Fingers with severe frostbite (left) can be saved from amputation with restored blood flow (right) after treatment with tenecteplase, papaverine, and heparin. Photos courtesy Dr. George R. Edmonson

WASHINGTON — Thrombolytic therapy has resulted in limb salvage among 18 patients with severe frostbite treated at one Minnesota hospital in the last few years.

Thrombolytic therapy has been available for management of frostbite for 10 years and has the potential to reduce amputations, but its use has not extended to the rural northern areas where most cases of frostbite occur.

Severe frostbite results in ischemia and blistering with subsequent demarcation and loss of tissue. Prostaglandins and other chemical mediators are released locally, resulting in intense spasm and blistering. Arterial thrombosis results from injury to endothelial cells that retract to expose subintimal collagen, subsequently triggering acute thrombosis after rewarming, according to Dr. George R. Edmonson of St. Paul (Minn.) Radiology.

Traditional treatment has simply been to rewarm the affected extremity, wait to see how much tissue recovers, then amputate the rest, but over the last couple of decades, investigators have been experimenting with intra-arterial infusion of various thrombolytic and vasodilating agents to dissolve clots and relieve arterial spasm in attempts to preserve more tissue.

At the annual meeting of the Society of Interventional Radiology, Dr. Edmonson described the process used at Regions Hospital, also in St. Paul. Patients are admitted to the burn unit, where the the affected limb is assessed. Diagnostic arteriography is done to assess small vessel occlusion and loss of "distal tuft blush" at the tips of digits. Catheters are positioned for simultaneous infusion of treatment drugs into each affected limb.

Since the mid-1990s, Dr. Edmonson and his associates have been treating frostbite of the extremities with a variety of combined antithrombotic, antiplatelet, and vasodilating agents. Initially, they used urokinase along with heparin and papaverine, then switched to reteplase, and now have moved to using tenecteplase (TNK) because of its superior plasma stability and higher fibrin specificity compared with reteplase, he explained.

During three unusually mild Minnesota winters, six patients aged 18-65 years with severe frostbite who were at risk for amputation were treated for up to 72 hours with intra-arterial TNK infusions at 0.25 mg/hour per limb with coaxial papaverine at 30 mg/hour per limb and intravenous heparin at 500 mcg/hour.

Of the six patients, three who had 16 involved digits responded well and required no amputations. The other three (6 limbs, 30 digits) had incomplete angiographic responses. Of those, two (4 limbs, 20 involved digits) improved following TNK infusion but then developed infections and required partial amputations. One patient—who needed intubation for alcohol withdrawal—failed to respond and lost 8 fingers, but his thumbs were saved.

Those patients were compared with surviving patients (aged 14-77 years) of 12 treated with the same protocol using various doses of reteplase and papaverine over a 2-year period. Six of the patients recovered with no amputations, four had lost 31 digits at 45 days, and two had amputations but more distally than would have been anticipated without treatment.

Fingers with severe frostbite (left) can be saved from amputation with restored blood flow (right) after treatment with tenecteplase, papaverine, and heparin. Photos courtesy Dr. George R. Edmonson

WASHINGTON — Thrombolytic therapy has resulted in limb salvage among 18 patients with severe frostbite treated at one Minnesota hospital in the last few years.

Thrombolytic therapy has been available for management of frostbite for 10 years and has the potential to reduce amputations, but its use has not extended to the rural northern areas where most cases of frostbite occur.

Severe frostbite results in ischemia and blistering with subsequent demarcation and loss of tissue. Prostaglandins and other chemical mediators are released locally, resulting in intense spasm and blistering. Arterial thrombosis results from injury to endothelial cells that retract to expose subintimal collagen, subsequently triggering acute thrombosis after rewarming, according to Dr. George R. Edmonson of St. Paul (Minn.) Radiology.

Traditional treatment has simply been to rewarm the affected extremity, wait to see how much tissue recovers, then amputate the rest, but over the last couple of decades, investigators have been experimenting with intra-arterial infusion of various thrombolytic and vasodilating agents to dissolve clots and relieve arterial spasm in attempts to preserve more tissue.

At the annual meeting of the Society of Interventional Radiology, Dr. Edmonson described the process used at Regions Hospital, also in St. Paul. Patients are admitted to the burn unit, where the the affected limb is assessed. Diagnostic arteriography is done to assess small vessel occlusion and loss of "distal tuft blush" at the tips of digits. Catheters are positioned for simultaneous infusion of treatment drugs into each affected limb.

Since the mid-1990s, Dr. Edmonson and his associates have been treating frostbite of the extremities with a variety of combined antithrombotic, antiplatelet, and vasodilating agents. Initially, they used urokinase along with heparin and papaverine, then switched to reteplase, and now have moved to using tenecteplase (TNK) because of its superior plasma stability and higher fibrin specificity compared with reteplase, he explained.

During three unusually mild Minnesota winters, six patients aged 18-65 years with severe frostbite who were at risk for amputation were treated for up to 72 hours with intra-arterial TNK infusions at 0.25 mg/hour per limb with coaxial papaverine at 30 mg/hour per limb and intravenous heparin at 500 mcg/hour.

Of the six patients, three who had 16 involved digits responded well and required no amputations. The other three (6 limbs, 30 digits) had incomplete angiographic responses. Of those, two (4 limbs, 20 involved digits) improved following TNK infusion but then developed infections and required partial amputations. One patient—who needed intubation for alcohol withdrawal—failed to respond and lost 8 fingers, but his thumbs were saved.

Those patients were compared with surviving patients (aged 14-77 years) of 12 treated with the same protocol using various doses of reteplase and papaverine over a 2-year period. Six of the patients recovered with no amputations, four had lost 31 digits at 45 days, and two had amputations but more distally than would have been anticipated without treatment.

Fingers with severe frostbite (left) can be saved from amputation with restored blood flow (right) after treatment with tenecteplase, papaverine, and heparin. Photos courtesy Dr. George R. Edmonson

CHICAGO — Skin graft donor site wounds treated with Silverlon dressing healed significantly faster than those treated with standard Xeroform gauze, albeit at a greater cost to the pocketbook.

Silverlon (Argentum Medical, LLC), a silver-impregnated wound dressing widely used in the treatment of partial thickness burns, also provided better initial postoperative and overall pain relief at the donor site than Xeroform (Tyco Healthcare Group), according to results of a small, prospective randomized trial.

However, Silverlon was associated with significantly greater daily wound care time by nurses than Xeroform (6 minutes vs. 2 minutes) and significantly higher cost per donor site ($22.99 vs. $0.47), Dr. Michael C. Albrecht and colleagues reported in a poster at the annual meeting of the American Burn Association.

"Because of the frequency of serial excision and grafting procedures in large burns and the necessity of rapid donor site healing while minimizing discomfort to the patient, Silverlon appears to be a superior dressing compared to Xeroform in achieving these goals," Dr. Albrecht and colleagues concluded.

The study included 18 men, mean age 26.6 years, with burns covering an average 8.5% (range 2%-20%) of total body surface area who were admitted to the U.S. Army Institute of Surgical Research (USAISR) burn unit from December 2005 to March 2007. Patients had symmetrically paired donor sites harvested by the same physician, and received both the Xeroform and Silverlon dressings, randomized to each donor site. The average time to wound healing was 10.2 days with Silverlon versus 11.4 days with Xeroform.

Although a single day improvement in wound healing does not sound dramatically different, it is clinically important to patients who require frequent reharvesting of donor sites to achieve complete wound coverage, Dr. Albrecht, a burn surgeon and principal investigator for dressing studies at the USAISR, said in an interview.

Over the previous 3 years at the USAISR, an average of 17% of all excision and grafting procedures required reharvesting of the donor sites.

Pain scores on a 10-point verbal scale were significantly lower with Silverlon than Xeroform on postoperative days 1-3; and were significantly lower overall with Silverlon (2.04 vs. 2.66).

There were no differences with inflammation indices or infection rates between the two dressings. At a mean of 48 days post surgery, scar quality was similar with Silverlon versus Xeroform, as determined by a modified Vancouver Burn Scar Assessment Scale (2.63 vs. 2.31) and by an independent and blinded reviewer using a 14-point scale (6.05 vs. 6.94), said Dr. Albrecht, who reported no conflicts of interest.

Significantly more patients preferred the Silverlon dressing than the Xeroform gauze (64% vs. 23%), while 13% had no preference. Xeroform gauze remains the standard dressing in the USAISR burn unit, said Dr. Albrecht, who suggested that resistance to change, rather than the higher cost of Silverlon, has kept Xeroform on the shelves.

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CHICAGO — Skin graft donor site wounds treated with Silverlon dressing healed significantly faster than those treated with standard Xeroform gauze, albeit at a greater cost to the pocketbook.

Silverlon (Argentum Medical, LLC), a silver-impregnated wound dressing widely used in the treatment of partial thickness burns, also provided better initial postoperative and overall pain relief at the donor site than Xeroform (Tyco Healthcare Group), according to results of a small, prospective randomized trial.

However, Silverlon was associated with significantly greater daily wound care time by nurses than Xeroform (6 minutes vs. 2 minutes) and significantly higher cost per donor site ($22.99 vs. $0.47), Dr. Michael C. Albrecht and colleagues reported in a poster at the annual meeting of the American Burn Association.

"Because of the frequency of serial excision and grafting procedures in large burns and the necessity of rapid donor site healing while minimizing discomfort to the patient, Silverlon appears to be a superior dressing compared to Xeroform in achieving these goals," Dr. Albrecht and colleagues concluded.

The study included 18 men, mean age 26.6 years, with burns covering an average 8.5% (range 2%-20%) of total body surface area who were admitted to the U.S. Army Institute of Surgical Research (USAISR) burn unit from December 2005 to March 2007. Patients had symmetrically paired donor sites harvested by the same physician, and received both the Xeroform and Silverlon dressings, randomized to each donor site. The average time to wound healing was 10.2 days with Silverlon versus 11.4 days with Xeroform.

Although a single day improvement in wound healing does not sound dramatically different, it is clinically important to patients who require frequent reharvesting of donor sites to achieve complete wound coverage, Dr. Albrecht, a burn surgeon and principal investigator for dressing studies at the USAISR, said in an interview.

Over the previous 3 years at the USAISR, an average of 17% of all excision and grafting procedures required reharvesting of the donor sites.

Pain scores on a 10-point verbal scale were significantly lower with Silverlon than Xeroform on postoperative days 1-3; and were significantly lower overall with Silverlon (2.04 vs. 2.66).

There were no differences with inflammation indices or infection rates between the two dressings. At a mean of 48 days post surgery, scar quality was similar with Silverlon versus Xeroform, as determined by a modified Vancouver Burn Scar Assessment Scale (2.63 vs. 2.31) and by an independent and blinded reviewer using a 14-point scale (6.05 vs. 6.94), said Dr. Albrecht, who reported no conflicts of interest.

Significantly more patients preferred the Silverlon dressing than the Xeroform gauze (64% vs. 23%), while 13% had no preference. Xeroform gauze remains the standard dressing in the USAISR burn unit, said Dr. Albrecht, who suggested that resistance to change, rather than the higher cost of Silverlon, has kept Xeroform on the shelves.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO — Skin graft donor site wounds treated with Silverlon dressing healed significantly faster than those treated with standard Xeroform gauze, albeit at a greater cost to the pocketbook.

Silverlon (Argentum Medical, LLC), a silver-impregnated wound dressing widely used in the treatment of partial thickness burns, also provided better initial postoperative and overall pain relief at the donor site than Xeroform (Tyco Healthcare Group), according to results of a small, prospective randomized trial.

However, Silverlon was associated with significantly greater daily wound care time by nurses than Xeroform (6 minutes vs. 2 minutes) and significantly higher cost per donor site ($22.99 vs. $0.47), Dr. Michael C. Albrecht and colleagues reported in a poster at the annual meeting of the American Burn Association.

"Because of the frequency of serial excision and grafting procedures in large burns and the necessity of rapid donor site healing while minimizing discomfort to the patient, Silverlon appears to be a superior dressing compared to Xeroform in achieving these goals," Dr. Albrecht and colleagues concluded.

The study included 18 men, mean age 26.6 years, with burns covering an average 8.5% (range 2%-20%) of total body surface area who were admitted to the U.S. Army Institute of Surgical Research (USAISR) burn unit from December 2005 to March 2007. Patients had symmetrically paired donor sites harvested by the same physician, and received both the Xeroform and Silverlon dressings, randomized to each donor site. The average time to wound healing was 10.2 days with Silverlon versus 11.4 days with Xeroform.

Although a single day improvement in wound healing does not sound dramatically different, it is clinically important to patients who require frequent reharvesting of donor sites to achieve complete wound coverage, Dr. Albrecht, a burn surgeon and principal investigator for dressing studies at the USAISR, said in an interview.

Over the previous 3 years at the USAISR, an average of 17% of all excision and grafting procedures required reharvesting of the donor sites.

Pain scores on a 10-point verbal scale were significantly lower with Silverlon than Xeroform on postoperative days 1-3; and were significantly lower overall with Silverlon (2.04 vs. 2.66).

There were no differences with inflammation indices or infection rates between the two dressings. At a mean of 48 days post surgery, scar quality was similar with Silverlon versus Xeroform, as determined by a modified Vancouver Burn Scar Assessment Scale (2.63 vs. 2.31) and by an independent and blinded reviewer using a 14-point scale (6.05 vs. 6.94), said Dr. Albrecht, who reported no conflicts of interest.

Significantly more patients preferred the Silverlon dressing than the Xeroform gauze (64% vs. 23%), while 13% had no preference. Xeroform gauze remains the standard dressing in the USAISR burn unit, said Dr. Albrecht, who suggested that resistance to change, rather than the higher cost of Silverlon, has kept Xeroform on the shelves.

ELSEVIER GLOBAL MEDICAL NEWS

SALT LAKE CITY — The Pressure Ulcer Scale for Healing proved superior to assessment by experienced nurses in determining status and progression of long-term care residents' wounds, researchers reported at the annual symposium of the American Medical Directors Association.

"It was surprising because we thought the clinical way was the better way," said Dr. Erica George-Saintilus with Long Island Jewish Medical Center, who presented a poster on her study at the center-affiliated Cold Spring Hills Center for Nursing and Rehabilitation in Woodbury, N.Y.

Whereas nurses assessed the wounds primarily by subjective impressions and wound size, the Pressure Ulcer Scale for Healing (PUSH) tool tallied three parameters:

▸ Wound size in scores representing skin area from none (0) to more than 24 cm

▸ Amount of exudate from none (0) to heavy (3).

▸ Tissue type from closed/resurfaced (0) to necrotic tissue/eschar (4).

The team reviewed records of all residents with stage II-IV ulcers in the 627-bed skilled nursing facility from 2004 through 2006. Weekly reports on the wounds included data sufficient to calculate a PUSH score as well as nurse assessments such as "improved," "deteriorated," or "unchanged." In patients with multiple wounds, the study tracked only one ulcer.

"There's no indication [from statistical analyses] that nurses' observations agree at all with the PUSH," said Dr. George-Saintilus.

Looking specifically at 2 months of data for 30 residents, the researchers determined that PUSH scores were better than the nurses' assessments at indicating the direction that a wound was taking. Dr. George-Saintilus pointed out instances in which a pressure ulcer that a nurse had recorded as "healed" returned and got worse. In contrast, PUSH scores were more likely to indicate the true progression of a wound.

Further, Dr. George-Saintilus and her colleagues discovered that the nurses' assessments were idiosyncratic. "Each nurse has her own way of giving her impression," the researcher said.

PUSH was introduced 11 years ago by the National Pressure Ulcer Advisory Panel, a coalition of corporate and professional organizations that sets care standards. AMDA's "Pressure Ulcers in the Long-Term Care Setting" clinical practice guideline cites PUSH as a "validated tool for characterizing and monitoring pressure ulcers." The guideline includes directions and a blank scoring sheet, and the advisory panel offers the same at http://www.npuap.org/PDF/push3.pdf

Dr. George-Saintilus said that her observations of nurses at the Cold Spring Hills facility, which now uses the PUSH tool, show that PUSH is actually quicker to use than the subjective system. The old record keeping included nurses' assessments and several wound parameters but didn't combine those data into a score that could be tracked as easily as the PUSH score. She said that PUSH "saves time and money."

SALT LAKE CITY — The Pressure Ulcer Scale for Healing proved superior to assessment by experienced nurses in determining status and progression of long-term care residents' wounds, researchers reported at the annual symposium of the American Medical Directors Association.

"It was surprising because we thought the clinical way was the better way," said Dr. Erica George-Saintilus with Long Island Jewish Medical Center, who presented a poster on her study at the center-affiliated Cold Spring Hills Center for Nursing and Rehabilitation in Woodbury, N.Y.

Whereas nurses assessed the wounds primarily by subjective impressions and wound size, the Pressure Ulcer Scale for Healing (PUSH) tool tallied three parameters:

▸ Wound size in scores representing skin area from none (0) to more than 24 cm

▸ Amount of exudate from none (0) to heavy (3).

▸ Tissue type from closed/resurfaced (0) to necrotic tissue/eschar (4).

The team reviewed records of all residents with stage II-IV ulcers in the 627-bed skilled nursing facility from 2004 through 2006. Weekly reports on the wounds included data sufficient to calculate a PUSH score as well as nurse assessments such as "improved," "deteriorated," or "unchanged." In patients with multiple wounds, the study tracked only one ulcer.

"There's no indication [from statistical analyses] that nurses' observations agree at all with the PUSH," said Dr. George-Saintilus.

Looking specifically at 2 months of data for 30 residents, the researchers determined that PUSH scores were better than the nurses' assessments at indicating the direction that a wound was taking. Dr. George-Saintilus pointed out instances in which a pressure ulcer that a nurse had recorded as "healed" returned and got worse. In contrast, PUSH scores were more likely to indicate the true progression of a wound.

Further, Dr. George-Saintilus and her colleagues discovered that the nurses' assessments were idiosyncratic. "Each nurse has her own way of giving her impression," the researcher said.

PUSH was introduced 11 years ago by the National Pressure Ulcer Advisory Panel, a coalition of corporate and professional organizations that sets care standards. AMDA's "Pressure Ulcers in the Long-Term Care Setting" clinical practice guideline cites PUSH as a "validated tool for characterizing and monitoring pressure ulcers." The guideline includes directions and a blank scoring sheet, and the advisory panel offers the same at http://www.npuap.org/PDF/push3.pdf

Dr. George-Saintilus said that her observations of nurses at the Cold Spring Hills facility, which now uses the PUSH tool, show that PUSH is actually quicker to use than the subjective system. The old record keeping included nurses' assessments and several wound parameters but didn't combine those data into a score that could be tracked as easily as the PUSH score. She said that PUSH "saves time and money."

SALT LAKE CITY — The Pressure Ulcer Scale for Healing proved superior to assessment by experienced nurses in determining status and progression of long-term care residents' wounds, researchers reported at the annual symposium of the American Medical Directors Association.

"It was surprising because we thought the clinical way was the better way," said Dr. Erica George-Saintilus with Long Island Jewish Medical Center, who presented a poster on her study at the center-affiliated Cold Spring Hills Center for Nursing and Rehabilitation in Woodbury, N.Y.

Whereas nurses assessed the wounds primarily by subjective impressions and wound size, the Pressure Ulcer Scale for Healing (PUSH) tool tallied three parameters:

▸ Wound size in scores representing skin area from none (0) to more than 24 cm

▸ Amount of exudate from none (0) to heavy (3).

▸ Tissue type from closed/resurfaced (0) to necrotic tissue/eschar (4).

The team reviewed records of all residents with stage II-IV ulcers in the 627-bed skilled nursing facility from 2004 through 2006. Weekly reports on the wounds included data sufficient to calculate a PUSH score as well as nurse assessments such as "improved," "deteriorated," or "unchanged." In patients with multiple wounds, the study tracked only one ulcer.

"There's no indication [from statistical analyses] that nurses' observations agree at all with the PUSH," said Dr. George-Saintilus.

Looking specifically at 2 months of data for 30 residents, the researchers determined that PUSH scores were better than the nurses' assessments at indicating the direction that a wound was taking. Dr. George-Saintilus pointed out instances in which a pressure ulcer that a nurse had recorded as "healed" returned and got worse. In contrast, PUSH scores were more likely to indicate the true progression of a wound.

Further, Dr. George-Saintilus and her colleagues discovered that the nurses' assessments were idiosyncratic. "Each nurse has her own way of giving her impression," the researcher said.

PUSH was introduced 11 years ago by the National Pressure Ulcer Advisory Panel, a coalition of corporate and professional organizations that sets care standards. AMDA's "Pressure Ulcers in the Long-Term Care Setting" clinical practice guideline cites PUSH as a "validated tool for characterizing and monitoring pressure ulcers." The guideline includes directions and a blank scoring sheet, and the advisory panel offers the same at http://www.npuap.org/PDF/push3.pdf

Dr. George-Saintilus said that her observations of nurses at the Cold Spring Hills facility, which now uses the PUSH tool, show that PUSH is actually quicker to use than the subjective system. The old record keeping included nurses' assessments and several wound parameters but didn't combine those data into a score that could be tracked as easily as the PUSH score. She said that PUSH "saves time and money."

CINCINNATI — Control of blood glucose levels through intensive insulin therapy has been shown to reduce morbidity in both surgical and medical ICU patients, as well as mortality in surgical ICU patients. Results of a retrospective study now suggest that implementation of this therapy in burn patients may reduce the rate of infectious complications but not mortality.

Maintaining mean blood glucose levels of less than 140 mg/dL reduced the rate of pneumonia, ventilator-associated pneumonia, and urinary tract infections in 71 burn patients who received intensive insulin therapy, compared with 81 burn patients in the same ICU during the year before the protocol was implemented, Dr. Mark R. Hemmila reported at the annual meeting of the Central Surgical Association.

But some discussants at the meeting questioned whether certain weaknesses in the study's design and differences in patient characteristics may have contributed to its results.

During the first year of an intensive insulin therapy protocol (July 2005 to June 2006), Dr. Hemmila and his colleagues at the University of Michigan, Ann Arbor, sought to bring burn patients' blood glucose levels to less than 140 mg/dL. In the previous year (July 2004 to June 2005), burn patients had received an insulin drip protocol when their blood glucose levels exceeded 150 mg/dL.

The patients in each group had a mean age in the early 40s, and close to three-fourths in each group were men. The investigators excluded patients with concomitant trauma and burn injuries or desquamating skin diseases.

The control and intensive insulin therapy groups had similar blood glucose levels upon admission (142 mg/dL vs. 130 mg/dL, respectively) and in terms of daily average (135 mg/dL vs. 129 mg/dL) as well as overall mean during their hospital stay (127 mg/dL vs. 126 mg/dL). The intensive insulin-treated and control groups each spent a similar percentage of time in the hospital with a mean daily blood glucose level greater than 140 mg/dL (22% vs. 35%, respectively). But compared with patients in the control group, those who were treated with intensive insulin therapy spent a significantly lower percentage of their time in the hospital with a maximum mean daily blood glucose level greater than 200 mg/dL (11% vs. 17%).

In multivariate analyses that adjusted for age, gender, the percentage of total body surface area burned, and inhalation injury, adding intensive insulin therapy did not significantly improve the outcomes obtained in burn patients in the year before the therapy was implemented. There were no improvements in mortality (7% vs. 9%, respectively, among intensive insulin vs. control patients), mean length of stay in the ICU (5 vs. 9 days), mean length of stay in the hospital overall (10 vs. 17 days), and mean number of days requiring ventilation (3 vs. 6 days).

However, intensive insulin therapy significantly reduced rates of pneumonia overall (16% vs. 37%), ventilator-associated pneumonia (10% vs. 31%), and urinary tract infection (6% vs. 22%).

The odds of developing infection were more than 11 times higher in patients with a maximum mean glucose of greater than 140 mg/dL than in those with a maximum blood glucose level of 140 mg/dL or less. Of patients with maximum blood glucose levels higher than 140 mg/dL, 61 had an infection and 32 did not, whereas those with blood glucose levels of 140 mg/dL comprised 6 with infection and 53 without. Based on these values, a maximum blood glucose level greater than 140 mg/dL predicted the development of infectious complications, Dr. Hemmila said.

"Measurement of a blood glucose level greater than 140 mg/dL should heighten the clinical suspicion for presence of an infection in patients with burn injury," he concluded.

Dr. Peter J. Fabri of the University of South Florida, Tampa, a discussant at the meeting, noted a recent study suggesting that the complication rate of tight blood glucose control may actually negate its benefits (N. Engl. J. Med. 2008;358:125–39). "We have to be very careful being critical when we look at these studies," Dr. Fabri said. "It's very rare that one thing is the only thing that changes in a busy, successful critical care unit over a 2-year period of time."

'A blood glucose level greater than 140 mg/dL should heighten the clinical suspicion for presence of an infection.' DR. HEMMILA

CINCINNATI — Control of blood glucose levels through intensive insulin therapy has been shown to reduce morbidity in both surgical and medical ICU patients, as well as mortality in surgical ICU patients. Results of a retrospective study now suggest that implementation of this therapy in burn patients may reduce the rate of infectious complications but not mortality.

Maintaining mean blood glucose levels of less than 140 mg/dL reduced the rate of pneumonia, ventilator-associated pneumonia, and urinary tract infections in 71 burn patients who received intensive insulin therapy, compared with 81 burn patients in the same ICU during the year before the protocol was implemented, Dr. Mark R. Hemmila reported at the annual meeting of the Central Surgical Association.

But some discussants at the meeting questioned whether certain weaknesses in the study's design and differences in patient characteristics may have contributed to its results.

During the first year of an intensive insulin therapy protocol (July 2005 to June 2006), Dr. Hemmila and his colleagues at the University of Michigan, Ann Arbor, sought to bring burn patients' blood glucose levels to less than 140 mg/dL. In the previous year (July 2004 to June 2005), burn patients had received an insulin drip protocol when their blood glucose levels exceeded 150 mg/dL.

The patients in each group had a mean age in the early 40s, and close to three-fourths in each group were men. The investigators excluded patients with concomitant trauma and burn injuries or desquamating skin diseases.

The control and intensive insulin therapy groups had similar blood glucose levels upon admission (142 mg/dL vs. 130 mg/dL, respectively) and in terms of daily average (135 mg/dL vs. 129 mg/dL) as well as overall mean during their hospital stay (127 mg/dL vs. 126 mg/dL). The intensive insulin-treated and control groups each spent a similar percentage of time in the hospital with a mean daily blood glucose level greater than 140 mg/dL (22% vs. 35%, respectively). But compared with patients in the control group, those who were treated with intensive insulin therapy spent a significantly lower percentage of their time in the hospital with a maximum mean daily blood glucose level greater than 200 mg/dL (11% vs. 17%).

In multivariate analyses that adjusted for age, gender, the percentage of total body surface area burned, and inhalation injury, adding intensive insulin therapy did not significantly improve the outcomes obtained in burn patients in the year before the therapy was implemented. There were no improvements in mortality (7% vs. 9%, respectively, among intensive insulin vs. control patients), mean length of stay in the ICU (5 vs. 9 days), mean length of stay in the hospital overall (10 vs. 17 days), and mean number of days requiring ventilation (3 vs. 6 days).

However, intensive insulin therapy significantly reduced rates of pneumonia overall (16% vs. 37%), ventilator-associated pneumonia (10% vs. 31%), and urinary tract infection (6% vs. 22%).

The odds of developing infection were more than 11 times higher in patients with a maximum mean glucose of greater than 140 mg/dL than in those with a maximum blood glucose level of 140 mg/dL or less. Of patients with maximum blood glucose levels higher than 140 mg/dL, 61 had an infection and 32 did not, whereas those with blood glucose levels of 140 mg/dL comprised 6 with infection and 53 without. Based on these values, a maximum blood glucose level greater than 140 mg/dL predicted the development of infectious complications, Dr. Hemmila said.

"Measurement of a blood glucose level greater than 140 mg/dL should heighten the clinical suspicion for presence of an infection in patients with burn injury," he concluded.

Dr. Peter J. Fabri of the University of South Florida, Tampa, a discussant at the meeting, noted a recent study suggesting that the complication rate of tight blood glucose control may actually negate its benefits (N. Engl. J. Med. 2008;358:125–39). "We have to be very careful being critical when we look at these studies," Dr. Fabri said. "It's very rare that one thing is the only thing that changes in a busy, successful critical care unit over a 2-year period of time."

'A blood glucose level greater than 140 mg/dL should heighten the clinical suspicion for presence of an infection.' DR. HEMMILA

CINCINNATI — Control of blood glucose levels through intensive insulin therapy has been shown to reduce morbidity in both surgical and medical ICU patients, as well as mortality in surgical ICU patients. Results of a retrospective study now suggest that implementation of this therapy in burn patients may reduce the rate of infectious complications but not mortality.

Maintaining mean blood glucose levels of less than 140 mg/dL reduced the rate of pneumonia, ventilator-associated pneumonia, and urinary tract infections in 71 burn patients who received intensive insulin therapy, compared with 81 burn patients in the same ICU during the year before the protocol was implemented, Dr. Mark R. Hemmila reported at the annual meeting of the Central Surgical Association.

But some discussants at the meeting questioned whether certain weaknesses in the study's design and differences in patient characteristics may have contributed to its results.

During the first year of an intensive insulin therapy protocol (July 2005 to June 2006), Dr. Hemmila and his colleagues at the University of Michigan, Ann Arbor, sought to bring burn patients' blood glucose levels to less than 140 mg/dL. In the previous year (July 2004 to June 2005), burn patients had received an insulin drip protocol when their blood glucose levels exceeded 150 mg/dL.

The patients in each group had a mean age in the early 40s, and close to three-fourths in each group were men. The investigators excluded patients with concomitant trauma and burn injuries or desquamating skin diseases.

The control and intensive insulin therapy groups had similar blood glucose levels upon admission (142 mg/dL vs. 130 mg/dL, respectively) and in terms of daily average (135 mg/dL vs. 129 mg/dL) as well as overall mean during their hospital stay (127 mg/dL vs. 126 mg/dL). The intensive insulin-treated and control groups each spent a similar percentage of time in the hospital with a mean daily blood glucose level greater than 140 mg/dL (22% vs. 35%, respectively). But compared with patients in the control group, those who were treated with intensive insulin therapy spent a significantly lower percentage of their time in the hospital with a maximum mean daily blood glucose level greater than 200 mg/dL (11% vs. 17%).

In multivariate analyses that adjusted for age, gender, the percentage of total body surface area burned, and inhalation injury, adding intensive insulin therapy did not significantly improve the outcomes obtained in burn patients in the year before the therapy was implemented. There were no improvements in mortality (7% vs. 9%, respectively, among intensive insulin vs. control patients), mean length of stay in the ICU (5 vs. 9 days), mean length of stay in the hospital overall (10 vs. 17 days), and mean number of days requiring ventilation (3 vs. 6 days).

However, intensive insulin therapy significantly reduced rates of pneumonia overall (16% vs. 37%), ventilator-associated pneumonia (10% vs. 31%), and urinary tract infection (6% vs. 22%).

The odds of developing infection were more than 11 times higher in patients with a maximum mean glucose of greater than 140 mg/dL than in those with a maximum blood glucose level of 140 mg/dL or less. Of patients with maximum blood glucose levels higher than 140 mg/dL, 61 had an infection and 32 did not, whereas those with blood glucose levels of 140 mg/dL comprised 6 with infection and 53 without. Based on these values, a maximum blood glucose level greater than 140 mg/dL predicted the development of infectious complications, Dr. Hemmila said.

"Measurement of a blood glucose level greater than 140 mg/dL should heighten the clinical suspicion for presence of an infection in patients with burn injury," he concluded.

Dr. Peter J. Fabri of the University of South Florida, Tampa, a discussant at the meeting, noted a recent study suggesting that the complication rate of tight blood glucose control may actually negate its benefits (N. Engl. J. Med. 2008;358:125–39). "We have to be very careful being critical when we look at these studies," Dr. Fabri said. "It's very rare that one thing is the only thing that changes in a busy, successful critical care unit over a 2-year period of time."

'A blood glucose level greater than 140 mg/dL should heighten the clinical suspicion for presence of an infection.' DR. HEMMILA

CHICAGO — Burn victims who are regular smokers prior to their injuries have poorer outcomes than do nonsmokers, data presented at the annual meeting of the American Burn Association suggest.

In a retrospective analysis of 240 patients, smokers had significantly more surgical procedures than did nonsmokers (1.3 vs. 0.8) and significantly longer hospital stays (13 vs. 9.5 days).

Additionally, smokers had an 85% increased risk of infection during inpatient treatment, said lead investigator Neal Doran, Ph.D., of the University of California, San Diego. The infection rate was 51% in smokers and 36% in nonsmokers, a significant difference.

The study included 80 patients, mean age 35 years, who smoked at least weekly, and 160 nonsmokers, mean age 37 years. The total body surface area burned was similar between smokers (average 7%, range 0.5%-35%) and nonsmokers (average 6%, range 0.3%-36%). The source of burns was flame in roughly 50% of cases, scald in 20%, contact burns in 10%, and chemical, tar, steam, and sunburns in the remainder.

Impaired wound healing, defined as skin graft failure, was not significantly different between smokers and nonsmokers (10% vs. 3%), Dr. Doran said. Impaired wound healing likely was not statistically different between groups because of the relatively few graft failures in either group, and also because graft failure—as a measure of wound healing—represents the extreme negative end of the healing continuum. Still, smokers were almost four times as likely to have graft failure compared with nonsmokers (odds ratio 3.95).

Previous studies have shown that smoking is a significant impediment to wound healing because of the effects of the various chemical components of cigarette smoke such as nicotine, carbon monoxide, and hydrogen cyanide—all of which inhibit oxygen delivery to the wound site.

Because of the longer hospital stays, the cost of treatment was about $3,150 more per smoker, not including the cost of surgeries.

Burn patients are three times more likely to smoke. "When someone has had a health scare, it is an ideal time to provide a motivational intervention intended to change [that person's] behavior," he said.

An audience member observed that 55% of smokers had flame burns and that this uncommon burn pattern results in deeper tissue injuriest that may account for the longer healing times reported among smokers. Dr. Doran responded that the rate of flame burns was not significantly different between the two groups, with 46% of nonsmokers also having flame burns.

Limitations of the study, conducted by Dr. Doran and associates, include the lack of information on the exact number of cigarettes smoked prior to injury and smoking status during hospitalization. Postdischarge outcomes are currently being analyzed.

CHICAGO — Burn victims who are regular smokers prior to their injuries have poorer outcomes than do nonsmokers, data presented at the annual meeting of the American Burn Association suggest.

In a retrospective analysis of 240 patients, smokers had significantly more surgical procedures than did nonsmokers (1.3 vs. 0.8) and significantly longer hospital stays (13 vs. 9.5 days).

Additionally, smokers had an 85% increased risk of infection during inpatient treatment, said lead investigator Neal Doran, Ph.D., of the University of California, San Diego. The infection rate was 51% in smokers and 36% in nonsmokers, a significant difference.

The study included 80 patients, mean age 35 years, who smoked at least weekly, and 160 nonsmokers, mean age 37 years. The total body surface area burned was similar between smokers (average 7%, range 0.5%-35%) and nonsmokers (average 6%, range 0.3%-36%). The source of burns was flame in roughly 50% of cases, scald in 20%, contact burns in 10%, and chemical, tar, steam, and sunburns in the remainder.

Impaired wound healing, defined as skin graft failure, was not significantly different between smokers and nonsmokers (10% vs. 3%), Dr. Doran said. Impaired wound healing likely was not statistically different between groups because of the relatively few graft failures in either group, and also because graft failure—as a measure of wound healing—represents the extreme negative end of the healing continuum. Still, smokers were almost four times as likely to have graft failure compared with nonsmokers (odds ratio 3.95).

Previous studies have shown that smoking is a significant impediment to wound healing because of the effects of the various chemical components of cigarette smoke such as nicotine, carbon monoxide, and hydrogen cyanide—all of which inhibit oxygen delivery to the wound site.

Because of the longer hospital stays, the cost of treatment was about $3,150 more per smoker, not including the cost of surgeries.

Burn patients are three times more likely to smoke. "When someone has had a health scare, it is an ideal time to provide a motivational intervention intended to change [that person's] behavior," he said.

An audience member observed that 55% of smokers had flame burns and that this uncommon burn pattern results in deeper tissue injuriest that may account for the longer healing times reported among smokers. Dr. Doran responded that the rate of flame burns was not significantly different between the two groups, with 46% of nonsmokers also having flame burns.

Limitations of the study, conducted by Dr. Doran and associates, include the lack of information on the exact number of cigarettes smoked prior to injury and smoking status during hospitalization. Postdischarge outcomes are currently being analyzed.

CHICAGO — Burn victims who are regular smokers prior to their injuries have poorer outcomes than do nonsmokers, data presented at the annual meeting of the American Burn Association suggest.

In a retrospective analysis of 240 patients, smokers had significantly more surgical procedures than did nonsmokers (1.3 vs. 0.8) and significantly longer hospital stays (13 vs. 9.5 days).

Additionally, smokers had an 85% increased risk of infection during inpatient treatment, said lead investigator Neal Doran, Ph.D., of the University of California, San Diego. The infection rate was 51% in smokers and 36% in nonsmokers, a significant difference.

The study included 80 patients, mean age 35 years, who smoked at least weekly, and 160 nonsmokers, mean age 37 years. The total body surface area burned was similar between smokers (average 7%, range 0.5%-35%) and nonsmokers (average 6%, range 0.3%-36%). The source of burns was flame in roughly 50% of cases, scald in 20%, contact burns in 10%, and chemical, tar, steam, and sunburns in the remainder.

Impaired wound healing, defined as skin graft failure, was not significantly different between smokers and nonsmokers (10% vs. 3%), Dr. Doran said. Impaired wound healing likely was not statistically different between groups because of the relatively few graft failures in either group, and also because graft failure—as a measure of wound healing—represents the extreme negative end of the healing continuum. Still, smokers were almost four times as likely to have graft failure compared with nonsmokers (odds ratio 3.95).

Previous studies have shown that smoking is a significant impediment to wound healing because of the effects of the various chemical components of cigarette smoke such as nicotine, carbon monoxide, and hydrogen cyanide—all of which inhibit oxygen delivery to the wound site.

Because of the longer hospital stays, the cost of treatment was about $3,150 more per smoker, not including the cost of surgeries.

Burn patients are three times more likely to smoke. "When someone has had a health scare, it is an ideal time to provide a motivational intervention intended to change [that person's] behavior," he said.

An audience member observed that 55% of smokers had flame burns and that this uncommon burn pattern results in deeper tissue injuriest that may account for the longer healing times reported among smokers. Dr. Doran responded that the rate of flame burns was not significantly different between the two groups, with 46% of nonsmokers also having flame burns.

Limitations of the study, conducted by Dr. Doran and associates, include the lack of information on the exact number of cigarettes smoked prior to injury and smoking status during hospitalization. Postdischarge outcomes are currently being analyzed.

SAN DIEGO — Treatment of stage II pressure ulcers with a self-adhesive polyurethane foam dressing was more cost effective than was treatment with standard saline-soaked gauze, according to a multicenter, randomized trial.

"The current wound care practice in the United States is still dominated by the traditional methods such as saline-soaked gauze or wet-to-dry gauze," Dr. Wyatt G. Payne said in a poster presented at the annual meeting of the Wound Healing Society.

"Many facilities still use this low-technology, low-cost dressing treatment because many practitioners are not fully convinced that advanced wound care products provide fully the benefits they claim, and as such do not warrant the increased costs per dressing. The increased cost per dressing of advanced wound care products leads to the perception that they are expensive, when they may actually be a more cost effective alternative because they need changing less often," he wrote.

Dr. Payne of the Bay Pines VA Healthcare System in St. Petersburg, Fla., and associates, randomized 36 patients with stage II pressure ulcers to receive Allevyn Thin self-adhesive polyurethane foam dressing (Smith & Nephew) or saline-soaked gauze. Each patient was assessed each week for 4 weeks, unless the ulcer closed.

Mean patient age was 73 years and more than half (61%) were men. The mean cost of dressing and other materials for patients in the polyurethane foam dressing group was $32 per week, compared with $58 per week for those in the saline-soaked gauze group. "This implies that a switch from gauze to polyurethane foam would make it possible to treat 80% more patients with the same materials budget," the researchers estimated.

Overall mean treatment cost per week was also lower for patients in the foam-dressing group, $91, compared with a mean of $209 for the saline-soaked gauze group. The savings of $118 per patient "is consistent with a saving in the cost on nursing time of $92 per week," Dr. Payne reported at the meeting, which was held in conjunction with a symposium on advanced wound care.

"This represents more than 3 hours of nursing time per patient per week (assuming a median wage of $28 per hour for a registered nurse)," he wrote.

Dressings were changed a mean of five times per week in the foam-dressing group, compared with a mean of 13 times per week in the saline-soaked gauze group. At the end of 4 weeks, 50% of the wounds in the foam-dressing group were closed, compared with 38% of those in the saline-soaked gauze group, but there was no evidence of a difference between the two groups in time to wound closure.

Total per patient costs over the 4-week evaluation period ranged from $265 to $315 in the foam-dressing group and from $691 to $781 in the saline-soaked gauze group. The number of days free of ulcer was 9 vs. 7, respectively.

Smith & Nephew funded the study. Dr. Payne said that he has no financial interest in the company.

ELSEVIER GLOBAL MEDICAL NEWS

SAN DIEGO — Treatment of stage II pressure ulcers with a self-adhesive polyurethane foam dressing was more cost effective than was treatment with standard saline-soaked gauze, according to a multicenter, randomized trial.

"The current wound care practice in the United States is still dominated by the traditional methods such as saline-soaked gauze or wet-to-dry gauze," Dr. Wyatt G. Payne said in a poster presented at the annual meeting of the Wound Healing Society.

"Many facilities still use this low-technology, low-cost dressing treatment because many practitioners are not fully convinced that advanced wound care products provide fully the benefits they claim, and as such do not warrant the increased costs per dressing. The increased cost per dressing of advanced wound care products leads to the perception that they are expensive, when they may actually be a more cost effective alternative because they need changing less often," he wrote.

Dr. Payne of the Bay Pines VA Healthcare System in St. Petersburg, Fla., and associates, randomized 36 patients with stage II pressure ulcers to receive Allevyn Thin self-adhesive polyurethane foam dressing (Smith & Nephew) or saline-soaked gauze. Each patient was assessed each week for 4 weeks, unless the ulcer closed.

Mean patient age was 73 years and more than half (61%) were men. The mean cost of dressing and other materials for patients in the polyurethane foam dressing group was $32 per week, compared with $58 per week for those in the saline-soaked gauze group. "This implies that a switch from gauze to polyurethane foam would make it possible to treat 80% more patients with the same materials budget," the researchers estimated.

Overall mean treatment cost per week was also lower for patients in the foam-dressing group, $91, compared with a mean of $209 for the saline-soaked gauze group. The savings of $118 per patient "is consistent with a saving in the cost on nursing time of $92 per week," Dr. Payne reported at the meeting, which was held in conjunction with a symposium on advanced wound care.

"This represents more than 3 hours of nursing time per patient per week (assuming a median wage of $28 per hour for a registered nurse)," he wrote.

Dressings were changed a mean of five times per week in the foam-dressing group, compared with a mean of 13 times per week in the saline-soaked gauze group. At the end of 4 weeks, 50% of the wounds in the foam-dressing group were closed, compared with 38% of those in the saline-soaked gauze group, but there was no evidence of a difference between the two groups in time to wound closure.

Total per patient costs over the 4-week evaluation period ranged from $265 to $315 in the foam-dressing group and from $691 to $781 in the saline-soaked gauze group. The number of days free of ulcer was 9 vs. 7, respectively.

Smith & Nephew funded the study. Dr. Payne said that he has no financial interest in the company.

ELSEVIER GLOBAL MEDICAL NEWS

SAN DIEGO — Treatment of stage II pressure ulcers with a self-adhesive polyurethane foam dressing was more cost effective than was treatment with standard saline-soaked gauze, according to a multicenter, randomized trial.

"The current wound care practice in the United States is still dominated by the traditional methods such as saline-soaked gauze or wet-to-dry gauze," Dr. Wyatt G. Payne said in a poster presented at the annual meeting of the Wound Healing Society.

"Many facilities still use this low-technology, low-cost dressing treatment because many practitioners are not fully convinced that advanced wound care products provide fully the benefits they claim, and as such do not warrant the increased costs per dressing. The increased cost per dressing of advanced wound care products leads to the perception that they are expensive, when they may actually be a more cost effective alternative because they need changing less often," he wrote.

Dr. Payne of the Bay Pines VA Healthcare System in St. Petersburg, Fla., and associates, randomized 36 patients with stage II pressure ulcers to receive Allevyn Thin self-adhesive polyurethane foam dressing (Smith & Nephew) or saline-soaked gauze. Each patient was assessed each week for 4 weeks, unless the ulcer closed.

Mean patient age was 73 years and more than half (61%) were men. The mean cost of dressing and other materials for patients in the polyurethane foam dressing group was $32 per week, compared with $58 per week for those in the saline-soaked gauze group. "This implies that a switch from gauze to polyurethane foam would make it possible to treat 80% more patients with the same materials budget," the researchers estimated.

Overall mean treatment cost per week was also lower for patients in the foam-dressing group, $91, compared with a mean of $209 for the saline-soaked gauze group. The savings of $118 per patient "is consistent with a saving in the cost on nursing time of $92 per week," Dr. Payne reported at the meeting, which was held in conjunction with a symposium on advanced wound care.

"This represents more than 3 hours of nursing time per patient per week (assuming a median wage of $28 per hour for a registered nurse)," he wrote.

Dressings were changed a mean of five times per week in the foam-dressing group, compared with a mean of 13 times per week in the saline-soaked gauze group. At the end of 4 weeks, 50% of the wounds in the foam-dressing group were closed, compared with 38% of those in the saline-soaked gauze group, but there was no evidence of a difference between the two groups in time to wound closure.

Total per patient costs over the 4-week evaluation period ranged from $265 to $315 in the foam-dressing group and from $691 to $781 in the saline-soaked gauze group. The number of days free of ulcer was 9 vs. 7, respectively.

Smith & Nephew funded the study. Dr. Payne said that he has no financial interest in the company.

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CORONADO, CALIF. — Two novel technologies are helping to control external bleeding when conventional methods such as direct pressure and gauze dressings fail.

These include products that contain chitosan or zeolite, Dr. Brant A. Putnam said at a meeting sponsored by the American College of Emergency Physicians.

Chitosan is a biodegradable, nontoxic carbohydrate derived from chitin, a naturally occurring substance. "It has a muco-adhesive property that binds everything together," said Dr. Putnam, chief of trauma and surgical care at Harbor-UCLA Medical Center in Torrance, Calif. "It probably activates platelets, and it may vasoconstrict locally. Then there are interactions with the red blood cell surface that we don't quite understand, so I'm sure there will be more research to follow."

Several animal studies have demonstrated its effectiveness as a hemostatic agent. In a human study published online Nov. 19, 2007, in the Journal of Emergency Medicine, paramedics used a hemostatic dressing made of chitosan (HemCon Bandage) in 34 wounds they couldn't control with direct pressure (doi:10.1016/j.jemermed.2007.05.043

The bandage, which was approved by the Food and Drug Administration in 2003 and requires users to cut it to the proper shape prior to application, controlled bleeding in 25 of the cases (74%) within 3 minutes. User error was a factor in six of the seven failures.

"You have to make sure that you put the right side down on the wound in order for the hemostasis to occur," Dr. Putnam explained.

The other technology proving effective for external hemostasis includes products that contain zeolite, a derivative of volcanic rock. When applied to gauze and placed on wounds, zeolite works as a molecular sieve and captures all the water locally, creating an exothermic reaction, said Dr. Putnam, who is also associate director of the Harbor-UCLA Medical Center general surgery residency program.

"We think that it dehydrates the wound of all the water properties, leaving a high concentration of all the clot-promoting components: the coagulation factors, the proteins, the cells," he explained.

The zeolite-based product QuikClot (Z-Medica Corp.), developed in 2002, is currently approved for external use only. But Dr. Putnam and his associates have used it on rare occasions to help pack life-threatening bleeding from internal wounds such as those caused by high-velocity gunfire. "I don't recommend that—I'm just saying that when we were faced with the life or death choice, we used it as part of packing internally, and the patients did very well," he said.

A recent survey of QuikClot's use in 69 cases by the U.S. military in Iraq, in 20 cases by civilian trauma surgeons, and in 14 cases by civilian first responders demonstrated an overall efficacy of 92% (J. Trauma 2008;64:1093–9). The researchers speculated that the QuikClot failures were due to the coagulopathic state of a patient from massive resuscitation or the inability to get the product directly to the source of bleeding.

Dr. Putnam said that he had no relevant disclosures to make.

CORONADO, CALIF. — Two novel technologies are helping to control external bleeding when conventional methods such as direct pressure and gauze dressings fail.

These include products that contain chitosan or zeolite, Dr. Brant A. Putnam said at a meeting sponsored by the American College of Emergency Physicians.

Chitosan is a biodegradable, nontoxic carbohydrate derived from chitin, a naturally occurring substance. "It has a muco-adhesive property that binds everything together," said Dr. Putnam, chief of trauma and surgical care at Harbor-UCLA Medical Center in Torrance, Calif. "It probably activates platelets, and it may vasoconstrict locally. Then there are interactions with the red blood cell surface that we don't quite understand, so I'm sure there will be more research to follow."

Several animal studies have demonstrated its effectiveness as a hemostatic agent. In a human study published online Nov. 19, 2007, in the Journal of Emergency Medicine, paramedics used a hemostatic dressing made of chitosan (HemCon Bandage) in 34 wounds they couldn't control with direct pressure (doi:10.1016/j.jemermed.2007.05.043

The bandage, which was approved by the Food and Drug Administration in 2003 and requires users to cut it to the proper shape prior to application, controlled bleeding in 25 of the cases (74%) within 3 minutes. User error was a factor in six of the seven failures.

"You have to make sure that you put the right side down on the wound in order for the hemostasis to occur," Dr. Putnam explained.

The other technology proving effective for external hemostasis includes products that contain zeolite, a derivative of volcanic rock. When applied to gauze and placed on wounds, zeolite works as a molecular sieve and captures all the water locally, creating an exothermic reaction, said Dr. Putnam, who is also associate director of the Harbor-UCLA Medical Center general surgery residency program.

"We think that it dehydrates the wound of all the water properties, leaving a high concentration of all the clot-promoting components: the coagulation factors, the proteins, the cells," he explained.

The zeolite-based product QuikClot (Z-Medica Corp.), developed in 2002, is currently approved for external use only. But Dr. Putnam and his associates have used it on rare occasions to help pack life-threatening bleeding from internal wounds such as those caused by high-velocity gunfire. "I don't recommend that—I'm just saying that when we were faced with the life or death choice, we used it as part of packing internally, and the patients did very well," he said.

A recent survey of QuikClot's use in 69 cases by the U.S. military in Iraq, in 20 cases by civilian trauma surgeons, and in 14 cases by civilian first responders demonstrated an overall efficacy of 92% (J. Trauma 2008;64:1093–9). The researchers speculated that the QuikClot failures were due to the coagulopathic state of a patient from massive resuscitation or the inability to get the product directly to the source of bleeding.

Dr. Putnam said that he had no relevant disclosures to make.

CORONADO, CALIF. — Two novel technologies are helping to control external bleeding when conventional methods such as direct pressure and gauze dressings fail.

These include products that contain chitosan or zeolite, Dr. Brant A. Putnam said at a meeting sponsored by the American College of Emergency Physicians.

Chitosan is a biodegradable, nontoxic carbohydrate derived from chitin, a naturally occurring substance. "It has a muco-adhesive property that binds everything together," said Dr. Putnam, chief of trauma and surgical care at Harbor-UCLA Medical Center in Torrance, Calif. "It probably activates platelets, and it may vasoconstrict locally. Then there are interactions with the red blood cell surface that we don't quite understand, so I'm sure there will be more research to follow."

Several animal studies have demonstrated its effectiveness as a hemostatic agent. In a human study published online Nov. 19, 2007, in the Journal of Emergency Medicine, paramedics used a hemostatic dressing made of chitosan (HemCon Bandage) in 34 wounds they couldn't control with direct pressure (doi:10.1016/j.jemermed.2007.05.043

The bandage, which was approved by the Food and Drug Administration in 2003 and requires users to cut it to the proper shape prior to application, controlled bleeding in 25 of the cases (74%) within 3 minutes. User error was a factor in six of the seven failures.

"You have to make sure that you put the right side down on the wound in order for the hemostasis to occur," Dr. Putnam explained.

The other technology proving effective for external hemostasis includes products that contain zeolite, a derivative of volcanic rock. When applied to gauze and placed on wounds, zeolite works as a molecular sieve and captures all the water locally, creating an exothermic reaction, said Dr. Putnam, who is also associate director of the Harbor-UCLA Medical Center general surgery residency program.

"We think that it dehydrates the wound of all the water properties, leaving a high concentration of all the clot-promoting components: the coagulation factors, the proteins, the cells," he explained.

The zeolite-based product QuikClot (Z-Medica Corp.), developed in 2002, is currently approved for external use only. But Dr. Putnam and his associates have used it on rare occasions to help pack life-threatening bleeding from internal wounds such as those caused by high-velocity gunfire. "I don't recommend that—I'm just saying that when we were faced with the life or death choice, we used it as part of packing internally, and the patients did very well," he said.

A recent survey of QuikClot's use in 69 cases by the U.S. military in Iraq, in 20 cases by civilian trauma surgeons, and in 14 cases by civilian first responders demonstrated an overall efficacy of 92% (J. Trauma 2008;64:1093–9). The researchers speculated that the QuikClot failures were due to the coagulopathic state of a patient from massive resuscitation or the inability to get the product directly to the source of bleeding.

Dr. Putnam said that he had no relevant disclosures to make.

SAN DIEGO — Use of Biobrane wound dressing in pediatric burn patients resulted in a short hospital stay and follow-up as an outpatient with few complications, results from a single-center study demonstrated.

Researchers reviewed the medical charts of 116 pediatric burn patients aged 0–18 years who received Biobrane wound dressing at the University Hospital trauma center in San Antonio, Tex., between 2002 and 2007.

Biobrane (Bertek Pharmaceuticals) is a synthetic nylon mesh that is bonded to silicone and coated with collagen peptides. It functions as an analogue to the dermis and its pores allow exudate to be drained. It has been shown to be a reasonable option in children, Dr. Cristiane M. Ueno said at the annual meeting of the Wound Healing Society.

The dressing "usually can be trimmed away after 1 week as the wound heals, decreasing the healing time when compared with some other dressings," Dr. Ueno of the University of Texas Health Science Center at San Antonio, said.

The average age of patients was 5 years, males outnumbered females 2:1, and more than two-thirds (68%) were Hispanic. Fifty-two percent of cases were scald injuries and 70% of the patients had second-degree burns.

Of the 116 patients who received Biobrane dressing, 58 had sustained burns to the upper extremity. More than two-thirds were admitted to the hospital for only 1–2 days for dressing care and instruction on care of the injury. Only seven complications occurred from the use of Biobrane, including one case of bacteremia, two cases of local infection, two cases of cellulitis, and two cases of fever, Dr. Ueno said at the meeting, held in conjunction with a symposium on advanced wound care.

The majority of patients needed only oral pain medications or mild conscious sedation, not general anesthesia, while undergoing debridement and Biobrane application and subsequent dressing changes. This, combined with the low risk of complications, suggests that the dressing could lower costs and reduce hospital stays in the pediatric burn population, said Dr. Ueno, who had no conflicts to disclose.

The child's burn is first cleaned with chlorhexidine and then bullae and nonviable tissue are removed (left). A Biobrane glove is then placed over the hand (right). Photos courtesy Dr. Cristiane M. Ueno

SAN DIEGO — Use of Biobrane wound dressing in pediatric burn patients resulted in a short hospital stay and follow-up as an outpatient with few complications, results from a single-center study demonstrated.

Researchers reviewed the medical charts of 116 pediatric burn patients aged 0–18 years who received Biobrane wound dressing at the University Hospital trauma center in San Antonio, Tex., between 2002 and 2007.

Biobrane (Bertek Pharmaceuticals) is a synthetic nylon mesh that is bonded to silicone and coated with collagen peptides. It functions as an analogue to the dermis and its pores allow exudate to be drained. It has been shown to be a reasonable option in children, Dr. Cristiane M. Ueno said at the annual meeting of the Wound Healing Society.

The dressing "usually can be trimmed away after 1 week as the wound heals, decreasing the healing time when compared with some other dressings," Dr. Ueno of the University of Texas Health Science Center at San Antonio, said.

The average age of patients was 5 years, males outnumbered females 2:1, and more than two-thirds (68%) were Hispanic. Fifty-two percent of cases were scald injuries and 70% of the patients had second-degree burns.

Of the 116 patients who received Biobrane dressing, 58 had sustained burns to the upper extremity. More than two-thirds were admitted to the hospital for only 1–2 days for dressing care and instruction on care of the injury. Only seven complications occurred from the use of Biobrane, including one case of bacteremia, two cases of local infection, two cases of cellulitis, and two cases of fever, Dr. Ueno said at the meeting, held in conjunction with a symposium on advanced wound care.

The majority of patients needed only oral pain medications or mild conscious sedation, not general anesthesia, while undergoing debridement and Biobrane application and subsequent dressing changes. This, combined with the low risk of complications, suggests that the dressing could lower costs and reduce hospital stays in the pediatric burn population, said Dr. Ueno, who had no conflicts to disclose.

The child's burn is first cleaned with chlorhexidine and then bullae and nonviable tissue are removed (left). A Biobrane glove is then placed over the hand (right). Photos courtesy Dr. Cristiane M. Ueno

SAN DIEGO — Use of Biobrane wound dressing in pediatric burn patients resulted in a short hospital stay and follow-up as an outpatient with few complications, results from a single-center study demonstrated.

Researchers reviewed the medical charts of 116 pediatric burn patients aged 0–18 years who received Biobrane wound dressing at the University Hospital trauma center in San Antonio, Tex., between 2002 and 2007.

Biobrane (Bertek Pharmaceuticals) is a synthetic nylon mesh that is bonded to silicone and coated with collagen peptides. It functions as an analogue to the dermis and its pores allow exudate to be drained. It has been shown to be a reasonable option in children, Dr. Cristiane M. Ueno said at the annual meeting of the Wound Healing Society.

The dressing "usually can be trimmed away after 1 week as the wound heals, decreasing the healing time when compared with some other dressings," Dr. Ueno of the University of Texas Health Science Center at San Antonio, said.

The average age of patients was 5 years, males outnumbered females 2:1, and more than two-thirds (68%) were Hispanic. Fifty-two percent of cases were scald injuries and 70% of the patients had second-degree burns.

Of the 116 patients who received Biobrane dressing, 58 had sustained burns to the upper extremity. More than two-thirds were admitted to the hospital for only 1–2 days for dressing care and instruction on care of the injury. Only seven complications occurred from the use of Biobrane, including one case of bacteremia, two cases of local infection, two cases of cellulitis, and two cases of fever, Dr. Ueno said at the meeting, held in conjunction with a symposium on advanced wound care.

The majority of patients needed only oral pain medications or mild conscious sedation, not general anesthesia, while undergoing debridement and Biobrane application and subsequent dressing changes. This, combined with the low risk of complications, suggests that the dressing could lower costs and reduce hospital stays in the pediatric burn population, said Dr. Ueno, who had no conflicts to disclose.

The child's burn is first cleaned with chlorhexidine and then bullae and nonviable tissue are removed (left). A Biobrane glove is then placed over the hand (right). Photos courtesy Dr. Cristiane M. Ueno