Update on the Critical Care Management of Severe Burns

Abstract

Care of the severely injured patient with burn requires correct diagnosis, appropriately tailored resuscitation, and definitive surgical management to reduce morbidity and mortality. Currently, mortality rates related to severe burn injuries continue to steadily decline due to the standardization of a multidisciplinary approach instituted at tertiary health care centers. Prompt and accurate diagnoses of burn wounds utilizing Lund-Browder diagrams allow for appropriate operative and nonoperative management. Coupled with diagnostic improvements, advances in resuscitation strategies involving rates, volumes, and fluid types have yielded demonstrable benefits related to all aspects of burn care. More recently, identification of comorbid conditions such as inhalation injury and malnutrition have produced appropriate protocols that aid the healing process in severely injured patients with burn. As more patients survive larger burn injuries, the early diagnosis and successful treatment of secondary and tertiary complications are becoming commonplace. While advances in this area are exciting, much work to elucidate immune pathways, diagnostic tests, and effective treatment regimens still remain. This review will provide an update on the critical care management of severe burns, touching on accurate diagnosis, resuscitation, and acute management of this difficult patient population.

Keywords

burn ICU resuscitation inhalation sepsis nutrition

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References

National Burn Repository 2009 Report: Dataset 5.0 American Burn Association, Chicago, IL http://www.ameriburn.org/2009NBRAnnualReport.pdf .

Wibbenmeyer LA , Amelon MJ , Torner JC , et al. Population-based assessment of burn injury in southern iowa: Identification of children and young-adult at-risk groups and behaviors. J Burn Care Rehabil. 2003;24(4):192-202.

Ryan CM , Schoenfeld DA , Thorpe WP , Sheridan RL , Cassem EH , Tompkins RG Objective estimates of the probability of death from burn injuries. N Engl J Med. 1998;338(6):362-366.

DeKoning EP , Hakenewerth A. , Platts-Mills TF , Tintinalli JE Epidemiology of burn injuries presenting to north carolina emergency departments in 2006-2007. Burns. 2009;35(6):776-782.

Wolf SE , Rose JK , Desai MH , Mileski JP , Barrow RE , Herndon DN Mortality determinants in massive pediatric burns. An analysis of 103 children with > or = 80% tbsa burns (> or = 70% full-thickness). Ann Surg. 1997;225(5):554-565; discussion 565-559.

Esselman PC Burn rehabilitation: an overview. Arch Phys Med Rehabil. 2007;88(12suppl2):S3-S6.

Harrington DT Burn injuries and burn care. Med Health R I. 2009;92(5):179-180.

Mann R. , Heimbach D. Prognosis and treatment of burns. West J Med. 1996;165(4):215-220.

McGwin G. Jr , Cross JM , Ford JW , Rue LW 3rd. Long-term trends in mortality according to age among adult burn patients. J Burn Care Rehabil. 2003;24(1):21-25.

10.

Church D. , Elsayed S. , Reid O. , Winston B. , Lindsay R. Burn wound infections. Clin Microbiol Rev. 2006;19(2):403-434.

11.

Grunwald TB , Garner WL Acute burns. Plast Reconstr Surg. 2008;121(5):311e-319e.

12.

Tschop J. , Martignoni A. , Reid MD , et al. Differential immunological phenotypes are exhibited after scald and flame burns. Shock. 2009;31(2):157-163.

13.

Cone JB What’s new in general surgery: burns and metabolism. J Am Coll Surg. 2005;200(4):607-615.

14.

Collis N. , Smith G. , Fenton OM Accuracy of burn size estimation and subsequent fluid resuscitation prior to arrival at the yorkshire regional burns unit. A three year retrospective study. Burns. 1999; 25(4):345-351.

15.

Perry RJ , Moore CA , Morgan BD , Plummer DL Determining the approximate area of a burn: an inconsistency investigated and reevaluated. BMJ. 1996;312(7042):1338.

16.

Wachtel TL , Berry CC , Wachtel EE , Frank HA The inter-rater reliability of estimating the size of burns from various burn area chart drawings. Burns. 2000;26(2):156-170.

17.

Neuwalder JM , Sampson C. , Breuing KH , Orgill DP A review of computer-aided body surface area determination: Sage ii and epri’s 3d burn vision. J Burn Care Rehabil. 2002;23(1):55-59; discussion 54.

18.

Cuttle L. , Pearn J. , McMillan JR , Kimble RM A review of first aid treatments for burn injuries. Burns. 2009;35(6):768-775.

19.

Sawada Y. , Urushidate S. , Yotsuyanagi T. , Ishita K. Is prolonged and excessive cooling of a scalded wound effective? Burns. 1997;23(1):55-58.

20.

Ofeigsson OJ , Mitchell R. , Patrick RS Observations on the cold water treatment of cutaneous burns. J Pathol. 1972;108(2): 145-150.

21.

Koumbourlis AC Electrical injuries. Crit Care Med. 2002;30 (11suppl):S424-S430.

22.

Latenser BA , Miller SF , Bessey PQ , et al. National burn repository 2006: a ten-year review. J Burn Care Res. 2007;28(5): 635-658.

23.

Latenser BA Critical care of the burn patient: the first 48 hours. Crit Care Med. 2009;37(10):2819-2826.

24.

Armour AD , Billmire DA Pediatric thermal injury: acute care and reconstruction update. Plast Reconstr Surg. 2009;124 (1suppl):117e-127e.

25.

Pruitt, BA Jr. Fluid and Electrolyte Replacement in the Burned Patient . Surg Clin N Am 1978; (58):1291-1312.

26.

Chung KK , Wolf SE , Cancio LC , et al. Resuscitation of severely burned military casualties: fluid begets more fluid. J Trauma. 2009;67(2):231-237; discussion 237.

27.

Cancio LC , Chavez S. , Alvarado-Ortega M. , et al. Predicting increased fluid requirements during the resuscitation of thermally injured patients. J Trauma. 2004 ;56(2):404-413; discussion 413-404.

28.

Reid RD , Jayamaha J. The use of a cardiac output monitor to guide the initial fluid resuscitation in a patient with burns. Emerg Med J. 2007 ;24(5):e32.

29.

Jaffe MB Partial C. O2 rebreathing cardiac output-operating principles of the nico system. J Clin Monit Comput. 1999;15(6): 387-401.

30.

Berton C. , Cholley B. Equipment review: new techniques for cardiac output measurement-oesophageal doppler, fick principle using carbon dioxide, and pulse contour analysis. Crit Care. 2002;6(3):216-221.

31.

Salinas J. , Drew G. , Gallagher J. , et al. Closed-loop and decision-assist resuscitation of burn patients . J Trauma. 2008;64 (4suppl):S321-332.

32.

Warden GD Burn shock resuscitation. World J Surg. 1992 ;16(1): 16-23.

33.

Goodwin CW , Dorethy J. , Lam V. , Pruitt BA Jr. Randomized trial of efficacy of crystalloid and colloid resuscitation on hemodynamic response and lung water following thermal injury. Ann Surg . 1983;197(5):520-531.

34.

Alderson P. , Bunn F. , Lefebvre C. , et al. Human albumin solution for resuscitation and volume expansion in critically ill patients. Cochrane Database Syst Rev. 2004;(4):CD001208.

35.

Nisanci M. , Eski M. , Sahin I. , Ilgan S. , Isik S. Saving the zone of stasis in burns with activated protein C: an experimental study in rats. Burns. 2010;36(3):397-402.

36.

Dulhunty JM , Boots RJ , Rudd MJ , Muller MJ , Lipman J. Increased fluid resuscitation can lead to adverse outcomes in major-burn injured patients, but low mortality is achievable . Burns. 2008;34(8):1090-1097.

37.

Ivy ME , Atweh NA , Palmer J. , Possenti PP , Pineau M. , D’Aiuto M. Intra-abdominal hypertension and abdominal compartment syndrome in burn patients . J Trauma. 2000;49(3):387-391.

38.

Tricklebank S. Modern trends in fluid therapy for burns. Burns. 2009;35(6):757-767.

39.

Brown RL , Greenhalgh DG , Kagan RJ , Warden GD The adequacy of limb escharotomies-fasciotomies after referral to a major burn center. J Trauma. 1994;37(6):916-920.

40.

Hershberger RC , Hunt JL , Arnoldo BD , Purdue GF Abdominal compartment syndrome in the severely burned patient. J Burn Care Res. 2007;28(5):708-714.

41.

Klein MB , Hayden D. , Elson C. , et al. The association between fluid administration and outcome following major burn: A multicenter study. Ann Surg. 2007;245(4):622-628.

42.

Steinvall I. , Bak Z. , Sjoberg F. Acute respiratory distress syndrome is as important as inhalation injury for the development of respiratory dysfunction in major burns. Burns. 2008;34(4): 441-451.

43.

Maybauer DM , Maybauer MO , Traber DL Resuscitation with hypertonic saline in burn shock and sepsis. Crit Care Med. 2006;34(6):1849-1850.

44.

Herndon DN , Thompson PB , Traber DL Pulmonary injury in burned patients. Crit Care Clin. 1985;1(1):79-96.

45.

Shirani KZ , Pruitt BA Jr , Mason AD Jr. The influence of inhalation injury and pneumonia on burn mortality. Ann Surg. 1987; 205(1):82-87.

46.

Palmieri TL , Warner P. , Mlcak RP , et al. Inhalation injury in children: a 10 year experience at shriners hospitals for children. J Burn Care Res. 2009;30(1):206-208.

47.

Craft B. , Kagan RJ Current management of burns. Medical Update for Psychiatrists . 1998;3(2):53-57.

48.

Hanumadass ML , Kagan RJ , and Matsuda T. Management of Pediatric Burns. In Vidyasagar, D and Sarnaik AP , ed. Neonatal and Pediatric Intensive Care. PSG Publishing Co. Littleton, MA; 1985:215-226.

49.

McAuliffe PF and Mozingo DW Inhalation Injury and Ventilator Management. In: Soper NJ , Saffle JR , eds. Problems in General Surgery: Thermal Injuries. Philadelphia, PA: Lippincott, Williams and Wilkins; 2002;20:97-105.

50.

Robb BW and Kagan RJ : Outpatient and Emergency Department Management of Thermal Injuries. Probl Gen Surg. 2003;7-15.

51.

Ware LB , Matthay MA The acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1334-1349.

52.

Pruitt BA Jr , Erickson DR , Morris A. Progressive pulmonary insufficiency and other pulmonary complications of thermal injury. J Trauma. 1975;15(5):369-379.

53.

Moritz AR , Henriques FC Studies of thermal injury II: the relative importance of time and surface temperature in the causation of cutaneous burns. Am J Pathol . 1947;23(5):695-720.

54.

Miller K. , Chang A. Acute inhalation injury. Emerg Med Clin North Am. 2003;21(2):533-557.

55.

Nieman GF , Clark WR Jr , Wax SD , Webb SR The effect of smoke inhalation on pulmonary surfactant. Ann Surg. 1980; 191(2):171-181.

56.

Herndon DN , Traber LD , Linares H. , et al. Etiology of the pulmonary pathophysiology associated with inhalation injury. Resuscitation. 1986;14(1-2):43-59.

57.

Mak G AS , Kagan R. Pediatric burns. In: Wheeler D WH , Shanley T , ed. Pediatric Critical Care Medicine. Springer-Verlag; 2007:1597-1606.

58.

Gauglitz GG , Finnerty CC , Herndon DN , Mlcak RP , Jeschke MG Mak G. , Allen S. , and Kagan RJ : Pediatric Burns. In: Wheeler D , Wong H , Shandley T , eds. Pediatric Critical Care Medicine: Basic Science and Clinical Evidence . London, UK: Springer-Verlag; 2007;1597-1606.

59.

Gonzalez-Castro A. , Llorca J. , Buron J. , Suberviola B. , Vallejo A. , Minambres E. Evaluation of the oxygenation ratio as long-term prognostic marker after lung transplantation. Transplant Proc . 2007;39(7):2422-2424.

60.

Krafft P. , Fridrich P. , Pernerstorfer T. , et al. The acute respiratory distress syndrome: definitions, severity and clinical outcome. An analysis of 101 clinical investigations. Intensive Care Med. 1996;22(6):519-529.

61.

Yilmaz M. , Iscimen R. , Keegan MT , et al. Six-month survival of patients with acute lung injury: prospective cohort study. Crit Care Med. 2007;35(10):2303-2307.

62.

Weaver LK , Howe S. , Hopkins R. , Chan KJ Carboxyhemoglobin half-life in carbon monoxide-poisoned patients treated with 100% oxygen at atmospheric pressure. Chest. 2000;117(3):801-808.

63.

Baud FJ , Barriot P. , Toffis V. , et al. Elevated blood cyanide concentrations in victims of smoke inhalation . N Engl J Med. 1991; 325(25):1761-1766.

64.

Barillo DJ Diagnosis and treatment of cyanide toxicity. J Burn Care Res. 2009;30(1):148-152.

65.

Reske A. , Bak Z. , Samuelsson A. , Morales O. , Seiwerts M. , Sjoberg F. Computed tomography-a possible aid in the diagnosis of smoke inhalation injury ? Acta Anaesthesiol Scand. 2005;49(2): 257-260.

66.

Wittram C. , Kenny JB The admission chest radiograph after acute inhalation injury and burns. Br J Radiol. 1994;67(800):751-754.

67.

Nugent N. and Herndon D. Diagnosis and Treatment of Inhalation Injury. In: Herndon , ed. Total Burn Care. Saunders ; Philadelphia, PA; 2007.

68.

Rabinowitz PM , Siegel MD Acute inhalation injury. Clin Chest Med. 2002;23(4):707-715.

69.

Ernst A. , Zibrak JD Carbon monoxide poisoning. N Engl J Med. 1998 ;339(22):1603-1608.

70.

Erupaka K. , Bruce EN , Bruce MC Prediction of extravascular burden of carbon monoxide (co) in the human heart . Ann Biomed Eng. 2010;38(2):403-438.

71.

Kealey GP Carbon monoxide toxicity. J Burn Care Res. 2009; 30(1):146-147.

72.

Gravvanis AI , Tsoutsos DA , Iconomou TG , Papadopoulos SG Percutaneous versus conventional tracheostomy in burned patients with inhalation injury. World J Surg. 2005;29(12): 1571-1575.

73.

Rodeberg DA , Housinger TA , Greenhalgh DG , Maschinot NE , Warden GD Improved ventilatory function in burn patients using volumetric diffusive respiration. J Am Coll Surg. 1994;179(5): 518-522.

74.

Carman B. , Cahill T. , Warden G. , McCall J. A prospective, randomized comparison of the volume diffusive respirator vs conventional ventilation for ventilation of burned children. 2001 aba paper . J Burn Care Rehabil. 2002;23(6):444-448.

75.

Cioffi WG , Graves TA , McManus WF , Pruitt BA Jr. Highfrequency percussive ventilation in patients with inhalation injury. J Trauma. 1989;29(3):350-354.

76.

Cioffi WG Jr , Rue LW 3rd , Graves TA , McManus WF , Mason AD Jr , Pruitt BA Jr. Prophylactic use of highfrequency percussive ventilation in patients with inhalation injury. Ann Surg. 1991;213(6):575-580; discussion 580-572.

77.

Rue LW 3rd , Cioffi WG , Mason AD , McManus WF , Pruitt BA Jr. Improved survival of burned patients with inhalation injury. Arch Surg. 1993;128(7):772-778; discussion 778-780.

78.

Kane TD , Greenhalgh DG , Warden GD , Goretsky MJ , Ryckman FC , Warner BW Pediatric burn patients with respiratory failure: predictors of outcome with the use of extracorporeal life support. J Burn Care Rehabil . 1999;20(2):145-150.

79.

Alpard SK , Zwischenberger JB Extracorporeal membrane oxygenation for severe respiratory failure. Chest Surg Clin N Am. 2002;12(2):355-378, vii.

80.

Nehra D. , Goldstein AM , Doody DP , Ryan DP , Chang Y. , Masiakos PT Extracorporeal membrane oxygenation for nonneonatal acute respiratory failure: The massachusetts general hospital experience from 1990 to 2008. Arch Surg . 2009;144(5):427-432; discussion 432.

81.

Thompson JT , Molnar JA , Hines MH , Chang MC , Pranikoff T. Successful management of adult smoke inhalation with extracorporeal membrane oxygenation. J Burn Care Rehabil . 2005;26(1):62-66.

82.

Sheridan RL , Hess D. Inhaled nitric oxide in inhalation injury . J Burn Care Res. 2009;30(1):162-164.

83.

Enkhbaatar P. , Murakami K. , Cox R. , et al. Aerosolized tissue plasminogen inhibitor improves pulmonary function in sheep with burn and smoke inhalation. Shock. 2004;22(1):70-75.

84.

Fu Z. , Yang Z. , Liu L. , Liu Z. , He B. , Wu J. [the influence of n-acetyl-l-cysteine on pulmonary injury and oxygen stress after smoke inhalation injury]. Zhonghua Shao Shang Za Zhi . 2002;18:152-154.

85.

Miller AC , Rivero A. , Ziad S. , Smith DJ , Elamin EM Influence of nebulized unfractionated heparin and n-acetylcysteine in acute lung injury after smoke inhalation injury. J Burn Care Res. 2009;30(2):249-256.

86.

Adhikari N. , Burns KE , Meade MO Pharmacologic treatments for acute respiratory distress syndrome and acute lung injury: systematic review and meta-analysis . Treat Respir Med. 2004; 3(5):307-328.

87.

Palmieri TL Use of beta-agonists in inhalation injury. J Burn Care Res. 2009;30(1):156-159.

88.

Bernard GR , Luce JM , Sprung CL , et al. High-dose corticosteroids in patients with the adult respiratory distress syndrome. N Engl J Med. 1987;317(25):1565-1570.

89.

Greenhalgh DG Steroids in the treatment of smoke inhalation injury. J Burn Care Res. 2009;30(1):165-169.

90.

Agarwal R. , Nath A. , Aggarwal AN , Gupta D. Do glucocorticoids decrease mortality in acute respiratory distress syndrome? A meta-analysis. Respirology. 2007;12(4):585-590.

91.

Murphy KD , Thomas S. , Mlcak RP , Chinkes DL , Klein GL , Herndon DN Effects of long-term oxandrolone administration in severely burned children . Surgery. 2004;136(2):219-224.

92.

Herndon DN , Tompkins RG Support of the metabolic response to burn injury. Lancet. 2004;363(9424):1895-1902.

93.

Chan MM , Chan GM Nutritional therapy for burns in children and adults. Nutrition. 2009;25(3):261-269.

94.

Carvajal HF A physiologic approach to fluid therapy in severely burned children. Surg Gynecol Obstet. 1980 ;150(3):379-384.

95.

Curreri PW Nutritional support of burn patients. World J Surg. 1978;2:215-222.

96.

Herndon DN , Curreri PW Metabolic response to thermal injury and its nutritional support. Cutis. 1978;22(4):501-506, 514.

97.

Hildreth MA , Herndon DN , Desai MH , Duke MA Reassessing caloric requirements in pediatric burn patients. J Burn Care Rehabil. 1988;9(6):616-618.

98.

Ireton-Jones C. , Jones JD Improved equations for predicting energy expenditure in patients: the ireton-jones equations. Nutr Clin Pract. 2002;17(1):29-31.

99.

Mayes T. , Gottschlich MM , Khoury J. , Warden GD Evaluation of predicted and measured energy requirements in burned children . J Am Diet Assoc. 1996;96(1):24-29.

100.

Schulman CI , Ivascu FA Nutritional and metabolic consequences in the pediatric burn patient. J Craniofac Surg. 2008; 19(4):891-894.

101.

Liusuwan Manotok RA , Palmieri TL , Greenhalgh DG The respiratory quotient has little value in evaluating the state of feeding in burn patients. J Burn Care Res. 2008;29(4): 655-659.

102.

Joffe A. , Anton N. , Lequier L. , et al. Nutritional support for critically ill children. Cochrane Database Syst Rev. 2009;(2): CD005144.

103.

Gottschlich MM , Jenkins ME , Mayes T. , Khoury J. , Kagan RJ , Warden GD The 2002 clinical research award. An evaluation of the safety of early vs delayed enteral support and effects on clinical, nutritional, and endocrine outcomes after severe burns. J Burn Care Rehabil. 2002;23(6):401-415.

104.

Rettmer RL , Williamson JC , Labbe RF , Heimbach DM Laboratory monitoring of nutritional status in burn patients. Clin Chem. 1992;38(3):334-337.

105.

Gore DC , Ferrando A. , Barnett J. , et al. Influence of glucose kinetics on plasma lactate concentration and energy expenditure in severely burned patients. J Trauma . 2000;49(4):673-677; discussion 677-678.

106.

Wolfe RR , Miller HI , Spitzer JJ Glucose and lactate kinetics in burn shock. Am J Physiol. 1977;232(4):E415-418.

107.

Jeschke MG , Boehning DF , Finnerty CC , Herndon DN Effect of insulin on the inflammatory and acute phase response after burn injury. Crit Care Med. 2007;35(9suppl):S519-523.

108.

Holm C. , Horbrand F. , Mayr M. , von Donnersmarck GH , Muhlbauer W.

Acute hyperglycaemia following thermal injury: friend or foe?

Resuscitation. 2004;60(1):71-77.

109.

Ellger B. , Westphal M. , Stubbe HD , Van den Heuvel I. , Van Aken H. , Van den Berghe G. [Glycemic control in sepsis and septic shock: friend or foe?]. Anaesthesist. 2008;57(1):43-48.

110.

Norbury WB , Jeschke MG , Herndon DN Metabolism modulators in sepsis: propranolol . Crit Care Med. 2007;35(9suppl): S616-620.

111.

Arbabi S. , Ahrns KS , Wahl WL , et al. Beta-blocker use is associated with improved outcomes in adult burn patients. J Trauma. 2004;56(2):265-269; discussion 269-271.

112.

Mohammadi AA , Bakhshaeekia A. , Alibeigi P. , et al. Efficacy of propranolol in wound healing for hospitalized burn patients. J Burn Care Res. 2009;30(6):1013-1017.

113.

Baron PW , Barrow RE , Pierre EJ , Herndon DN Prolonged use of propranolol safely decreases cardiac work in burned children . J Burn Care Rehabil. 1997;18(3):223-227.

114.

Herndon DN , Hart DW , Wolf SE , Chinkes DL , Wolfe RR Reversal of catabolism by beta-blockade after severe burns. N Engl J Med. 2001;345(17):1223-1229.

115.

Jeschke MG , Norbury WB , Finnerty CC , Branski LK , Herndon DN Propranolol does not increase inflammation, sepsis, or infectious episodes in severely burned children. J Trauma. 2007;62(3):676-681.

116.

Peng X. , Yan H. , You Z. , Wang P. , Wang S. Effects of enteral supplementation with glutamine granules on intestinal mucosal barrier function in severe burned patients. Burns. 2004;30(2):135-139.

117.

Alexander JW Nutritional pharmacology in surgical patients . Am J Surg. 2002;183:349-352.

118.

Gottschlich MM , Jenkins M. , Warden GD , et al. Differential effects of three enteral dietary regimens on selected outcome variables in burn patients. JPEN J Parenter Enteral Nutr. 1990;14(3):225-236.

119.

Saffle JR , Wiebke G. , Jennings K. , Morris SE , Barton RG Randomized trial of immune-enhancing enteral nutrition in burn patients. J Trauma. 1997;42(5):793-800; discussion 800-792.

120.

Aida T. , Murata J. , Asano G. , Kanda Y. , Yoshino Y. Effects of polyprenoic acid on thermal injury. Br J Exp Pathol . 1987; 68(3):351-358.

121.

Voruganti VS , Klein GL , Lu HX , Thomas S. , Freeland-Graves JH , Herndon DN Impaired zinc and copper status in children with burn injuries: Need to reassess nutritional requirements. Burns. 2005;31(6):711-716.

122.

Jeschke MG , Finnerty CC , Suman OE , Kulp G. , Mlcak RP , Herndon DN The effect of oxandrolone on the endocrinologic, inflammatory, and hypermetabolic responses during the acute phase postburn . Ann Surg. 2007;246(3):351-360; discussion 360-352.

123.

Miller JT , Btaiche IF Oxandrolone treatment in adults with severe thermal injury. Pharmacotherapy. 2009;29(2):213-226.

124.

Wolf SE , Edelman LS , Kemalyan N. , et al. Effects of oxandrolone on outcome measures in the severely burned: a multicenter prospective randomized double-blind trial. J Burn Care Res. 2006;27(2):131-139; discussion 140-131.

125.

Caldwell FT Jr , Bowser BH , Crabtree JH The effect of occlusive dressings on the energy metabolism of severely burned children. Ann Surg. 1981;193(5):579-591.

126.

Thomson PD , Moore NP , Rice TL , Prasad JK Leukopenia in acute thermal injury: evidence against topical silver sulfadiazine as the causative agent. J Burn Care Rehabil. 1989;10(5):418-420.

127.

Wasiak J. , Cleland H. Burns (minor thermal). Clin Evid. 2005; (14):2388-2396.

128.

Wasiak J. , Cleland H. , Campbell F. Dressings for superficial and partial thickness burns. Cochrane Database Syst Rev. 2008;(4): CD002106.

129.

Demling RH , DeSanti L. Management of partial thickness facial burns (comparison of topical antibiotics and bio-engineered skin substitutes). Burns. 1999;25(3):256-261.

130.

Supp DM and Boyce ST Engineered Skin Substitutes: Practices and Pitfalls. Clin Dermatol. 2005;23:403-412.

131.

Hart DW , Wolf SE , Chinkes DL , et al. Effects of early excision and aggressive enteral feeding on hypermetabolism, catabolism, and sepsis after severe burn. J Trauma. 2003;54(4):755-761; discussion 761-754.

132.

Barret JP , Herndon DN Modulation of inflammatory and catabolic responses in severely burned children by early burn wound excision in the first 24 hours. Arch Surg . 2003; 138(2):127-132.

133.

Barret JP , Herndon DN Effects of burn wound excision on bacterial colonization and invasion. Plast Reconstr Surg. 2003;111: 2):744-750; discussion 751-742.

134.

Xiao-Wu W. , Herndon DN , Spies M. , Sanford AP , Wolf SE Effects of delayed wound excision and grafting in severely burned children. Arch Surg. 2002 ;137(9):1049-1054.

135.

Monafo WW Initial management of burns. N Engl J Med. 1996; 335:1581-1586.

136.

Muangman P. , Sullivan SR , Honari S. , Engrav LH , Heimbach DM , Gibran NS The optimal time for early excision in major burn injury. J Med Assoc Thai. 2006;89(1):29-36.

137.

Herndon DN , Barrow RE , Rutan RL , Rutan TC , Desai MH , Abston S. A comparison of conservative versus early excision. Therapies in severely burned patients. Ann Surg. 1989;209:(5): 547-552; discussion 552-543.

138.

Wang Y. , Tang HT , Xia ZF , et al. Factors affecting survival in adult patients with massive burns . Burns. 2010;36(1):57-64.

139.

Nguyen LN , Nguyen TG Characteristics and outcomes of multiple organ dysfunction syndrome among severe-burn patients. Burns. 2009;35(7):937-941.

140.

Murray CK , Hoffmaster RM , Schmit DR , et al. Evaluation of white blood cell count, neutrophil percentage, and elevated temperature as predictors of bloodstream infection in burn patients . Arch Surg. 2007;142(7):639-642.

141.

Barati M. , Alinejad F. , Bahar MA , et al. Comparison of wbc, esr, crp and pct serum levels in septic and non-septic burn cases. Burns. 2008;34(6):770-774.

142.

Bargues L. , Chancerelle Y. , Catineau J. , Jault P. , Carsin H. Evaluation of serum procalcitonin concentration in the icu following severe burn. Burns. 2007;33(7):860-864.

143.

Neely AN , Fowler LA , Kagan RJ , Warden GD Procalcitonin in pediatric burn patients: an early indicator of sepsis? J Burn Care Rehabil. 2004;25(1):76-80.

144.

Venet F. , Tissot S. , Debard AL , et al. Decreased monocyte human leukocyte antigen-dr expression after severe burn injury: correlation with severity and secondary septic shock. Crit Care Med. 2007;35(8):1910-1917.

145.

Carr JA , Phillips BD , Bowling WM The utility of bronchoscopy after inhalation injury complicated by pneumonia in burn patients: results from the national burn repository. J Burn Care Res. 2009;30(6):967-974.

146.

Wahl WL , Taddonio MA , Arbabi S. , Hemmila MR Duration of antibiotic therapy for ventilator-associated pneumonia in burn patients. J Burn Care Res. 2009;30(5):801-806.

147.

Mosier MJ , Pham TN American burn association practice guidelines for prevention, diagnosis, and treatment of ventilator-associated pneumonia (vap) in burn patients. J Burn Care Res. 2009;30(6):910-928.

148.

Wibbenmeyer L. , Danks R. , Faucher L. , et al. Prospective analysis of nosocomial infection rates, antibiotic use, and patterns of resistance in a burn population . J Burn Care Res. 2006;27(2): 152-160.

149.

Newton T. , Still JM , Law E. A comparison of the effect of early insertion of standard latex and silver-impregnated latex foley catheters on urinary tract infections in burn patients. Infect Control Hosp Epidemiol. 2002;23(4):217-218.

150.

Davenport K. , Keeley FX Evidence for the use of silver-alloy-coated urethral catheters. J Hosp Infect. 2005;60(4): 298-303.

151.

Schuerer DJ , Zack JE , Thomas J. , et al. Effect of chlorhexidine/ silver sulfadiazine-impregnated central venous catheters in an intensive care unit with a low blood stream infection rate after implementation of an educational program: a before-after trial. Surg Infect (Larchmt). 2007;8(4):445-454.

152.

Rickard CM , Lipman J. , Courtney M. , Siversen R. , Daley P. Routine changing of intravenous administration sets does not reduce colonization or infection in central venous catheters . Infect Control Hosp Epidemiol. 2004;25(8):650-655.