January 2023 - Burn Trauma
January 2023
EAST Monthly Literature Review
"Keeping You Up-to-Date with Current Literature"
Brought to you by the EAST Manuscript and Literature Review Committee
This issue was prepared by EAST Burn Surgery Committee Member Shawn Tejiram, MD.
Thank you to Haemonetics for supporting the EAST Monthly Literature Review.
In This Issue: Burn Trauma
Scroll down to see summaries of these articles
Article 1 reviewed by Shawn Tejiram, MD
Efficacy of a Novel LAM Femoral Cutaneous Block Technique for Acute Donor Site Pain. Hill DM, Ly A, Desai JP, Atmeh KR, Velamuri SR, Jones J. J Burn Care Res. 2023 Jan 5;44(1):16-21.
Article 2 reviewed by Shawn Tejiram, MD
Admission Frailty Score Are Associated With Increased Risk of Acute Respiratory Failure and Mortality in Burn Patients 50 and Older. Galet C, Lawrence K, Lilienthal D, Hubbard J, Romanowski KS, Skeete DA, Mashruwala N. J Burn Care Res. 2023 Jan 5;44(1):129-135.
Article 1
Efficacy of a Novel LAM Femoral Cutaneous Block Technique for Acute Donor Site Pain. Hill DM, Ly A, Desai JP, Atmeh KR, Velamuri SR, Jones J. J Burn Care Res. 2023 Jan 5;44(1):16-21.
Donor sites produce intense pain that can be more painful than the burn injury itself. This can increase opioid consumption and related adverse events. Opioid agonists are the most common medication utilized for analgesia in patients with burn injuries and carry many risks. Multimodal analgesia is also not a perfect solution due metabolic alterations, drug interactions, or side effects. Regional anesthesia for donor sites have been suggested as a novel solution, but literature demonstrating this technique is limited. This study sought to evaluate whether a novel continuous LAM (lateral, anterior, medial) block for acute donor site pain of the thigh could provide adequate pain control, reduce opioid usage, and avoid rehabilitation delays.
The authors performed an observational case series nearly three years in length of patients admitted to a single verified burn center who underwent continuous LAM block for donor site pain by the acute pain service (APS) team. The ultrasound-guided LAM block procedure administered bupivacaine targeting the lateral femoral cutaneous nerve and the intermediate and medial cutaneous branches of the femoral nerve. A catheter was inserted through the needle allowing continuous or intermittent additional bupivacaine. A member of the APS team assessed the patient daily and adjusted the regimen accordingly. Additional standard analgesia factoring in as needed pain management, comorbidities, frailty, and wound care were available for patients. A total of 47 patients were treated with 53 LAM blocks. The median percent TBSA burned was 5.3% (2.0%, 11.0%). Three-quarters of patients had a history of substance use with 17% being opioids, and a little over a quarter had a polysubstance use history. Donor site location was balanced between the left and right thigh. Median time from admission to the LAM block procedure was 7 days (2.5, 11.5 days). Most blocks were performed intraoperatively. Bupivacaine (0.25–0.5 %) was utilized for each LAM block bolus with a median dose of 20 ml (15, 20 ml) at insertion and 8 ml/hour (6, 10 ml/hour) of 0.125% given continuously or intermittently bolused (60, 120, or 180 minute intervals). The median quadriceps strength for the patient population was assessed as a 5 out of 5 (3.5, 5) on Day 1 post-block, and 5 out of 5 (5, 5) when all daily during infusion strength assessments were considered. The median number of days after LAM block to ambulation, or post-block ambulation, was 2 days (1, 3 days). Opioid usage was significantly reduced and sustained (p < .001) after LAM block placement. Despite reduced opioid utilization, pain was adequately controlled. No significant adverse events were specifically related to the LAM block, including local anesthetic systemic toxicity (LAST), donor/LAM site or catheter infection, nausea or vomiting, itch, falls, or neurologic complications.
Local anesthesia allows for single needle insertion, reduced local anesthetic dose requirement, full range of motion and strength, expanded area of coverage, and can be used safely for prolonged periods. Patients are able to participate fully in their rehabilitation, which can impact functional outcomes and LOS. The block can be performed preoperatively and “mapped,” allowing a surgeon to harvest within the anesthetized area. The novel LAM block adequately alleviated donor site pain, was safely performed, and continued for prolonged periods when necessary. Motor strength remained intact, allowing unencumbered therapy participation and reducing fall risks. This novel technique could be considered in donor site pain control.
Article 2
Admission Frailty Score Are Associated With Increased Risk of Acute Respiratory Failure and Mortality in Burn Patients 50 and Older. Galet C, Lawrence K, Lilienthal D, Hubbard J, Romanowski KS, Skeete DA, Mashruwala N. J Burn Care Res. 2023 Jan 5;44(1):129-135.
The number of older burn patients susceptible to severe burn injury are increasing. Studies have shown that older patients have worse outcomes following burn injury. In recent years, tools like the Canadian Study of Health and Aging clinical frailty scale (CSHA-CFS) have been investigated to predict outcomes of older burn patients. High pre-injury frailty scores in older burn patients have been shown to predict mortality and discharge to skilled nursing facilities (SNF). However, its ability to predict burn-related complications has not been explored. This study sought to evaluate the ability of the CSHA-CFS to predict burn-related outcomes such as graft loss, wound infection, acute respiratory failure, and acute kidney injury in burn patients 50 years and older.
The authors retrospectively queried their institution’s burn registry to identify patients 50 years and older admitted for cutaneous burn injury only from July 2009 to June 2019. Their institution does not perform a frailty assessment at admission, so pre-injury frailty scores were determined by independent scorers using the CSHA-CFS. Frailty was defined as a score of five or more. A total of 851 patients were included and 154 were identified as “Frail” and 697 as “Non-Frail” based on CSHA-CF scoring. Univariate analysis showed that frail patients were significantly older, and the majority sustained flame burn injuries. The average %TBSA, 2nd, and 3rd degree burn were significantly lower for the frail group. No significant difference was observed in term of ICU LOS, days on a ventilator, or presence of inhalation injury between the groups. Frail patients were less likely to have skin grafting during their stay. No significant difference was observed in the incidence of graft loss between non-frail and frail patients (46.8% vs. 31%; P = .100), the number of patients with graft loss ≥20% (22.2% vs. 23.1%; P = .939), or the number of days from graft placement to graft loss (24.3 ± 22.4 days vs. 16.4 ± 12.5 days, P = .068). There was no significant difference in developing wound infection complications or acute kidney injury. However, frail patients were more likely to develop acute respiratory failure. There was no significant difference in mortality rates between the groups. Palliative care transitions occurred for all frail mortalities (n = 10; 100%) and for 26 non-frail patients (86.9%) who died within 3 days after admission. A larger proportion of frail patients were discharged home with healthcare services or to SNF, rehabilitation and/or long-term acute care facilities. On multivariate analysis, no association was observed between frailty and hospital length of stay/TBSA (LOS/TBSA) or increased risk of skin graft loss.
Stepwise binary logistic regression analysis showed frailty was a stronger predictor of mortality than Baux scores and was significantly associated with acute respiratory failure. In multinomial logistic regression analysis, higher Baux scores, undergoing skin grafting, and developing acute respiratory failure were positively associated with discharge requiring higher level of care (discharge to SNF, rehabilitation and/or long-term acute care facilities). Adding frailty to this model did not affect these associations. Finally, Baux scores and developing acute respiratory failure were positively associated with discharge to hospice whereas undergoing skin grafting was inversely associated with discharge to hospice. Adding frailty to this model did not affect these associations either. Frailty was the strongest predictor of discharge to hospice.
No prospective studies to date have looked at outcomes and goals of care discussions or using frailty to predict morbidity and mortality for the burn patient. This study demonstrated a strong association between frailty on admission and acute respiratory failure, mortality, and discharge disposition requiring higher healthcare resources. Using frailty as a scoring system can allow the burn team to provide valuable insights into the care of the burn patient and set realistic expectations ahead of time with patients and their family.
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