Burn wound cellulitis (BWC) is the second leading complication reported in burns. In this study we sought to identify demographic variables, burn factors, and other factors that may predispose patients to BWC. Regional data was obtained through retrospective medical record review of burn patients treated between May 2009 to April 2013 for BWC within 8 days of the injury. The patients were matched 1:2 with contemporaneously treated patients. Similarly, the National Burn Repository was queried to identify burn patients with BWC between the years 2002 to 2011, which were then compared to the remaining entries who did not have BWC reported. The data sets were analyzed separately. Univariate and multiple variable analyses were performed to evaluate risk factors for BWC. The risk factors that were consistent regionally and nationally were older age, male sex, African-American race (protective), lower extremity burns, scald burns, and full thickness burns. The treatment delay was only collected regionally, and was associated with an eight times increased risk. The factors that were inconsistent or significant in one sample only were smoking status, psychiatric conditions, upper extremity burns, and the place of injury. Cellulitis remains a significant problem for the burn community. Future prospective analyses need to clarify the impact of these factors as well as other factors on the development of BWC. Preventing BWC from occurring through earlier intervention or targeted prophylactic antibiotics may help reduce morbidity and decrease associated healthcare costs.

Sepsis, a dysregulated response to infection, is a leading cause of death after burn injury. Changes in the immune response as well as the loss of the skin, the primary barrier to infection, contribute to the increased risk for infection and sepsis in burn patients. This higher risk is further compounded by the development of the systemic inflammatory response and hypermetabolic state, which limit the utility of commonly used infection markers. As such, the development of sepsis biomarkers after burn injury is an imperative. A sepsis biomarker would facilitate earlier diagnosis and treatment of sepsis, thus decreasing length of stay, morbidity, and mortality after burn injury. Numerous different biomarkers, ranging from acute phase reactants, cytokines, and inflammatory markers to omics analyses and extracellular vesicles have been assessed as potential biomarkers in burn sepsis. To date no single biomarker has proven useful as the sole indicator for sepsis. The future of burn sepsis biomarkers will likely require a panel of biomarkers from all categories. The purpose of this review article is to list the various biomarkers that have been studied in burn sepsis and describe their clinical utility and future use in patients with burn injury.

Burn care continues to improve and larger total body surface area (TBSA) burn survival is increasing. These survivors require more extensive care than smaller burns and are at higher risk for wound/scar-related complications. Prior work has shown low rates of follow-up for burn survivors linked to socioeconomic factors such as housing insecurity and substance use. There are limited studies that evaluate socioeconomic factors that contribute to follow-up and reconstructive surgery rates in massively burned patients. Patients who survived to discharge with >50% TBSA burns and planned return to the treating institution were included in the study. Univariate and multivariate analyses were performed on the data collected. Sixty-five patients were included with an average TBSA of 63.1%. Fifty-three patients (81.5%) attended at least one follow-up appointment with median of 4 follow-up appointments. Younger patients (33 ± 9 vs 44 ± 11; P = .0006), patients with larger TBSA burns (65 ± 13 vs 55 ± 5%; P = .02), those with private insurance, and those without housing insecurity (1.8% vs 45.4%; P = .003) were more likely to follow up. On multivariate regression analysis, patients with housing insecurity were independently associated with lack of follow-up (OR: 0.009; CI: 0.00001-0.57). Thirty-five patients had at least one reconstructive surgery and 31 patients had reconstructive surgery after discharge. No patients with housing insecurity underwent reconstructive surgery. Follow-up rates in massive burns were higher than reported for smaller TBSA burns and more than half received reconstructive surgery. Housing-insecure patients should be targeted for improved follow-up and access to reconstructive surgery.

Previous iterations of burn severity (mild, moderate, and severe) were not data-driven and were outdated. Clustering analyses have gained popularity for identifying homogenous subgroups from heterogeneous medical conditions, such as asthma, sepsis, and lung disease. There is no consensus in burn literature regarding what constitutes massive burns. The current classification includes a 20% total body surface area (TBSA) burn and a 95% TBSA burn as severe. Latent class and hierarchical clustering analyses were applied to the American Burn Association National Burn Research Dataset. Cluster variables included length of stay, length of stay, intensive care unit length of, number and type of procedures, and number and type of complications. Nonclustering variables were evaluated after clustering, including burned TBSA, inhalation injury, mortality, discharge disposition, age, sex, and race. Latent class analysis suggested 3 clusters. Hierarchical clustering analysis was applied to the most severe latent class, creating 4 total burn severity groups. In total, 112 297 patients were included in the final analysis. The mean TBSA burned for each class is 4.26 ± 4.91 for minor, 8.07 ± 8.39 for moderate, 22.76 ± 17.31 for severe and 36.72 ± 21.61 for massive. The age and sex proportions were similar among all clusters. The clustering variables steadily increased for each severity cluster. Mortality was the highest in the massive cluster (18.2%). Data-informed categories of burn severity were formed using clustering analyses, which will be helpful for triage, data benchmarking, and class-specific research.

Fluid creep occurs when resuscitation after extensive burn injury reaches volumes higher than predicted. Since this has been described in patients with high opioid requirements, continuous analgesics and sedatives, including dexmedetomidine, have been avoided during resuscitation. This study sought to describe the impact of dexmedetomidine on fluid resuscitation requirements. This retrospective cohort study included adult patients with burns greater than 20% total body surface area (TBSA) resuscitated between January 2017 and June 2022 at a regional burn center. Patients deceased within 48 hours of burn were excluded. The primary outcome was volume of fluid required in the first 24 and 48 hours postburn. Secondary outcomes were the incidence of fluid-related adverse events within 7 days postburn. A total of 170 patients were included: 55 in the dexmedetomidine cohort and 115 in the control cohort. After propensity matching for variables associated with fluid creep, the dexmedetomidine cohort required 4.2 ± 1.7 mL/kg/%TBSA in the first 24 hours compared to 3.6 ± 1.1 mL/kg/%TBSA in the control cohort (P = 0.03). The difference was no longer significant at 48 hours (P = 0.11). There were no differences in the incidence of acute respiratory distress syndrome, delayed escharotomy/fasciotomy, intra-abdominal hypertension, or renal replacement therapy. Dexmedetomidine exposure during acute resuscitation resulted in increased fluid requirements in the first 24 hours, suggesting it is independently associated with fluid creep; however, this increase was not sustained at 48 hours. Clinical significance of this finding is unclear, as there was no increase in adverse events related to excessive fluid resuscitation between cohorts.

During fluid resuscitation (FR) for acute burns, patients may require vasopressor (VP) administration. Reasons for requiring VP during FR remains unclear. To date, no study has evaluated risk factors for requiring VP in burn shock, although one study indicated presumed sepsis and size of burn as risk factors for developing hypotension in burn patients requiring urgent intubation. In other shock states such as septic shock, various risk factors, including advanced age and comorbidities such as cancer, have been identified in limited studies in patients who decompensate despite adequate FR. We sought to investigate risk factors to help predict which patients may require VP during acute burn FR. This is a retrospective study of burn patients admitted to an ABA verified burn center over a five-year period who received FR. Patients who died within 24 hours were excluded. Basic demographics, medications prior to admission, laboratory results, fluids, urine output, mortality, length of stay (LOS), and mortality prediction scores were collected. VP administration during FR was defined as any VP administered during the first 48 hours. Univariate analyses were performed using SPSS 25.0. P < 0.05 was considered significant. A total of 111 patients met the inclusion criteria with 20 (18.0%) patients requiring VP during FR. VP were initiated 4.97 (± 11.2) hours after admission and were continued for 18.7 (± 45.9) hours in the VP group. Patients who required VP during FR were older (54.6 vs. 42.2 years, p = 0.032), had larger full thickness body surface area burned (37.7 vs. 14.5, p = 0.006), and had a higher revised Baux score (102.1 vs. 83.2, p = 0.001). No significant differences were observed regarding comorbidities or medications taken prior to admission, with the exception of patients who took dihydropyridine calcium channel blockers presenting a higher likelihood of requiring VP (15% vs. 3.3%, p = 0.038). Lactated Ringer’s requirements were higher in the first 24 hours for patients who received VP (15.9 L vs. 10.9 L, p = 0.014). VP administration did not affect LOS, but patients did have a higher rate of mortality (45% vs. 17.6%, p = 0.008) and dialysis requirement (10% vs. 0%, p = 0.002). Older patients with higher Baux scores and greater amounts full-thickness burns are more likely to require VP during their acute burn FR. VP use was correlated with need for dialysis and mortality. Our study was limited by its retrospective nature and small sample size, thus additional risk factors may be identified in a larger study. Larger studies are needed to identify risk factors in patients who require VP during burn FR. This remains a high risk group.