Which of the following is true regarding nutritional needs ofburn patients?
The hypermetabolic response in burn injury may raise baseline metabolic rates by as much as 200%. This can lead to catabolism of muscle proteins and decreased lean body mass that may delay functional recovery. Early enteral feeding for patients with burns larger than 20% TBSA is safe, and may reduce loss of lean body mass, slow the hypermetabolic response, and result in more efficient protein metabolism. Calculating the appropriate caloric needs of the burn patient can be challenging. A commonly used formula in nonburned patients is the Harris-Benedict equation, which calculates caloric needs using factors such as gender, age, height, and weight. This formula uses an activity factor for specific injuries, and for burns, the basal energy expenditure is multiplied by two. The Harris-Benedict equation may be inaccurate in burns of less than 40% TBSA, and in these patients the Curreri formula may be more appropriate. This formula estimates caloric needs to be 25 kcal/kg/day plus 40 kcal/% TBSA/ day.
The anabolic steroid oxandrolone has been extensively studied in pediatric patients as well, and has demonstrated improvements in lean body mass and bone density in severely burned children. The weight gain and functional improvements seen with oxandrolone may persist even after stopping administration of the drug. A recent double-blinded, randomized study of oxandrolone showed decreased length of stay, improved hepatic protein synthesis, and no adverse effects on the endocrine function, though the authors noted a rise in transaminases with unclear clinical significance.
A 14-year-old girl sustains a steam burn measuring 6 by 7 inches over the ulnar aspect of her right forearm. Blisters develop over the entire area of the burn wound, and by the time the patient is seen 6 hours after the injury, some of the blisters have ruptured spontaneously. All of the following therapeutic regimens might be considered appropriate for this patient EXCEPT:
A number of different acceptable regimens exist for treating small, superficial second-degree burn injuries. In all cases, the necrotic epithelium is first debrided. Topical antibacterial agents then may be applied and the wounds treated open or closed with dressings changed daily or every other day. Biologic dressings (homografts or heterografts) may be applied to superficial second-degree burns at the time of initial debridement. Typically, these dressings quickly adhere to the wounds, relieve pain, and promote rapid epithelialization. These dressings should not be sutured in place, however, because suturing creates the potential for a closedspace infection and for conversion of a second degree to a full-thickness injury. If a biologic dressing does not adhere, it should be removed immediately, and the wound should then be treated with topical antibacterial agents.
Which is FALSE concerning surgical treatment of burn wounds?
The strategy of early excision and grafting in burned patients revolutionized survival outcomes in burn care. Excision is performed with repeated tangential slices using a Watson or Goulian blade until viable, diffusely bleeding tissue remains. The downside of tangential excision is a high blood loss, though this may be ameliorated using techniques such as instillation of an epinephrine tumescence solution underneath the burn. Pneumatic tourniquets are helpful in extremity burns, and compresses soaked in a dilute epinephrine solution are necessary adjuncts after excision. A fibrinogen and thrombin spray sealant (Tisseel Fibrin Sealant; Baxter, Deerfield, IL) also has beneficial effects on both hemostasis and graft adherence to the wound bed. Since full thickness burns are impractical for most burn wounds, split-thickness sheet autografts harvested with a power dermatome make the most durable wound coverings, and have a decent cosmetic appearance. In larger burns, meshed auto grafted skin provides a larger area of wound coverage. This also allows drainage of blood and serous fluid to prevent accumulation under the skin graft with subsequent graft loss. Areas of cosmetic importance, such as the face, neck, and hands, should be grafted with nonmeshed sheet grafts to ensure optimal appearance and function. Options for temporary wound coverage include human cadaveric allograft, which is incorporated into the wound but is rejected by the immune system and must be eventually replaced.
A 45-year-old woman is admitted to a hospital because of a third-degree burn injury to 40% of her TBSA, and her wounds are treated with topical silver sulfadiazine cream (Silvadene). Three days after admission, a burn wound biopsy semiquantitative culture shows 104 Pseudomonas organisms per gram of tissue. The patient's condition is stable at this time.
The most appropriate management for this patient would be to:
Bacterial proliferation in a burn wound may occur despite topical antibacterial agents. When bacterial proliferation has escaped control, as proved by quantitative burn wound biopsy, administration of antibiotics by needle clysis beneath the eschar is indicated. This therapy is most effective if initiated early, before invasive burn wound sepsis has developed or wound colonization has reached greater than 104 organisms per gram of tissue. Systemic antibiotics usually are ineffective at this point because by the third day after a burn, blood flow to a burn wound is markedly decreased. Thus, adequate levels of antibiotic are not achieved at the eschar-viable tissue interface where the bacterial proliferation is occurring. Before the use of subeschar antibiotics, Pseudomonas sepsis of burn wounds accompanied by ecthyma gangrenosum was uniformly fatal in children. Once colonization of a burn wound has occurred, surgical excision is extremely dangerous, as systemic seeding will occur.
Fourteen days after admission to the hospital for a 30% partial thickness burn and hemodynamic instability requiring central venous access, a patient develops a spiking temperature curve. On physical examination, the central venous catheter insertion site was red, tender, and warm.
The best treatment for this complication is to:
Burn patients often require central venous access for fluid resuscitation and hemodynamic monitoring. Because of the anatomic relation of their burns to commonly used access sites, burn patients may be at higher risk for catheter-related bloodstream infections. The 2009 CDC NHSN report (http://www.cdc.gov/nhsn/dataStat.html) indicates that American burn centers have higher infectious complication rates than any other ICUs. Because burn patients may commonly exhibit leukocytosis with a documented bloodstream infection, practice has been to rewire lines over a guidewire and to culture the catheter tip. However, this may increase the risk of catheterrelated infections in burned patients and a new site should be used if at all possible.
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