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Examining Obesity and Its Association With Burn Injury: A Secondary Analysis of the Transfusion Requirement in Burn Care Evaluation Study
Kelly, E. J., Reese, A. D., Carney, B. C., Keyloun, J. W., Palmieri, T. L., Moffatt, L. T., Shupp, J. W., Tejiram, S.
The Journal of surgical research. 2023;290:221-231
Abstract
INTRODUCTION Literature examining the connection between obesity and burn injuries is limited. This study is a secondary analysis of a multicenter trial data set to investigate the association between burn outcomes and obesity following severe burn injury. MATERIALS AND METHODS Body mass index (BMI) was used to stratify patients as normal weight (NW; BMI 18.5-25), all obese (AO; any BMI>30), obese I (OI; BMI 30-34.9), obese II (OII; BMI 35-39.9), or obese III (OIII; BMI>40). The primary outcome examined was mortality. Secondary outcomes included hospital length of stay (LOS), number of transfusions, injury scores, infection occurrences, number of operations, ventilator days, intensive care unit LOS, and days to wound healing. RESULTS Of 335 patients included for study, 130 were obese. Median total body surface area (TBSA) was 31%, 77 patients (23%) had inhalation injury and 41 patients died. Inhalation injury was higher in OIII than NW (42.1% versus 20%, P = 0.03). Blood stream infections (BSI) were higher in OI versus NW (0.72 versus 0.33, P = 0.03). Total operations, ventilator days, days to wound healing, multiorgan dysfunction score, Acute Physiology and Chronic Health Evaluationscore, hospital LOS, and intensive care unit LOS were not significantly affected by BMI classification. Mortality was not significantly different between obesity groups. Kaplan-Meier survival curves did not significantly differ between the groups (χ(2) = 0.025, P = 0.87). Multiple logistic regression identified age, TBSA, and full thickness burn as significant independent predictors (P < 0.05) of mortality; however, BMI classification itself was not predictive of mortality. CONCLUSIONS No significant association between obesity and mortality was seen after burn injury. Age, TBSA, and percent full- thickness burn were independent predictors of mortality after burn injury, while BMI classification was not.
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An innovated elastic compression hemostasis technique for extremity excision in patients with extensive burns: A prospective clinical randomized controlled trial
Shen C, Liu X, Zhang B, Cai J, Sun T, Li D, Deng H, Yuan H
Surgery. 2023
Abstract
OBJECTIVE To introduce an innovative elastic compression hemostasis technique for extremity excision in extensively burnt patients and investigate its effectiveness. METHODS Ten patients were included and divided into 2 groups: the control group (4 patients, 12 extremities) receiving the conventional hemostasis technique and the experimental group (6 patients, 14 extremities) receiving the innovative technique. General data of the patients were collected, excision size measured, hemostasis time recorded, average blood loss per 1% total body surface area of the excised wound calculated, incidence of subcutaneous hematoma and take rate determined. RESULTS The 2 groups had no statistical difference in the baseline data. Average blood loss per 1% total body surface area of the excised wound in the upper and the lower extremities was (62.1 ± 11.5) mL and (35.6 ± 11.0) mL in the experimental group, significantly less than (94.3 ± 6.9) mL and (82.3 ± 6.2) mL in the control group; a reduction of 34.1% and 56.8% respectively. Hemostasis time in the upper and the lower extremities were (5.0 ± 0.7) min/1% total body surface area and (2.6 ± 0.3) min/1% total body surface area, respectively, in the experimental group, significantly less than (7.4 ± 0.6) min/1% total body surface area and (4.0 ± 0.9) min/1% total body surface area in the control group; a reduction of 31.8% and 34.9% respectively. The incidences of subcutaneous hematoma were 7.1% and 8.3%, and the take rate (85.9 ± 6.0)% and (86.5 ± 4.8)% in the experimental and the control group, respectively, with no statistically significant differences. CONCLUSION The innovative elastic compression hemostasis technique is a reliable new method that significantly reduces blood loss during extremity excision in patients with extensive burns and is worth wider understanding and application.
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Effect of single dose intravenous tranexamic acid on blood loss in tangential excision of burn wounds - A double blind randomised controlled trial
K, S. A., Kumar, P., Subair, M., Sharma, R. K.
Burns : Journal of the International Society for Burn Injuries. 2022;48(6):1311-1318
Abstract
INTRODUCTION This study was carried out to evaluate role of intravenous tranexamic acid (TXA) in reducing blood loss during tangential excision of burns. METHODS This was a single center, prospective double-blinded parallel arm superiority randomized placebo-controlled trial. Patients (15-55 years) with deep dermal thermal burns <30% undergoing tangential excision were randomly assigned (1:1) to TXA and placebo groups. Patients in TXA and placebo groups received injection TXA 15 mg/kg and 10 ml saline respectively, 10 min preoperatively. Primary outcome was volume of blood loss per square centimeter area of burn excised. Secondary outcomes were total volume of blood loss, postoperative hemoglobin, intraoperative fluid requirement, blood transfusion, graft take and length of hospitalization (LOH). RESULTS Thirty patients were included. Both groups were comparable in terms of Body Mass Index (BMI) preoperative hemoglobin, area of burn excised, duration of surgery and the intraoperative temperature. The average blood loss per square centimeter burn area excised was found to be significantly lower in TXA when compared to placebo group (mean difference: 0.28 ± 0.025 ml/cm(2); p = 0.000). The total volume of blood loss was lower in TXA group (258.7 ± 124.10 ml vs 388.1 ± 173.9 ml; p = 0.07). None of the patients required transfusion. The requirement of intra-operative fluids was similar between the two groups (crystalloids: p = 0.236; colloids: p = 0.238). Postoperative hemoglobin, length of hospitalization and graft-take were comparable between the two groups. CONCLUSION TXA reduced blood loss per unit burn area of tangential excision in <30%TBSA burn, however, we found no significant effect on postoperative Hb and transfusion.
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Evaluation of the Effect of Platelet-Rich Fibrin on Wound Healing at Split-Thickness Skin Graft Donor Sites: A Randomized, Placebo-Controlled, Triple-Blind Study
Vaheb M, Karrabi M, Khajeh M, Asadi A, Shahrestanaki E, Sahebkar M
The international journal of lower extremity wounds. 2020;:1534734619900432
Abstract
Split-thickness skin grafting (STSG) is widely used to heal wounds resulting from trauma, burns, and chronic wounds. This study aimed to determine the true effect of platelet-rich fibrin (PRF) on patients with burn wounds requiring STSG during treatment of donor wounds. This randomized, triple-blind clinical trial was conducted on patients who referred to the burn ward of Vasei Hospital of Sabzevar, Iran, from May 2017 to May 2018. The donor site was randomly divided into 2 groups: PRF and control (Vaseline petrolatum gauze) using Vaseline gauze. In the intervention group, the PRF gel was applied to the wound and covered with Vaseline gauze and wet dressing. Conversely, only Vaseline gauze and wet dressing were applied to the control group. Outcome evaluation was conducted using paired t test and Wilcoxon signed rank-sum test, as appropriate, on days 8 and 15. The mean age of the patients was 33.10 +/- 2.60 years, and 51.50% were male. The mean wound healing time in the PRF and control groups was 11.80 +/- 3.51 and 16.30 +/- 4.32 days, respectively (P < .001). The PRF group showed significantly higher wound healing rates than the control group at 8 and 15 days dressing (P < .001 and P < .001, respectively). Moreover, the mean wound healing for all wound healing indices diagnosed by 2 specialists in PRF was higher than control group on days 8 and 15 (P < .001). We found a statistically significant difference on days 8 and 15 regarding the mean pain levels between the 2 groups (P < .001). The findings showed that PRF can significantly increase the time and rate of donor wound healing compared with conventional treatment and also reduce the severity of pain.
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The best strategy for red blood cell transfusion in severe burn patients, restrictive or liberal: A randomized controlled trial
Salehi SH, Daniali M, Motaghi P, Momeni M
Burns : journal of the International Society for Burn Injuries. 2020
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Abstract
INTRODUCTION Although blood transfusion is common in burns, data are lacking in appropriate transfusion thresholds. It has been reported that a restrictive blood transfusion policy decreases blood utilization and improves outcomes in critically ill adults, but the impact of a restrictive blood transfusion policy in burn patients is unclear. We decided to investigate the outcome of decreasing the blood transfusion threshold. MATERIAL AND METHODS Eighty patients with TBSA > 20% who met our inclusion criteria were included. They were randomly divided into control and intervention groups. The intervention group received packed cells only when Hemoglobin declined to less than 8 g/dL at routine laboratory evaluations. While the control group received packed-cell when hemoglobin was declined to less than 10 g/dl. The total number of the received packed cell before, during and after any surgical procedure was recorded. The outcome was measured by the evaluation of the infection rate and other complications. RESULT The mean hemoglobin level before transfusion was 7.7 ± 0.4 g/dL in the restrictive group and 8.8 ± 0.7 g/dL in the liberal group. The mean number of RBC unit transfusion per patient in the restrictive group was significantly lower than the traditional group (3.28 ± 2.2 units vs. 5.9 ± 3.7 units) (p-value = 0.006). The total number of RBC transfused units varied significantly between the two groups (p-value = 0.014). The number of transfused RBC units outside the operation room showed a significant difference between groups (restrictive: 2.8 ± 1.4 units vs. liberal: 4.4 ± 2.6 units) (p = 0.004). We did not find any significant difference in mortality rate or other outcome measures between groups. CONCLUSION Applying the restrictive transfusion strategy in thermal burn patients who are highly prone to all kinds of infection, does not adversely impact the patient outcome, and results in significant cost savings to the institution and lower rate of infection. We conclude that the restrictive transfusion practice during burn excision and grafting is well tolerated and effective in reducing the number of transfusions without increasing complications. CLINICAL TRIAL REGISTRATION REFERENCE IRCT20190209042660N1.
PICO Summary
Population
Adult thermal burn patients (n= 80).
Intervention
Restrictive transfusion threshold: haemoglobin less than 8 g/dL (n= 40).
Comparison
Liberal transfusion threshold: haemoglobin less than 10 g/dL (n= 40).
Outcome
The mean haemoglobin level before transfusion was 7.7 ± 0.4 g/dL in the restrictive group and 8.8 ± 0.7 g/dL in the liberal group. The mean number of RBC unit transfusion per patient in the restrictive group was significantly lower than the traditional group (3.28 ± 2.2 units vs. 5.9 ± 3.7 units). The total number of RBC transfused units varied significantly between the two groups. The number of transfused RBC units outside the operation room showed a significant difference between groups (restrictive: 2.8 ± 1.4 units vs. liberal: 4.4 ± 2.6 units). No significant difference in mortality rate or other outcome measures between groups was found.
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Autologous Platelet Rich Plasma As A Preparative for Resurfacing Burn Wounds with Split Thickness Skin Grafts
Gupta S, Goil P, Thakurani S
World J Plast Surg. 2020;9(1):29-32
Abstract
BACKGROUND Split thickness skin graft is a widely accepted technique to cover large defects. Shearing, hematoma and infection have often been attributed as major causes for graft loss. Autologous platelet rich plasma (PRP) has been used in various treatment modalities in the field of plastic surgery for its healing, adhesive and hemostatic properties owing to the growth factors that are released. This Study primarily throws light on the usage of PRP over difficult Burn wound beds to augment graft uptake and attenuate complications. METHODS The patients were divided into two groups of those who were subjected to use of autologous PRP as a preparative burn surfacing and the control group who underwent standard method of treatment. RESULTS Patients in PRP group significantly showed a higher graft adherence rate as compared to those with other method. It also reduced pain, and hematoma formation. CONCLUSION Application of PRP is a safe, cost effective, easy method to increase graft adherence rate in patients with burns where graft loss is noticed and there is shortage of donor sites.
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Examining 1:1 Versus 4:1 Packed Red Blood Cell to Fresh Frozen Plasma Ratio Transfusion During Pediatric Burn Excision
Tejiram S, Sen S, Romanowski KS, Greenhalgh DG, Palmieri TL
Journal of burn care & research : official publication of the American Burn Association. 2020
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Abstract
Blood transfusions following major burn injury are common due to operative losses, blood sampling, and burn physiology. While massive transfusion improves outcomes in adult trauma patients, literature examining its effect in critically ill children is limited. The study purpose was to prospectively compare outcomes of major pediatric burns receiving a 1:1 vs 4:1 packed red blood cell (PRBC) to fresh frozen plasma (FFP) transfusion strategy during massive burn excision. Children with >20% total body surface area (TBSA) burns were randomized to a 1:1 or 4:1 PRBC/FFP transfusion ratio during burn excision. Parameters examined include patient demographics, burn size, Pediatric Risk of Mortality (PRISM) scores, Pediatric Logistic Organ Dysfunction (PELOD) scores, laboratory values, total blood products transfused, and the presence of blood stream infections or pneumonia. A total of 68 children who met inclusion criteria were randomized into two groups (n=34). Mean age, PRISM scores, estimated blood loss (600 mL (400 - 1175 mL) v 600 mL (300 - 1150 mL), p = 0.68), ventilator days (5 v 9, p = 0.47), and length of stay (57 v 60 days, p = 0.24) had no difference. No differences in frequency of blood stream infection (20 v 18, p = 0.46) or pneumonia events (68 v 116, p = 0.08) were noted. On multivariate analysis, only TBSA burn size, inhalation injury, and PRISM scores (p < 0.05) were significantly associated with infections.
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Restrictive Transfusion Strategy Is More Effective in Massive Burns: Results of the TRIBE Multicenter Prospective Randomized Trial
Palmieri TL, Holmes JH, Arnoldo B, Peck M, Cochran A, King BT, Dominic W, Cartotto R, Bhavsar D, Tredget E, et al
Military Medicine. 2018
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Objectives: Studies suggest that a restrictive transfusion strategy is safe in burns, yet the efficacy of a restrictive transfusion policy in massive burn injury is uncertain. Our objective: compare outcomes between massive burn (≥60% total body surface area (TBSA) burn) and major (20-59% TBSA) burn using a restrictive or a liberal blood transfusion strategy. Methods: Patients with burns ≥20% were block randomized by age and TBSA to a restrictive (transfuse hemoglobin <7 g/dL) or liberal (transfuse hemoglobin <10 g/dL) strategy throughout hospitalization. Data collected included demographics, infections, transfusions, and outcomes. Results: Three hundred and forty-five patients received 7,054 units blood, 2,886 in massive and 4,168 in restrictive. Patients were similar in age, TBSA, and inhalation injury. The restrictive group received less blood (45.57 +/- 47.63 vs. 77.16 +/- 55.0, p < 0.03 massive; 11.0 +/- 16.70 vs. 16.78 +/- 17.39, p < 0.001) major). In massive burn, the restrictive group had fewer ventilator days (p < 0.05). Median ICU days and LOS were lower in the restrictive group; wound healing, mortality, and infection did not differ. No significant outcome differences occurred in the major (20-59%) group (p > 0.05). Conclusions: A restrictive transfusion strategy may be beneficial in massive burns in reducing ventilator days, ICU days and blood utilization, but does not decrease infection, mortality, hospital LOS or wound healing.
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Efficacy of lyophilised platelet-rich plasma powder on healing rate in patients with deep second degree burn injury: a prospective double-blind randomized clinical trial
Yeung C Y, Hsieh P S, Wei L G, Hsia L C, Dai L G, Fu K Y, Dai N T
Annals of Plastic Surgery. 2018;80((2S, Suppl 1):):S66-S69.
Abstract
Platelet-rich plasma (PRP) is a kind of plasma that is rich in platelets after processing. It includes various growth factors and cytokines, which speed up the process of wound healing and hemostasis. The PRP solution used in this study is diluted from lyophilized PRP powder, which decreased the possibility of contamination, facilitated the storage, and prolonged the storage life. From in vitro fibroblast proliferation testing, the numbers of PRP supplement were performed for 1, 4, and 7 times by continuous replacement of culture medium each day. Four times of lyophilized PRP supplement was selected for clinical study due to sufficient promotion of fibroblast proliferation. Next, 27 patients of deep second-degree burn wound were included in this study. Patients were assigned to two groups: PRP group (n = 15) and control group (n = 12). A concentration of 1.0 x 10 platelets/cm (wound area) according to wound size was sprayed on the wound evenly. Function was mainly assessed by the percentage of wound closure and bacteria picking out rate in 2 and 3 weeks. The wound closure at 3 weeks showed a significant difference in PRP group (P < 0.05). The healing rate of PRP group reached nearly 80% and made a breakthrough of 90% in 3 weeks, showing a significant difference compared with the control group (P < 0.05). Lyophilized PRP can be considered as an effective treatment to increase healing rate in patients with deep second-degree burn injury.
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The Effects of Storage Age of Blood in Massively Transfused Burn Patients: A Secondary Analysis of the Randomized Transfusion Requirement in Burn Care Evaluation Study
Cartotto R, Taylor SL, Holmes JH 4th, Peck M, Cochran A, King BT, Bhavsar D, Tredget EE, Mozingo D, Greenhalgh D, et al
Critical Care Medicine. 2018;46((12):):e1097-e1104.
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OBJECTIVES Major trials examining storage age of blood transfused to critically ill patients administered relatively few blood transfusions. We sought to determine if the storage age of blood affects outcomes when very large amounts of blood are transfused. DESIGN A secondary analysis of the multicenter randomized Transfusion Requirement in Burn Care Evaluation study which compared restrictive and liberal transfusion strategies. SETTING Eighteen tertiary-care burn centers. PATIENTS Transfusion Requirement in Burn Care Evaluation evaluated 345 adults with burns greater than or equal to 20% of the body surface area. We included only the 303 patients that received blood transfusions. INTERVENTIONS The storage ages of all transfused red cell units were collected during Transfusion Requirement in Burn Care Evaluation. A priori measures of storage age were the the mean storage age of all transfused blood and the proportion of all transfused blood considered very old (stored ≥ 35 d). MEASUREMENTS AND MAIN RESULTS The primary outcome was the severity of multiple organ dysfunction. Secondary outcomes included time to wound healing, the duration of mechanical ventilation, and in-hospital mortality. There were 6,786 red cell transfusions with a mean (+/- SD) storage age of 25.6 +/- 10.2 days. Participants received a mean of 23.4 +/- 31.2 blood transfusions (range, 1-219) and a mean of 5.3 +/- 10.7 units of very old blood. Neither mean storage age nor proportion of very old blood had any influence on multiple organ dysfunction severity, time to wound healing, or mortality. Duration of ventilation was significantly predicted by both mean blood storage age and the proportion of very old blood, but this was of questionable clinical relevance given extreme variability in duration of ventilation (adjusted r ≤ 0.01). CONCLUSIONS Despite massive blood transfusion, including very old blood, the duration of red cell storage did not influence outcome in burn patients. Provision of the oldest blood first by Blood Banks is rational, even for massive transfusion.