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Background For extensively burned patients in whom donor sites for skin coverage are scarce, cultured epidermal autografting (CEA) is a reliable method for developing tissue coverage. A biodegradable temporizing matrix (BTM) can be applied for wound bed temporization while CEA is being manufactured. This temporizing matrix allows for the integration of vascular tissue supporting a neodermis onto which a skin graft can be applied. Delamination of the sealing membrane overlying this neodermis is required before skin grafting. CEA manufacturer guidelines suggest wound bed preparation occur one to two days prior to CEA grafting, and traditional practice amongst burn surgeons, including at our institution, is to delaminate BTM the day before CEA placement. However, optimal timing of delamination prior to CEA has not been investigated and variability in this practice exists. Methods In this case report, we compare BTM delamination 24 h prior versus immediately before CEA placement in a patient with 75% total body surface area burns whose wounds were covered with BTM and subsequently treated with CEA. The “take” of autograft at two sites that were delaminated in a delayed versus immediate fashion were compared. Results The BTM from the patient’s anterior trunk was delaminated a day prior to CEA placement, while his anterior left leg BTM was delaminated with immediate CEA placement. On day 13 after CEA placement, we observed 100% and 90% take at the anterior torso and anterior left leg, respectively. At 1 and 5 months after CEA placement, the anterior left leg was also found to have complete graft take. Conclusion Although the reconstruction site where BTM delamination with delayed CEA placement seemed to initially demonstrate minor improvement in skin graft take in the early post-operative period in this patient, the ultimate outcome was complete graft take at both sites without morbidity regardless of the delayed versus immediate approach. If similar outcomes between these approaches are confirmed in prospective studies, broader use of immediate CEA placement after BTM delamination may reduce the number of operative cases, overall operative time, hospital length of stay, and overall costs while providing expeditious care of the extensively burned patient.

INTRODUCTION: Severe injury provokes coagulopathy and systemic inflammatory response syndrome (SIRS) that, in concurrence, greatly increase the risk of life-threatening complications including bleeding, thrombosis, and multi-organ dysfunction syndrome (MODS), making it a leading cause of death and disability worldwide. For centuries, surgeons have observed hyperactivation of the enzyme plasmin (hyperfibrinolysis) following severe injury and its detrimental effects on bleeding in these patients. Recently, it has been demonstrated that the function of plasmin extends well beyond fibrinolysis to the modulation of inflammation and coagulation, suggesting it may alter the systemic inflammatory and coagulation response to severe injury. We hypothesize that early hyperactivation of plasmin augments systemic inflammation and coagulopathy following severe injury. METHODS: To test this hypothesis, we used burn as a model of severe injury in which patients develop SIRS and coagulopathy without bleeding, allowing us to study the consequences of plasmin activation aside from hemorrhage. Thirty-one burn patients with >5% total body surface area (TBSA) burns admitted to the Vanderbilt University Medical Center Burn Unit were enrolled upon patient consent along with 10 healthy volunteers. Blood was collected serially for the length of hospital stay beginning upon admission. To study the clinical condition and control study variables, we administered a 30% TBSA burn to mice in a parallel study, collecting blood serially beginning at 1-hour post-burn (N=6/group). Control mice received similar preparation in the absence of a burn. Outputs assessed for humans and mice were the same. Plasma plasmin-antiplasmin complexes (PAPc) were used as a measure for plasmin activation, plasma IL-6, IL-1β, and TNFα were used to measure systemic inflammation, and plasma antithrombin III (ATIII) deficiency and platelet count were used to measure coagulopathy. To study the role of plasmin(ogen) in burn-induced coagulopathy and inflammation in a preliminary experiment, plasminogen+/- mice with 50% normal circulating plasminogen and plasmin activity received a similar burn. Both human and animal studies were previously approved by Vanderbilt University IRB and IACUC respectively. RESULTS: In burn patients without inhalation injury, PAPc levels significantly increased in proportion to the severity of injury measured by %TBSA (p CONCLUSION: Studies in severe injuries and elective surgeries have demonstrated that early inhibition of plasmin activation by antifibrinolytic drugs not only reduced bleeding, but also systemic inflammation. Our results suggest an association between plasmin activation, platelet loss, and systemic inflammation following burn injury in both human and mouse models. While the study in Plg+/- mice implicates plasmin in burn-induced inflammation, future studies will examine the mechanistic role of plasmin activation in burn-induced systemic inflammation and coagulopathy using genetic and pharmacologic tools to manipulate plasmin in a mouse model. While the systemic response to burn injury is similar to that of other severe injuries, future studies will investigate the relationship between plasmin activation, coagulopathy, and SIRS in general trauma. As a critical modulator of hemostasis and inflammation, our findings support plasmin as a potential therapeutic target for regulating trauma-induced coagulopathy and SIRS, beyond inhibition of fibrinolysis. Disclosures Schoenecker: OrthoPediatrics: Consultancy.

Abdominal contouring operations are in high demand after massive weight loss. Anecdotally, wound problems seemed to occur frequently in this patient population. Our study was designed to delineate risk factors for wound complications after body contouring. Our retrospective institutional analysis was assembled from 222 patients between 2001 and 2006 who underwent either abdominoplasty (N = 89) or panniculectomy (N = 133). Weight loss surgery (WLS) before body contouring occurred in 63% of our patients. Overall the wound complication rate in these patients was 34%: healing-disturbance 11%, wound infection 12%, hematoma 6%, and seroma 14%. WLS patients had an increase in wound complications overall (41% vs. 22%; P < 0.01) and in all categories of wound complications compared with non-WLS-patients by univariate methods of analysis. In a multivariate regression model, only American Society of Anesthesiologists Physical Status Classification was a significant independent risk factor for wound complications. In conclusion, WLS patients are at increased risk for wound complications and American Society of Anesthesiologists Physical Status Classification is the most predictive of risk.

Introduction Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) can be challenging to treat due to pain with wound care and ongoing fluid loss. The purpose of this study is to determine the role of porcine xenograft as a modality for wound coverage. Material and Methods A retrospective review from 2006 to 2014 was performed at a regional burn center on all patients admitted with the diagnosis of SJS ( 30% TBSA involvement). Patients who received porcine xenograft had physiologic and biochemical parameters compared in the 24 h before and after graft placement. In addition, xenograft patients were compared to historical controls that received traditional wound care which included silver impregnated dressings. Outcomes and variables collected included intravenous fluid given, urine output, pain scores (1–10), pain medication for wound care, biochemical markers, skin infections, hospital length of stay, and mortality. Results Eight patients had placement of a porcine xenograft. Median age was 50 years (IQR 41, 66) and 2 were male. Median % TBSA affected was 76 (IQR 64, 80). The median amount of fluid (ml/kg/day/%TBSA) administered decreased from 1.45 (IQR 1.03, 1.78) to 0.9 (IQR 0.65, 1.08) after xenograft placement (p = 0.02). The median amount of intravenous fluid (ml/kg/day/%TBSA) administered in the treatment group and historical control group was 0.9 (IQR 0.65, 1.08) and 0.8 (IQR 0.7, 1.47) respectively (p = 0.72). The median amount of urine output (ml/kg/day) in the treatment group and historical control group was 34.2 (IQR 22, 44.38) and 22 (IQR 11.25, 38.13) respectively (p = 0.17). Pain scores significantly decreased from 5.5 (IQR 2.5, 8.25) pre-xenograft to 2.8 (IQR 0.75, 4) post-xenograft placement (p = 0.03). There was a significant difference in pain scores between the treatment group and historical control group, 2.8 (IQR 0.75, 4) and 6 (IQR 5, 8) respectively (p = 0.02). Each study patient underwent moderate sedation for wound care prior to xenograft placement and one study patient required one moderate sedation for wound care after xenograft placement. One patient in the xenograft placement group was diagnosed with a cutaneous infection compared to 4 patients in the historical control group (p = 0.63). The mortality was 12.5% in each group. Conclusions Placement of a porcine xenograft in patients with SJS, SJS/TEN overlap, or TEN is associated with a significant reduction in intravenous fluid use, pain scores, and pain medication. Further study with larger sample sizes is warranted to evaluate for statistically significant differences in outcomes after porcine xenograft placement for SJS, SJS/TEN overlap or TEN.

Objective: Burn injuries remain a large financial burden on the healthcare system. According to CDC statistics (2010), nonfatal and hospitalized burns in the U.S. cost $1.8 billion for an annual incidence of ∼486,000 cases. To date, no technique proves to be the ideal therapy of deep partial-thickness burns. In this study, we review a trial usage of ACell (ACell, Inc.) wound matrix on deep partial-thickness burns. Approach: Burn patients were admitted through the Vanderbilt Emergency Department. Three were consented to receive ACell therapy. Each patient suffered extremity burns, to which ACell MatriStem matrix was applied. Time to epithelialization and healing was monitored up to 1 month postintervention. Results: ACell MatriStem matrix use in deep partial-thickness burns enabled healing by 29 days on average without requiring autografts. The average total body surface area (TBSA) of injury was 7.2% with average TBSA treated with ACell equal to 2.5%. All burn sites underwent re-epithelialization after 5....

We evaluated the efficacy of subatmospheric pressure and hyperbaric oxygen (HBO) as adjuncts in the treatment of hypoxic full-thickness wounds in a rabbit model. We hypothesized that subatmospheric pressure and HBO independently are effective in improving wound healing in the ischemic wound model and that when they are used in combination there is an increased positive effect on wound healing. Using a standard ischemic wound model four full-thickness wounds were created on each ear of 41 male New Zealand white rabbits (N = 82 ears). On each rabbit one ear was dressed with the vacuum-assisted closure (VAC) device and connected to suction; the other was dressed identically without the suction and suction tubing. Twenty rabbits were treated with HBO daily for 10 days at 2.0 atmospheres absolute for 90 minutes plus descent and ascent times. Necropsy on all rabbits was performed on postoperative day 10. Four ischemic wound treatment groups were evaluated: Group 1 (N = 21) VAC dressing alone; Group 2 (N = 20) VAC dressing plus HBO; Group 3 (N = 21) VAC dressing to suction alone; and Group 4 (N = 20) VAC dressing to suction and HBO. Using light microscopy a veterinary pathologist blinded to treatment groups quantified peak granulation tissue, granulation tissue gap, and epithelialization tissue gap. Data were analyzed by analysis of variance with significance indicated by P < 0.05. Statistical significance was found in a comparison of VAC dressing to suction and VAC dressing alone for peak granulation tissue and granulation tissue gap both with and without use of HBO. VAC device use appears to increase the rate of healing in a rabbit ischemic wound model. HBO therapy did not significantly affect the rate of healing in this model.