Abstract Introduction Elderly burn patients face disproportionately higher morbidity and mortality even with smaller injuries. It is likely that rural populations face additional struggles like longer commute times and access to specialized care. The purpose of this study was to compare demographic and patient outcomes of rural and urban elderly burn patients at a verified burn center. Methods An analysis of data was performed on patients 65 or older admitted between 2000 and 2022. They were classified as rural or urban using Rural–Urban commuting codes from 2020 in relation to patients’ zip codes. A RUCA code of 7 or above was considered rural. Demographics, injury characteristics, comorbidities, procedures, and outcomes were compared. We used t-tests and chi-squares with the significance set to p<.05. Results A total of 776 patients (mean age 75) were included in the study, with 14.6%(n = 113) from rural areas and 85.4% from urban. Males made up 63.3% of the population with a similar distribution between the rural and urban groups. Majority of the patients were Caucasian (84.4%), though the race distribution varied significantly with no rural African American patients compared to 12.4% in the urban group. Furthermore, 100% of the rural population was non-Hispanic. The mean time to presentation was significantly longer for the rural group (4.69 vs. 2.21). The mean number of OR Procedures was also higher for the rural group (3.43 vs. 2.87). Lastly the payer source varied significantly(p=.0045) with the rural population mainly using Medicaid (13.76% vs. 4.98%) and the urban population mainly using private/commercial Insurance (13.84% vs 5.50%). Difference for all other parameters (TBSA, LOS, mortality rate, co-morbidities) were not significant though some (mortality, co-morbidities) reached clinical significance. Conclusions In this study of elderly burn patients at a tertiary burn center, rural patients presented later after injury compared to urban patients and required more procedures but showed similar mortality, LOS, and TBSA. Delay in the time to presentation did not adversely impact outcomes. Applicability of Research to Practice Recognizing differences in burn care for rural population and the necessity of prevention strategies for elderly rural populations as well as possible guidelines for patient transfer. Funding for the study N/A.

OBJECTIVE:ABRUPT2 was a prospective, randomized, multicenter trial to determine whether lactated Ringer's + 5% albumin (Alb) reduces resuscitation requirements compared to lactated Ringer's (LR) alone in major burns. SUMMARY BACKGROUND DATA:The prospective, observational, multicenter ABRUPT study(1) found that initiation of albumin rapidly lowered fluid input and improved urine output in patients with burns ≥ 20% TBSA. METHODS:Based on the ABRUPT trial, inclusion was increased to ≥ 25% TBSA and ≥ 20% full-thickness. Patients ≥ 18 years were randomized to receive LR or Alb (2/3 LR + 1/3 5% albumin) for initial resuscitation. The initial rate was 2-4 ml/kg/% TBSA and adjusted to urine output (0.5-1 mL/kg/hour). For safety or excessive fluid volumes (> 250 mL/kg in 24 hours), investigators could crossover between assigned study arms. RESULTS:The study was stopped at 99 subjects (Alb-48, LR-51) due to declining enrollment in 19/27 centers. Mean % TBSA burn was 46%. Twenty-six (51%) LR patients crossed over to Alb, but there were no crossovers from Alb to LR. Despite crossovers, following intention-to-treat, there were statistically significant (p 0.001) increased fluids at 24 and 48 hours for the LR group compared to Alb. The LR group averaged 1.5 (95% CI: 0.59,2.3) ml/kg/%TBSA and 2.1 (95% CI: 1.0,3.1) ml/kg/%TBSA times higher fluids compared to Alb at 24 and 48 hours, respectively. There were no differences in mortality, time to healing or acute kidney injury. CONCLUSION:The use of 5% albumin significantly reduced fluid requirements compared to LR alone in the first 48 hours after injury.

Abstract Introduction Over 160 000 skin grafts are performed annually in The United States. Opioids remain the mainstay treatment of postsurgical pain despite their numerous adverse effects. Alternative analgesic strategies in lieu of the current standard of care (SOC) are proposed to improve pain control in graft donor sites and reduce opioid burden. Methods A randomized control trial was conducted with patients 18 years of age and older admitted to an accredited burn center. Patients with burn injuries ≤5% total body surface area (TBSA) of deep partial/full thickness involvement were undergoing their first autografting procedure with donor sites limited to the anterior or lateral thigh. Phase 1 of the trial included 50 patients with a 1:1 blinded randomization to local liposomal bupivacaine infiltration or SOC local lidocaine infiltration. Phase 2 enrolled an additional 24 patients assigned to receive a regional nerve block, totaling 74 subjects. Postoperative pain was assessed using the Visual Analog Scale (VAS), and opioid use was quantified in morphine milligram equivalents (MME); both measures were recorded starting 24 hours preoperative to postoperative day three. Results Patients who received a regional nerve block in Phase 2 required a lower initial postoperative opioid dose compared to those receiving lidocaine (p=.0018). First pain scores recorded postoperatively were lower in the nerve block cohort (p=.0051) as well as scores taken on day three (p=.0236) (Table 1). No differences were found in regard to MME within Phase 2. Phase 1 comparing bupivacaine to lidocaine infiltration identified no significant differences. Conclusions The use of nerve block demonstrated a trend in reducing pain postoperatively compared to current SOC lidocaine infiltration. On average, pain scores in the nerve block cohort were lower than lidocaine, displaying clinical relevance despite absence of statistical significance which may reflect the limited sample size. Applicability of Research to Practice As regional nerve blocks are an effective strategy to manage postoperative pain in skin graft donor sites and reduce reliance on opioids, they should be more commonly utilized in clinical practice. Reduction of opioid requirements in the inpatient setting, and therefore decreasing opioid burden and adverse effects, will enhance patient recovery and exposure amid the broader efforts to address the ongoing opioid crisis. Funding for the study N/A.

Frostbite injuries can have lasting sequelae including amputations, intolerance to cold, chronic pain, paresthesia, and inability to return to work. Despite this morbidity, the treatment of frostbite remains understudied. The FRostbite ObServational Trial (FROST) aims to address this gap through a multicenter evaluation of treatment practices and outcomes. As part of FROST, we reviewed institutional frostbite care protocols from 16 participating sites across North America. Practices were categorized as demonstrating uniform agreement (≥90% mentioned the practice), consensus ($\ge$75%), or majority if ($\ge$50%). Uniform agreement was limited to use of rapid rewarming and thrombolytics, the latter being influenced by site selection criteria for FROST participation. Consensus was achieved in multiple areas (such as urgency of treatment, perfusion assessment, the therapeutic windows for pharmaceutical interventions, and the therapeutic dosing of IV thrombolytics). Protocols varied on grades for thrombolytic treatment initiation, prostacyclin analog use, postthrombolytic anticoagulation treatment and duration, the role of physical or occupational therapy, splinting, and appropriate wound care. This manuscript provides a synthesis of protocols and expert opinions for the acute management of frostbite injury. This synthesized protocol may serve as a tool for centers to develop their own standard protocol to facilitate care for frostbite patients. Additionally, current opportunities for frostbite research and improving care are detailed in the manuscript. Education regarding prevention of injury and the need for emergent treatment is needed for both the public and the medical community.

Abstract Introduction Post-burn neck contractures, characterized by restricted movement due to scar tissue formation, significantly impact both function and aesthetics. Numerous treatment options exist, including surgical interventions, physical therapy, and assistive devices. However, the relative effectiveness of these treatments remains unclear, particularly in improving neck mobility and reducing long-term complications. This systematic review aims to evaluate and compare the effectiveness of various treatment modalities for post-burn neck contractures, focusing on range of motion (ROM), pain reduction, and functional improvement. Methods We conducted a systematic search across databases including PubMed, CINAHL, and Cochrane from January to March 2024. The inclusion criteria encompassed randomized controlled trials (RCTs), observational studies, and case series examining interventions for post-burn neck contractures. Outcome measures included ROM, pain scores (Visual Analog Scale), scar recurrence, graft take, and complication rates. Data were analyzed following Cochrane protocols and PRISMA guidelines. Results A total of 28 studies met inclusion criteria, covering both surgical and non-surgical interventions. Surgical methods, particularly the use of free flaps, demonstrated the most significant improvement in ROM and patient mobility, with lower rates of scar recurrence compared to skin grafts and tissue expansion techniques. Non-surgical interventions, while less effective in severe cases, showed moderate improvements in ROM and pain reduction. The lack of standardized outcome measures across studies presented challenges in direct comparison. Conclusions The variability in study designs and outcome measures highlights the need for standardized metrics in future research to better assess and compare treatment effectiveness. Long-term follow-up studies are recommended to evaluate the durability of these interventions. Applicability of Research to Practice The lack of standardized outcome measures makes it difficult to compare treatments and assess long-term effectiveness. Establishing consistent metrics, especially for range of motion and scar quality, is essential for improving clinical decision-making and advancing research in post-burn neck contracture management. Funding for the study N/A.

Abstract Introduction The overall incidence of postoperative nausea and vomiting (PONV) observed 2 to 24 hours following general anesthesia may range from 25 to 30% and is commonly due to volatile inhalation agents and opioid analgesics. Besides patient dissatisfaction, PONV can delay recovery and discharge from anesthesia care. PONV is less frequent after monitored anesthesia care (MAC) anesthesia. Burn patients may receive MAC for burn dressing change. There has been minimal research about the incidence of PONV in burn patients following anesthesia. To our knowledge, this may be one of the first reports of PONV incidence following MAC for burn dressing change. Objective: To investigate the incidence of PONV following MAC for patients undergoing burn dressing change. Methods Following IRB approval, the electronic medical record (EMR) of burn patients undergoing MAC anesthesia from January 1, 2016, to December 31, 2024, in our burn unit were retrospectively reviewed. Patient demographics, burn injury etiology, comorbidities, TSBA%, opioids, prophylactic antiemetics, and type and dose of medications administered for MAC were analyzed. The primary outcome was the incidence of PONV documented in the EMR within two hours immediately post dressing change prior to discharge from anesthesia. Results EMR data of 207 burn patients undergoing MAC were evaluated. PONV occurred in 5 of 207 (2.4%) patients. Comparing patient demographics in the PONV versus no PONV groups, there was no difference regarding age, BMI, and TBSA%. In the PONV group, the mean age (+/- SD) was 40.2 +/- 13.9 years, BMI 27.5 +/- 4.1, and TBSA% 14.9 +/- 11.9. Caucasian males were the largest gender group. The most common physical class was ASA 3: 3/5 (60%) in patients with PONV, and 105/202 (52%) in patients without PONV. Propofol was the most common sedative medication, followed by ketamine and dexmedetomidine. Opioids included fentanyl and hydromorphone. Antiemetics included ondansetron and dexamethasone. Conclusions MAC anesthesia can be used for patients undergoing burn dressing change. The incidence of PONV in the two-hour period immediately following MAC anesthesia was low at 2.4%. Male gender and the use of propofol, ketamine and prophylactic antiemetics are possible factors contributing to the low incidence of PONV following MAC anesthesia for dressing change. This is an area of research that deserves further attention. Applicability of Research to Practice The incidence of PONV following MAC anesthesia for burn dressing change is low. Medication choice can help influence and decrease the incidence of PONV. Use of sedative medications with low antiemetic potential, such as propofol, prophylactic antiemetics, such as ondansetron and dexamethasone, and use of ketamine to help minimize opioids are important considerations in these patients. Funding for the study N/A.

Following global Phase III trials, a single-arm expanded access program at 23 burn centers in the United States (2019-2024) provided centers with additional experience in treating adult and pediatric burn patients with NexoBrid, and maintaining burn care preparedness for mass casualty incidents. Eligible patients included children (<18-years-old) and adults (≥18-years-old) with deep thermal burns covering up to 30% of the total body surface area. NexoBrid application was followed by standard care. Patients were monitored weekly until wound closure, and again after 3 and 12 months. Outcomes included incidence and time to eschar removal, need for surgical excision or escharotomy, length of hospital stay, wound closure, and Modified Vancouver Scar Scale. A total of 239 patients (215 adult, 24 pediatric) received NexoBrid, with 142 (131 adult, 11 pediatric) completing the 12-month follow-up. Mean ages were 41 and 11 years, respectively. The mean treated target wound area was approximately 6% of the total body surface area, with 38 circumferential burns. Eschar removal was achieved in 95% of adults and 100% of pediatric patients within 4 hours. Surgical excision was performed in 4% of adults, but not in pediatric cases. No escharotomies were needed. The median length of stay was 10 days. Wound closure occurred by 22 days (adults) and 28 days (pediatric). Safety data were consistent with previous trials. NexoBrid demonstrated comparable outcomes vs previous Phase III trials and potential efficacy in preventing burn-induced compartment syndrome.

Introduction Age, total body surface area (TBSA), and inhalation injury are well-established predictors of mortality following burn injury. However, contemporary institutional data are needed to evaluate additional determinants of mortality and assess temporal trends in modern burn care systems. This study examined mortality predictors and longitudinal trends among adult burn patients admitted to a regional burn center over a fifteen-year period, specifically to determine whether the mortality rate changed significantly over the study period. Methods A retrospective review was conducted of 4117 adult burn patient records from an institutional burn registry, admitted between 2007 and 2021. Patients younger than 18 years and those with missing essential data were excluded. Demographic variables, burn characteristics, TBSA, inhalation injury, injury mechanism, comorbidities, length of stay, ICU days, and ventilator days were analyzed. Statistical tests included chi-square, Wilcoxon rank-sum, Cochran–Armitage trend test, Jonckheere–Terpstra test, and logistic regression. Results Among 4117 patients, 161 (3.9%) died. Non-survivors were significantly older than survivors (61.25 ± 17.99 vs. 44.47 ± 17.29 years; p < 0.0001) and sustained larger burns (mean TBSA 39.51 ± 30.27% vs. 6.36 ± 9.23%; p < 0.0001). Flash/flame injuries accounted for the majority of deaths (72.67%; p < 0.0001). Inhalation injury was substantially more frequent among non-survivors than survivors (39.1% vs. 6.7%; p < 0.0001). Non-survivors required significantly more ICU days (6.92 ± 14.79 vs. 3.20 ± 9.44; p < 0.0001) and ventilator days (5.89 ± 12.88 vs. 1.86 ± 7.66; p < 0.0001). They also experienced more complications (1.54 ± 1.10 vs. 0.42 ± 0.92; p < 0.0001) and had a greater comorbidity burden (1.41 ± 1.03 vs. 1.21 ± 0.99; p = 0.0079). Overall mortality did not significantly change over time (p = 0.0523). Conclusion Age, TBSA, inhalation injury, and comorbidity burden were associated with mortality in adult burn patients, corroborating determinants established in prior literature. Over the fifteen-year period, institutional mortality did not change significantly, while patient age, comorbidity burden, and injury severity among non-survivors increased over time.

BACKGROUND:Large surface area burn injuries compromise skin integrity and are associated with significant morbidity and mortality. Skin autografts are essential for wound healing but are limited in patients with extensive burns due to insufficient donor site availability, resulting in delays in wound coverage. Cultured epidermal autograft (CEA) provides burn wound coverage in patients with extremely limited donor sites, but its success is limited by fragility, lack of basement membrane-anchoring cells, and susceptibility to shear and pressure, particularly over the lower extremities. METHODS:We present two adult patients with total body surface area burns greater than 80% who underwent treatment with CEA and external fixation of the lower extremities. Burn wounds were excised and temporarily covered with allograft skin prior to CEA application. A triplanar external fixation device was used to suspend the lower extremities off the bed surface to minimize shear and pressure on CEA-treated areas. RESULTS:Following application, both patients demonstrated near-perfect graft adherence, with wounds healing within four weeks and durable epithelial coverage at 12 weeks. No complications related to external fixation were observed. The use of external fixation to suspend the lower extremities reduced shear forces and improved CEA take. This approach provided stable wound healing, facilitated wound care, and demonstrated excellent functional recovery. CONCLUSIONS:External fixation may serve as a valuable adjunct in improving outcomes of CEA in patients with extensive burn injuries involving the lower extremities.

Abstract Introduction Older adults face disproportionately high morbidity and mortality after burn injury due to altered tissue composition, reduced mobility, cognitive decline, and sensory impairment. The modified Baux score - a composite measure of age, total body surface area (TBSA) burned, and inhalation injury - remains the most utilized model for acute burn mortality risk prediction. Frailty, however, has emerged as a significant determinant of adverse outcomes and has been used to discuss ICU utilization, prolonged ventilation, non-home discharge, and mortality risk. Despite its broad application, frailty has not been systematically examined as a mortality risk factor following burn injury. This study is the first to evaluate frailty in the context of established burn mortality models, with the goal of determining its predictive value for both in-hospital and long-term survival. Methods A multicenter consortium of 12 burn centers compiled a retrospective dataset of patients aged ≥60 years admitted for burn injury. A total of 1632 records were available, incorporating 156 demographic and clinical variables, as well as Canadian Study of Health and Aging–Clinical Frailty Scale (CFS) scores. Records missing frailty or mortality data were excluded. The primary outcomes were in-hospital mortality (IHM) and long-term mortality (LTM), defined as all-cause death within three years of injury. Predictive performance was assessed using area under the curve (AUC) modeling, trained on 80% of the dataset and validated on the remaining 20%. Results A total of 1209 patients were included for IHM models and 915 for LTM models. CFS was an independent predictor of IHM (AUC 62.6%; p=.000003) compared to the Baux score (90.2%). When combined, frailty improved prediction accuracy for IHM (AUC 91.8%; p = < 0.000001). The largest mortality risk increase was observed at CFS ≥4 (IHM AUC 60.3%, p=.00001; LTM AUC 69.7%, p = < 0.000001). For LTM, frailty outperformed Baux (76.2% vs. 51.8%), underscoring its importance beyond the acute phase. Conclusions Frailty, particularly CFS ≥4, significantly augments mortality prediction in older adult burn survivors, complementing the established modified Baux score for in-hospital outcomes and providing superior prognostic value for long-term survival. Applicability of Research to Practice These findings support routine incorporation of frailty into burn mortality prediction models. Early identification of frailty may improve risk stratification, guide resource allocation, and provide the foundation for future prospective studies. Funding for the study N/A.

Abstract Introduction Older adults make up a growing proportion of burn patients and present unique challenges requiring tailored approaches. Frailty, defined as decreased physiologic reserve and vulnerability to stressors, has emerged as an important predictor of outcomes in this population. In burn care, frailty may influence decisions about candidacy, timing, and extent of surgery, but its role remains unclear. We aimed to examine the association between frailty and operative decision-making in older adult burn patients. Methods Following IRB approval, we conducted a retrospective multicenter cohort study of patients ≥60 years admitted to 12 burn centers (1/2017–12/2019). Demographics, injury characteristics, and operative variables were collected. Frailty was measured with the Canadian Study of Health and Aging Clinical Frailty Scale and categorized as fit (< 4), prefrail (=4), or frail (>4). Univariate and multivariate analyses were performed to assess associations between frailty and operative decision-making. p<.05 was significant. Results Of 1478 patients with clinical frailty scores collected, 767 underwent surgery. Surgical patients were more often fit (371, 59.3%) than prefrail (190, 54.3%) or frail (206, 41%) (p<.0001). Among males, surgery was more common in the fit (274, 73.9%) and prefrail (138, 72.6%) groups than the frail (122, 59.2%). Frail patients were older (70 [64–79]) compared with prefrail (70 [64–76]) and fit (66 [62–74]) (p<.001). Injury type differed, with most patients sustaining flame or flash burns (p=.007), but TBSA and inhalation injury did not vary by frailty. Frail patients had more operations (1 [1–3]) than prefrail (1 [1–2]) and fit (1 [1–2]) (p=.005). Time from injury to surgery was longest in prefrail patients, followed by frail, and shortest in fit (5 [3–10.3] vs. 4 [2–9] vs. 4 [2–7], p=.004). Prefrail patients were most likely to undergo complete excision and grafting in one operation (50.5% vs. 49.6% vs. 39.8%, p=.04). Frail patients had greater allograft use (32%) compared with prefrail (30.5%) and fit (21.3%) (p=.007). Dermal substitute use and graft failure did not differ by frailty category. On multivariate analysis, allograft use was independently associated with TBSA (OR 1.03 [1.02–1.05]) and frailty (fit vs. frail OR 0.51 [0.34–0.76]). Treatment in a single operation was associated with TBSA (OR 0.95 [0.94–0.97]) and frailty (fit vs. frail OR 1.67 [1.16–2.38]; prefrail vs. frail OR 1.66 [1.10–2.52]). Conclusions Frailty influences operative care in older burn patients. Fit patients undergo surgery sooner and in fewer stages, while frail patients require more procedures and more often receive allograft. Applicability of Research to Practice Frailty assessment at admission provides prognostic and operative planning value and should be integrated into burn care to support surgical decision-making and patient-centered care. Funding for the Study N/A.

Abstract Background/Objective Human Albumin Solution (Alb) is widely used in burn shock resuscitation (BSR), even though prospective randomized studies are 20-50 years old. The observational ABRUPT1 study found that Alb lowered resuscitation volumes and improved urine output (UO). ABRUPT2 provides the only modern randomized prospective study comparing Alb to crystalloid. The purpose was to compare BSR using albumin to crystalloids alone. The hypothesis is that Alb reduces fluid volumes compared to lactated Ringer’s (LR) alone for BSR. Methods An international multicenter randomized prospective trial comparing 5% Alb to LR alone during BSR, among adults with burns >25% TBSA with >20% TBSA full thickness injury. Patients randomized to Alb received fluids consisting of one-third 5% Alb and two thirds LR, starting between 8-12 hours post burn. Resuscitation was titrated to achieve UO of 0.5-1 mL/kg/hr. For safety or excessive resuscitation volumes, investigators were allowed to crossover patients between assigned study arms in the 1st 48 hr. All analyses are based on intention-to-treat. The primary outcome was the volume of fluid administered in the 1st 24 hours. Results The study was halted at 99 subjects (Alb n = 48, LR n = 51) of a planned 400, due to slow enrollment and a 51% crossover rate from LR to Alb in the 1st 48 hr with no Alb to LR crossovers. The overall study population’s mean +/- SD age was 45.9□15.9 years, 80% were male, with 45.7□13.9% TBSA burn, 37.5□14.9% full-thickness burn, 13.3% with smoke inhalation injury, and 97.0% with flame burns. Total fluid administration in mL/kg/% TBSA burn for LR and Alb respectively were 5.21□2.53 versus 3.88□2.13 at 24 hours. Regression models which controlled for age, burn size and inhalation injury found that the LR group had received 150% more fluid in mL/kg/%TBSA burn (p=.001) and 210% more fluid (p<.001) than the albumin group at 24 and 48 hours, respectively (Figure). I:O ratios at 24 and 48 hours were lower in the Alb group (p<.001). LR patients who crossed over to Alb displayed elevated and chaotic I:O ratios characteristic of a “runaway” resuscitation, which stabilized upon initiation of Alb. Alb patients had significantly lower peak lactate and peak intra-abdominal pressure. There were no significant differences between Alb and LR in time to wound healing, Acute Kidney Injury, or mortality. Conclusions Administration of Alb at 8-12 hours post burn resulted in a statistically significant and clinically important reduction in fluid resuscitation volumes, improved UO, and lower peak lactate and IAP compared to using LR alone. Alb was also effective in rescuing uncontrolled runaway resuscitations. Applicability of Research to Practice Alb is an effective strategy to lower BSR volumes and to rescue patients receiving excessive crystalloid volumes during BSR. Funding for the study Department of Defense.

Abstract Introduction With resident participation in burn rotations and numbers of available burn surgeons continuing to decline, more and more burn units are augmenting their burn teams with Advanced Practice Providers (APPs), both Nurse Practitioners and Physician Assistants. Our burn center had not hired a new APP in over a decade. With a new hire pending, straight out of their NP program, we developed an APP Orientation Program to qualify our new team member in their new role. Methods We conducted a survey of six past and current burn APPs from three institutions and one physician assistant student that had rotated through our unit to obtain their perspectives on the list of knowledge and skill domains required for the burn APP role. We surveyed our four burn surgeons to derive the list of required domains, validating this list with a burn surgeon from another institution with significant prior involvement in APP orientation. After integrating the APP and surgeon-derived lists, we created a multi-faceted APP Orientation Program including a six month period of weekday shifts working alongside our current APPs and surgeons to introduce day to day work-flow and surgical management of burns, a first-assist course for operative training, “buddy” calls with the existing APPs to get experience with burn call overnight and on weekends, and weekly seminars on burn-specific topics delivered one-on-one by the attending surgeons on a rotating basis. A checklist was maintained to track acquisition of the required competencies. Results After the completion of our APP Orientation Program, we surveyed our burn APPs, burn surgeons, and burn unit nursing management using a 5-point Likert scale. Most responders (88%, 7/8) strongly agreed that they were aware we had created a formal APP orientation. Of all responders, 75 % (6/8) strongly agreed that they were satisfied with the process and that the orientation successfully provided the information necessary to onboard a new APP. The rest of the responders for the previous two questions answered that they agreed with the statements. When asked if the process should be utilized for the next APP hire, 62.5% (5/8) said they strongly agreed and 37.5% (3/8) said they agreed. There were no responses that were neutral or that expressed disagreement to any of the four questions asked. Additionally, we had planned for our new APP to have six months of shift overlap with our current APPs but she was able to begin practicing independently in her role at four months. Conclusions As more APPs are needed for coverage of burn units, a structured orientation program can make the on-boarding process smoother and more satisfying for all involved. Development of a national standard burn APP curriculum could be useful and developing an ABA certification for burn APPs similar to the FABA or CBRN designations should be considered. Applicability of Research to Practice Directly applicable to the hiring and onboarding of new APPs in the burn unit. Funding for the Study N/A.

Abstract Introduction Older adults are known to have a high risk of malnutrition at presentation, which is associated with increased morbidity and mortality. This study focuses on nutritional interventions and outcomes in older adult burn patients. Methods We utilized a multi-center database that specifically assessed the outcomes of older adult burn patients (60 years+). Patient demographics, hospitalization data, and clinical course were analyzed using a post hoc pairwise test with Bonferroni correction. A mixed effect generalized linear model was run specific to survival as an outcome measure. Patients who elected to go comfort care were excluded. Results The study group included 712 patients, nourished (admission albumin ≥3.0 g/dL, n = 442) and malnourished (admission albumin <3.0 g/dL, n = 270) with 57.9% of nourished and 73.7% of malnourished patients receiving supplemental nutrition. The malnourished group presented with increased total body surface area burns (p = < 0.001), higher revised Baux scores (p = < 0.001), and higher frailty score (p = < 0.001). The malnourished group had a statistically significant difference in need for supplemental nutrition (p=.001). However, the type of supplemental nutrition was not significant between groups. Mortality (p = < 0.001) showed the only statistically significant difference. When stratified by admission albumin, ARDS (p=.001) and catheter-associated blood stress infections (p=.001) were seen at higher rates in those with lower albumin levels. When comparing survivors to non-survivors, the differences between TBSA (p = < 0.001), modified Baux score (p = < 0.001), admission albumin (p = < 0.001), and length of ICU stay (p = < 0.001) were statistically significant. Non-survivors had higher rates of supplemental nutrition (81.8%), specifically in the form of tube feeds (93.7%) (p = < 0.001). Non-survivors had higher rates of ARDS (16.9%, p = < 0.001), cardiac arrest (13%, p = < 0.001) and abdominal compartment syndrome (7.8% p = < 0.001). A mixed effect generalized linear model for mortality revealed that for every one-point increase in admission albumin, the odds of death lowered by 54%. Conclusions This retrospective study demonstrates those older adults who presented with malnourishment had higher TBSA burns and increased rates of complications. Those burn patients who survived had higher rates of nutritional support than non-survivors with non-survivors. Admission albumin correlated strongly with risk of mortality should be utilized as an additional marker to help predict risk mortality in this population. Applicability of Research to Practice Our findings suggest that nutritional status prior to burn injury and in the post burn resuscitation is vital to improving survival in older adult patients. Funding for the study N/A.

Older adults make up a growing population of burn patients but pose unique physiological challenges that require specialized care. Comprehensive multicenter data are limited, and single-center studies lack the power to answer key questions for this group. This study assessed the feasibility of forming an unfunded multicenter trial group to study older burn patients and piloted a retrospective study to explore trends in their care and their clinical outcomes. After Institutional Review Board approval and executing data use agreements, 12 North American burn centers collected standardized data on patients aged 60 and older treated from 2017-2019. Demographics, burn characteristics, interventions, and outcomes were gathered from each site's burn care quality platform submissions or electronic medical record and entered in a centralized REDCap database. Among the 1632 patients included in the database, median age was 68 years; most were male (67%) and White (73%) with a median BMI of 27.5. Median burn size was 3.5% total surface area, and patients arrived a median of 4.7 hours post-injury. The median modified Baux score was 76.2. Patients typically underwent one operation within 3 days of arrival, leading to a median hospital stay of 6 days and ICU stay of 1 day. In-hospital mortality was 10.4%, and median time to wound healing was 40 days. This pilot demonstrates that an unfunded multicenter collaboration is feasible and can generate meaningful data to guide care for older burn patients. Strong inter-institutional collaboration and communication and standardized data definitions were key to success.

BACKGROUND:Pressure ulcers impose a significant healthcare burden on both the individual and societal level. The gold standard for treatment is flap reconstruction, which historically has high complication and recurrence rates. The aim of our study was to determine factors associated with complications and recurrence in our large patient population. METHODS:Retrospective chart review of patients who underwent muscle, myocutaneous, or fasciocutaneous flaps from January 2010 to July 2022 for pressure ulcer reconstruction at our tertiary academic institution. Demographic and outcome data were analyzed to determine factors associated with complications and recurrence. RESULTS:A total of 326 patients met inclusion criteria, with 418 flaps performed. Recurrence occurred in 98 flaps (23.4%), and the complication rate was 48.3%. Factors significantly associated with recurrence (p < 0.05) included elevated preoperative CRP, current tobacco use, post-operative infection, and non-compliance. Factors associated with lower recurrence included higher preoperative prealbumin (p = 0.01), preoperative IV antibiotics (p < 0.0001), and autonomic dysfunction (p = 0.04). Preoperative osteomyelitis, present in 70.2% of cases, was not linked to recurrence but was associated with higher complication rates (p = 0.01). A pre-operative optimization algorithm was created. Patients who followed it had lower recurrence (17.3%) and complication rates (46.4%) compared to those who did not (24.6% and 48.7%, respectively). CONCLUSION:Modifiable pre- and post-operative factors influence pressure ulcer recurrence following flap reconstruction. Optimizing nutrition, infection control, smoking cessation, and patient compliance may improve outcomes.

Abstract Introduction Older adults represent a growing proportion of burn patients and face complex surgical decision-making. While early excision and grafting are standard, advancing age, comorbidities, and reduced physiologic reserve complicate operative planning. The factors influencing whether older patients undergo surgery remain unclear. Understanding how patient characteristics, injury patterns, and frailty status affect operative selection is essential to guide treatment and align care with patient goals. Methods We conducted a retrospective multicenter cohort study of patients ≥60 years admitted to 12 burn centers between January 2017 and December 2019. Data included demographics, comorbidities, injury characteristics, and operative status. Frailty was assessed with the Canadian Study of Health and Aging Clinical Frailty Scale. Univariate and multivariate analyses identified factors associated with operative treatment. p<.05 was considered significant. Results Operative data were available for 1528 patients; 784 underwent surgery. There were no significant differences in age, race, ethnicity, or homelessness between groups. Surgical patients had larger burns (6.1% vs. 2.5%, p<.0001), were less likely to have inhalation injury (7.9% vs. 10.8%, p<.0001), had lower albumin (3.1 vs. 3.5, p<.0001), and lower frailty scores (4 vs. 4, p<.0001). Males were more likely to undergo surgery (53.2% vs. 47.4%, p=.03). Patients with alcoholism (62.3% vs. 37.7%, p=.009) and hypertension (53.6% vs. 46.4%, p=.05) more often had surgery. Those with heart failure (39.3% vs. 60.7%, p=.008), smoking (45.0% vs. 55.1%, p=.005), functional dependence (28.6% vs. 55.1%, p=.0002), or respiratory disease (34.2% vs. 65.8%, p<.0001) were less likely to undergo surgery. In-hospital mortality did not differ, but surgical patients had improved long-term survival (54.9% vs. 45.1%, p=.003). On multivariate analysis, surgery was independently associated with burn size (OR = 1.07 [1.04–1.09]), frailty (OR = 0.76 [0.66–0.88]), inhalation injury (OR = 0.51 [0.28–0.92]), and respiratory disease (OR = 0.42 [0.29–0.92]). Conclusions Surgical treatment was more likely in patients with larger burns, lower frailty scores, and without major comorbidities. Male sex, hypertension, and alcoholism increased surgical likelihood, while frailty, dependence, smoking, and respiratory disease reduced it. Although in-hospital mortality did not differ, surgery conferred improved long-term survival. These findings highlight the influence of physiologic reserve and comorbidity on surgical candidacy in older burn patients. Applicability of Research to Practice Frailty and comorbidity assessment should be part of routine burn care to guide surgical decisions, anticipate nonoperative needs, and support shared decision-making. Funding for the Study N/A.

Under monitored anesthesia care (MAC), patients breathe spontaneously under moderate to deep sedation accompanied by various levels of analgesia. MAC has safely been used for burn dressing changes (BDC). Dosing, respiratory and hemodynamic effects of various medications used during MAC for BDC has not been completely evaluated. This prospective observational study approved by our IRB was conducted from May 15, 2023, to July 25, 2024. After informed consent, 80 patients ≥18 years old were enrolled. A total of 118 MACs were evaluated regarding patient demographics, MAC duration, instances of apnea, hypoxia, and hypotension. Statistics was evaluated by T-test and ANOVA. P< 0.05 was set as a statistical significance. Choice and timing of anesthetics, doses, hypotension, changes in mean arterial pressure (MAP), apnea, hypoxia, and pre- vs post- MAC pain scores (0=no pain, 10=maximum pain) were evaluated. Of 80 patients, most were Caucasian males with BMI >30, cardiac comorbidities, TSBA >20% with 69% having 3rd degree burns. MAC duration varied from 25 to 150 minutes. Of 118 MACs, apnea was observed in 84 cases, hypoxia in 34, and hypotension in 24. Most commonly used medications were propofol, midazolam. and ketamine. Bolus administration of hydromorphone resulted in a decrease of ≥10 mmHg MAP within 10 minutes. Ketamine was used as a sub-anesthetic dose (mean 0.320 mg/kg ±0.19). Difference in MAP values and pain comparison are shown in Table 1. Among cases where the MAP maximum-minimum difference was >50 mmHg, pre-vs post anesthesia pain comparison showed a clinical but not statistically significant increase in pain scores (Graph 1). Multiple medications, dosing and order selection were administered. A greater number of medications administered did not necessarily imply a better MAC. When respiratory, hemodynamic and pain score changes are taken into consideration, further prospective studies are needed to help determine a recommended approach regarding MAC for BDC, preferably using a smaller number of medications enhancing a long-acting analgesia coverage. Lack of a recommended approach resulted in the administration of numerous medications and doses. The goal of proper selection and dosing is good anesthesia with minimal hemodynamic and respiratory changes, and good post-MAC pain control. N/A

Monitored Anesthesia Care (MAC) is a technique that enables a smooth workflow of patient care during burn dressing change (BDC) with concurrent satisfaction ratings among patients, burn nurse/techs and anesthesia providers. While the safety and efficacy of MAC has previously been described, safety and efficacy of multiple MACs for BDC has not been reported previously. This prospective observational study, approved by our hospital IRB, was conducted from October 7, 2023, to March 31, 2024. Three male burn patients who underwent multiple (13,16 and 22 each) BDCs under MAC were analyzed. To evaluate the safety of MAC, the duration, anesthetic choice, order and instances of hypoxia, apnea or hypotension were noted. Mean arterial pressure (MAP) changes and pain scores were evaluated to look for any correlation with medication choice or pain outcome reported by the patient. Individual MAC durations varied from 45 to 150 minutes. Propofol was used in all cases, followed in descending order of midazolam, ketamine, and fentanyl. The number of medications varied from 4 to 7 in each MAC. Incidence of apnea, hypoxia, and hypotension was 37, 6 and 36, respectively. Each instance was recognized and treated properly without any ill effects using interventions such as jaw thrust, repositioning or administering vasopressors. Anesthetic medication dosages are shown in Table 1. After multiple MACs, no lab deterioration or tachyphylaxis was observed. The difference between the start and end MAP values were within the < 20 mmHg range in 48 cases. More fluctuations in MAP values were seen when the patients were under anesthesia. Comparing pre- vs post-MAC pain scores showed an increase in 14 cases, no change in 15, and decrease in 22. Although there is not a standardized approach regarding MAC for BDC, the multiple medication variety administered did not appear to affect the safety and efficacy of the three patients who received multiple MACs. However, more studies are needed to recommend combinations of medications and dosages to achieve more stable hemodynamics and better analgesia both during and after MAC. Administration of multiple MAC anesthetics for burn dressing change is safe and effective with no laboratory deterioration or medication tachyphylaxis. N/A