Background: Extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) are modalities used in critically ill patients suffering organ failure and metabolic derangements. Although the effects of CRRT have been extensively studied, the impact of simultaneous CRRT and ECMO is less well described. The purpose of this study is to evaluate the incidence and the impact of CRRT on outcomes of patients receiving ECMO. Methods: A single center, retrospective chart review was conducted for patients receiving ECMO therapy over a 6-year period. Patients who underwent combined ECMO and CRRT were compared to those who underwent ECMO alone. Intergroup statistical comparisons were performed using Wilcoxon/ Kruskal-Wallis and chi-square tests. Logistic regression was performed to identify independent risk factors for mortality. Results:The demographic and clinical data of 92 patients who underwent ECMO at our center were reviewed including primary diagnosis, indications for and mode of ECMO support, illness severity, oxygenation index, vasopressor requirement, and presence of acute kidney injury. In those patients that required ECMO with CRRT, we reviewed urine output prior to initiation, modality used, prescribed dose, net fluid balance after 72 h, requirement of renal replacement therapy (RRT) at discharge, and use of diuretics prior to RRT initiation. Our primary endpoint was survival to hospital discharge. During the study period, 48 patients required the combination of ECMO with CRRT. Twenty-nine of these patients survived to hospital discharge. Of the 29 survivors, 6 were dialysis dependent at hospital discharge. The mortality rate was 39.5% with combined ECMO/CRRT compared to 31.4% among those receiving ECMO alone (p = 0.074). Of those receiving combined therapy, nonsurvivors were more likely to have a significantly positive net fluid balance at 72 h (p = 0.001). A multivariate linear regression analysis showed net positive fluid balance and increased age were independently associated with mortality. Conclusions: Use of CRRT is prevalent among patients undergoing ECMO, with over

Burn patients are a unique population when considering strategies for ventilatory support. Frequent surgical operations, inhalation injury, pneumonia, and long durations of mechanical ventilation add to the challenging physiology of severe burn injury. We aim to provide a practical and evidence-based review of mechanical ventilation strategies for the critically ill burn patient that is tailored to the bedside clinician.

Treatment of patients with severe burn injuries is complex, relying on attentive fluid resuscitation, successful management of concomitant injuries, prompt wound assessment and closure, early rehabilitation, and compassionate psychosocial care. The goal of fluid resuscitation is to maintain organ perfusion at the lowest possible physiologic cost. This requires careful, hourly titration of the infusion rate to meet individual patient needs, and no more; the risks of over-resuscitation, such as compartment syndromes, are numerous and life-threatening. Recognizing runaway resuscitations and understanding how to employ adjuncts to crystalloid resuscitation are paramount to preventing morbidity and mortality. This article provides an update on fluid resuscitation techniques in burn patients, to include choosing the initial fluid infusion rate, using alternate endpoints of resuscitation, and responding to the difficult resuscitation.

The use of a polyp tracking registry and notification program improves adherence to current polyp surveillance guidelines.

Introduction Fungal wound infections (FWI) cause morbidity and increase mortality in burn patients. Our burn center experienced 44 patients with fungal wound colonization (FWC) and/or FWI between JAN 2015 and JAN 2019. In response, we undertook a performance improvement project to prevent and treat FWC and FWI. Methods Members of the multidisciplinary team met to develop a clinical practice guideline (CPG) for the prevention and management of FWC and FWI based on current evidence. We focused on patients with elevated risk, that is, with burns ≥20% total body surface area (TBSA) and in the Burn ICU (BICU). Interventions included: utilizing alternating silver sulfadiazine and mafenide acetate creams upon admission; reducing the use of mafenide acetate solution; utilizing silver nitrate solution post-operatively; and applying topical nystatin cream or powder for suspected FWC or FWI. We educated all staff members and updated order sets and training materials. We collected data on all burn patients who had a wound biopsy out of concern for possible infection. Biopsy results were categorized as FWC or FWI. Retrospective data were collected for MAR 2020 - MAR 2021 (PRE). Post-implementation, prospective data collection began MAR 2022 (POST) and will continue for one year. Adherence to the CPG was assessed by chart review. Mann-Whitney and Fischer Exact tests were performed. Results The PRE (n=15) and POST (n=9) groups were similar in age (43±13 vs. 48±18 years) but differed in TBSA (49±19 vs 28±25%, p< .05). PRE group biopsies showed FWC in 0 patients and FWI in 11 of 15 patients (73%); 8 of these (53%), all with FWI, died. In the POST group, FWC was found in 1 patient (11%) and FWI was found in 2 of 9 patients (22%); one death occurred in the patient with FWC. Adherence to the CPG for admission topical wound care was 7% in the PRE group vs 89% in the POST group (p=0.0001); adherence to the CPG for day-of-biopsy topical wound care was 27% in the PRE group vs 89% in the POST group (p< 0.01). Conclusions Adherence to a CPG for the prevention and treatment of FWC and FWI was associated with a lower (but not statistically significant) prevalence of these complications. Limitations include a difference in the TBSA between the 2 groups and potential concurrent changes in practice. Ongoing data collection includes the evaluation of other potential contributing factors. Applicability of Research to Practice Fungi are common in the environment, and when combined with immunosuppression and extensive open wounds, may cause wound infection in burn patients. More research is needed to further evaluate effective treatments for the prevention and treatment of FWC and FWI in these patients.

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Introduction Patients who require extracorporeal membrane oxygenation (ECMO) have a very high mortality if they develop septic shock. Extracorporeal blood purification has been studied as an adjunct to antimicrobials but has yielded mixed or even disappointing results. The Seraph-100 Microbind Affinity Blood Filter (ExThera Medical Corporation, Martinez, CA) is currently undergoing clinical trials. The filter consists of polyethylene beads, coated in heparin sulfate, that irreversibly binds bacteria, fungi, viruses, and toxins. Seraph-100 therapy is traditionally delivered through conventional hemodialysis or continuous renal replacement therapy (CRRT), with the filter being placed in-line with these circuits. We present a case of a burn patient on veno-venous (VV) ECMO in septic shock, who was treated with a Seraph filter by connecting it directly to the ECMO circuit. Methods We present a case. Results A 34-year-old male presented with 56% thermal burns and grade 1 inhalation injury from a fuel tank explosion. He underwent a large-volume resuscitation for burn shock with lactated Ringer’s and albumin, receiving 18,152 mL (163 mL/kg) in the first 24 hours. He was placed on CRRT for acute kidney injury and underwent escharotomies of the hands and legs. On day 4, he developed bacteremia, septic shock and progressed to acute respiratory distress syndrome requiring VV ECMO. Extracorporeal blood purification was started via the Seraph-100 filter. Due to limitations of blood flow rates on CRRT, the Seraph-100 filter was added directly into the ECMO circuit. Inflow tubing was connected to an existing port on the oxygenator (Fig 1) and returned to the venous drainage by cutting a new port into the drainage tubing (Fig 2). The filter itself did not require any special configuration or orientation (Fig 3). This configuration allowed for pressures generated by the ECMO circuit to drive blood flow through the Seraph-100 filter (Fig 4). After 6 hours of treatment, vasopressor requirements drastically decreased. Conclusions Complications related to the Seraph-100 filter are rare but may include catheter thrombosis. This is typically due to the type of catheter used and/or the blood-flow rate through the filter rather than the filter itself. This issue was avoided with the ECMO configuration. Similarly, clinicians can avoid transient hypotension, blood loss from a clotted circuit, catheter-site bleeding, and other complications frequently associated with a renal replacement circuit.

Introduction The COVID-19 pandemic came as an unexpected challenge to many healthcare systems around the world. Many centers struggled to provide COVID-19 ICU-level care while also maintaining adequate care for non-COVID-19-related conditions, especially in critical care specialty units like trauma and burn. We present a case series of our early experiences treating COVID-19 in a burn center. Methods We present a case. Results See Table 1. Though one case was admitted prior to initiation of universal testing, routine infection-control protocols limited exposure to personnel and prevented transmission to staff. In May 2020, we implemented the use of N95 mask and eye protection during all aerosolizing procedures, N95 mask use in all ORs, and universal surgical mask use in all rooms regardless of COVID-19 status. An in-house risk-stratification system was used to screen patients based on symptoms and exposure. Burn-center admissions were screened at a lower threshold than throughout the institution given the unique nature of burn injury. Eventually, because of increasing community spread, all admissions to the hospital were universally screened with RT-PCR prior to admission. To minimize exposure to non-COVID patients and Burn Center staff, COVID-19 positive burn admissions were assessed on a case-by-case basis. High acuity patients were admitted to the Burn Center and followed by the COVID consult team. Lower acuity patients were admitted to the Burn Center but were treated on the medical COVID unit and followed by the burn consult service. Conclusions The COVID 19 pandemic has strained healthcare systems worldwide. Development and implementation of universal screening, testing, infection-control precautions, and triage strategies are critical elements of burn care during the COVID-19 pandemic. As we prepare for future surges due to more transmissible variants, implementation of standard protocols enables continued provision of quality care, preservation of the healthcare workforce, and efficient use of resources.