Development of a pediatric burn pain and anxiety management program

To facilitate effective management of pain and anxiety, and to permit more objective assessment of changes in this management, a pain and anxiety guideline was developed and has been followed uniformly for 3 years. The guideline describes four patient care categories: (1) ventilated acute, (2) nonventilated acute, (3) chronic acute, and (4) reconstructive. A small and consistent formulary was emphasized. A specific guideline for background, procedural, and transition pain and anxiety management was developed for each patient care category. All pain and anxiety medications given to all acutely burned children admitted to the Institute for 12 consecutive months were recorded, and daily pain and anxiety discomfort scores were noted using a 5-level action-based bedside scoring system. Doses of individual pain and anxiety medications were calculated as mg per kg per patient-day in each category, and all doses were found to be within guideline specifications. The efficacy of the guideline was judged by four discomfort scores: (1) background pain, (2) procedural pain, (3) background anxiety, and (4) procedural anxiety, and were adequate in all patient categories. There were no complications related to overmedication experienced during the interval. Our objective was to develop a guideline for pain and anxiety management that: (1) was safe and effective over a broad range of ages and injury acuities seen in the unit, (2) was explicit in its recommendations, (3) had a limited formulary to optimize staff familiarity with agents used, and (4) took advantage of the presence of a bedside nurse to continuously evaluate efficacy and intervene when needed through dose-ranging. Although many drugs are appropriate, our choices were based on institutional familiarity and simplicity. This process of developing a clear and consistent guideline can be duplicated in any unit.     

Pharmacokinetics of a single dose of teicoplanin in burn patients

Patients with severe burns are susceptible to infection with Gram-positive organisms including methicillin-resistant Staphylococcus aureus, and often require higher antibiotic dosages compared with other patients. This study examined the pharmacokinetics of a single iv dose of teicoplanin (12 mg/kg) in 15 adults and five children with severe burns. Adults were aged 21-82 years with a median total body surface area (TBSA) burn of 30% (range 15-60%). Children were aged 10 months-l0 years with median TBSA burn of 15% (10-30%). At 12 h, the median serum teicoplanin concentration was 12.8 mg/L (9.027.1 mg/L) in adults and 7.6 mg/L (6.6-l0.8 mg/L) in children, (P < 0.01); at 24 h, the corresponding values were 8.3 mg/L (4.6-l2.9 mg/L) and 5.2 mg/L (4.2-6.0 mg/L). Using a three-compartment model, the median terminal half life in adults was 114 h (47-278 h). Children fitted a two-compartment model with a terminal half-life of 38 h (2l-41 h). The median concentration of teicoplanin in fluid from the burn wound was 60% of the serum antibiotic concentration. A single iv dose of 12 mg/kg of teicoplanin was sufficient to produce therapeutic serum concentrations in burn patients for 24 h, but monitoring of antibiotic levels in serum may be advisable in those with high total clearance, especially children.     

Multiple malignant melanoma and squamous-cell carcinoma in a burn scar

Malignant melanoma arising in a burn scar is very rare. Only 12 cases have been reported until now. We report a case of multiple malignant melanoma and squamous-cell carcinoma arising in the same burn scar. Reported cases of malignant melanoma arising in burn scars are also reviewed. Results of immunohistochemical studies and HLA typing of our patient and a review of previous cases suggest the aggressive behavior of malignant melanoma in burn scars.     

Coping with body image changes following a disfiguring burn injury.

The influence of emotion-focused coping on distress following disfiguring injury was examined. Two types of emotion-focused coping (i.e., venting emotions vs. mental disengagement) were assessed in 78 patients with burn injury at baseline during acute hospitalization. Body image dissatisfaction (BID) was assessed 1 week and 2 months following discharge. Use at baseline of both venting emotions and mental disengagement, compared with use of only one or neither of these coping methods, was associated at the 2-month postdischarge follow-up with significantly higher BID related to nonfacial aspects of appearance and with a greater negative social impact of disfigurement. D. M. Wegner's (1994) theoretical model of mental control and a proposed motivational analysis are used to interpret these findings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Improved burn scar assessment with use of a new scar-rating scale

The subjective assessment of scar appearance is a widely used method in the evaluation of burn outcomes and the efficacy of treatment methods. The purpose of this study is to design a numeric scar-rating scale with better interrater reliability than has previously been reported. The rating scale assesses scar surface, thickness, border height, and color differences between a scar and the adjacent normal skin. Eight raters were trained with use of a standardized set of photographs that provide examples of the scores to be assigned to each level of severity of each scar characteristic. The raters then rated 10 photographs of different scars, referring to the teaching set of pictures for comparison. The intraclass correlation (interrater reliability) was 0.94, 0.95, 0.90, and 0.85 for scar surface, border height, thickness, and color, respectively. This rating system has proved to be a useful tool for the evaluation of scar surface, thickness, border height, and color.     

Ciprofloxacin pharmacokinetics in burn patients

Cyproterone acetate (CPA), a synthetic progestin recently found to induce genotoxic effects in hepatocytes from female rats and from humans of both genders, and two structural analogues, chlormadinone acetate (CMA) and megestrol acetate (MGA), have been compared for their capacity to induce DNA repair synthesis as measured by quantitative autoradiography. Exposure of primary human hepatocytes for 20 h to concentrations of CPA, CMA and MGA ranging from 2 to 50 microM induced positive responses in cultures from donors of both genders and the amounts of DNA repair elicited by the three progestins were similar. Under the same experimental conditions substantial differences were observed in the amounts of DNA repair elicited by the three progestins in primary hepatocytes from female rats, their potency decreasing in the following order CPA > CMA > MGA, and the three compounds failed to induce DNA repair in hepatocytes from male rats. These results, which agree with previous findings, suggest that for these sex steroids extrapolation to humans of results obtained in rats might be questionable.     

Pharmacological nutrition after burn injury

Burn patients develop pathophysiological alterations, which include extensive nitrogen loss, malnutrition, markedly increased metabolic rate and immunologic deficiency. This predisposes burn patients to frequent infections, poor wound healing, increased length of hospitalization and increased mortality. The nutritional support requires high protein and high energy diets preferably administered enterally soon after injury. The effects of increased dietary components such as glutamine, arginine and (n-3) fatty acids and related compounds have been evaluated in burn victims. These components, when supplied in quantities two to seven times of those in normal diets of healthy persons, appear to have beneficial pharmacological effects on the pathophysiological alterations associated with burns. However, the efficacy of immune-enhancing diets remains to be convincingly shown.