Treatment

Recommendations

Identify and Treat the Cause
1 Take a history and perform a physical examination of the burned skin. Level of Evidence
Not Assessed


Address patient-centered Concerns
2 Provide ongoing support and education that is appropriate for the age, developmental, cognitive, and psychological status of the patient, family, and/or caregivers throughout all phases of recovery. Level of Evidence
Not Assessed
3 Enable the patient to identify the functional implications of his/her individual scar and contribute to planning future needs. Level of Evidence
Not Assessed
4 Ensure adequate pain management using a combination of medications and non-pharmacological techniques to allow for optimum function. Level of Evidence
Not Assessed
5 Discuss with the patient and encourage return to work as soon as possible. Level of Evidence
Not Assessed


Provide Local Wound Care
6 Assess depth, location, extent and etiology of the burn to determine management approaches. Level of Evidence
Not Assessed
7 Provide adequate oral or intravenous pain management to burn patients. Level of Evidence
Not Assessed
8 Debride loose necrotic tissue, cleanse gently with a bland soap, apply appropriate topical antimicrobial agents twice daily, and use appropriate wound dressings. Level of Evidence
Not Assessed
9 Treat superficial and medium-depth partial thickness burns to achieve epithelialization, preserve viable dermal appendages and prevent hypertrophic scarring. Level of Evidence
Not Assessed
10 Use skin grafting and pressure garments as necessary for optimal functional and cosmetic outcomes in deeper partial-thickness wounds and in full-thickness wounds. Level of Evidence
Not Assessed
11 Use early excision and skin grafting whenever feasible. Level of Evidence
Not Assessed
12 Involve the rehabilitation team in patient care as soon as possible after the burn. Level of Evidence
Not Assessed
13 Institute follow-up care for all burn patients for at least 2 months. Level of Evidence
Not Assessed
14 Provide comprehensive patient and family education about wound care, nutrition, avoidance of ultraviolet light, and management of pruritus Level of Evidence
Not Assessed


Provide Organizational Support
15 Empower an interprofessional burn team ensuring involvement of appropriate professionals, e.g., Dietitian, OT, PT, and provide education and support. Level of Evidence
Not Assessed


Background

Initial assessment and management of the burn patient includes attention to the airway, breathing, circulation and thermoregulation. Initial assessment of burns includes depth, location, extent and etiology of the burn.

Initial management

• Pain relief is the initial focus of burn management. Minor burns may be treated effectively with oral analgesics, whereas serious burns usually require intravenous analgesics. Analgesics should be administered before dressing procedures and as needed.

• Debridement of loose necrotic tissue, gentle cleansing with a bland soap and application of dressings constitutes the traditional approach to burn management. The periphery of the wound should be shaved to remove hairs that can harbour bacteria. Blisters with a diameter greater than 1–2 cm should be debrided.

• Initial topical antibiotic therapy should address gram-positive organisms, whereas after longer periods of time, gram-negative flora predominate. Milder antimicrobial agents, such as bacitracin, neosporin, polysporin and mupirocin, are used to treat small and superficial wounds. More potent agents, such as silver sulfadiazine, mafenide acetate and silver nitrate, may delay epithelialization. These agents are used to prevent bacterial invasion of extensive and deeper wounds. Topical antibiotic therapy is typically administered twice daily until complete epithelialization has occurred.

Clinical approaches

Approaches to clinical management differ, depending on burn wound depth:

• Superficial and medium-depth partial thickness burn wounds: Management objectives are uncomplicated epithelialization, usually within 10–14 days, with preservation of viable dermal appendages and prevention of hypertrophic scarring.

• Deeper partial-thickness wounds: These burns may require pressure garments to minimize hypertrophic scar formation. If healing has not occurred by 10–14 days, consideration should be given to skin grafting, which decreases scarring and speeds healing and recovery of function.

• Full-thickness wounds: As all dermal appendages are destroyed, skin grafting is required to prevent contraction. Grafting can address functional and cosmetic issues in wounds covering <35% total body surface area (TBSA). With larger wounds, the focus of grafting is survival and recovery of function.

Surgical management

No prospective randomized trials have compared early excision with grafting after wound separation. However, the treatment of choice is now early excision and grafting. Selection of patients for surgical excision includes consideration of the following factors:
• Patient age
• Extent and location of the burn:
o In the management of small burns, full-thickness grafts with primary closure of the donor site produce minimal morbidity and excellent functional and cosmetic results.
o Sheet grafts are ideal for the face and burns covering <40% TBSA. Burns >40% TBSA may require skin expansion with a meshing device.
o For burns >25% TBSA, excision is usually initiated 3–5 days after injury. Indeterminate-depth wounds may require 10–14 days to determine the need for grafting.
o For massive burns (>40–50% TBSA) serial excision is performed every 2–3 days until the entire eschar has been removed, followed by skin grafting or use of biosynthetic dressings.
o Optimal function and cosmetic results are achieved by grafting critical areas first.
• Associated injuries and illnesses
• Availability of autologous and allogeneic skin
• Excisional timing, location and technique
• Selection of graft donor sites.

Negative pressure wound therapy may assist in securing difficult skin grafts and optimize vascularization of matrix products.

Rehabilitation

Comprehensive rehabilitation begins as soon as possible after injury and usually involves a rehabilitation team. Successful functional and cosmetic outcomes may involve early range-of-motion exercises, appropriate positioning, pressure garments, splinting, and pressure facemasks. Pressure on healed wounds must be maintained 23 hours per day and used until scars have matured, approximately 12–18 months.

Follow-up care

Follow-up care of all partial- and full-thickness burns is critical. If wounds have epithelialized within 2–3 weeks of injury, patients should be followed for at least 2 months to monitor re-pigmentation and development of scar hypertrophy. Wounds healing in more than 3 weeks or requiring grafting may need pressure therapy.

Patient and family education is critical and should include instructions for wound care, appropriate nutrition to support wound healing and avoidance of ultraviolet light exposure for at least 1 year. Pruritus, which is common, should be managed to prevent scratching and damage to the healed skin

References

Essential Publications
1 Anticonvulsant drugs Quality Indicator
 Type: Systematic review
Wiffen P, Collins S, McQuay H, Carroll D, Jadad A, Moore A. Anticonvulsant drugs for acute and chronic pain. Cochrane Database of Systematic Reviews 2005, Issue 3.
A well-organized, well-conducted systematic review with important implications for practice and research. There is however a lack of evidence showing that anticonvulsants have a beneficial effect on acute pain.
2 Hyperbaric oxygen therapy Quality Indicator
 Type: Systematic review
Villanueva E, Bennett MH, Wasiak J, Lehm JP. Hyperbaric oxygen therapy for thermal burns. Cochrane Database of Systematic Reviews 2004, Issue 2.
This is a well-conducted systematic review that highlights the need for more evidence related to the topic of HBOT effectiveness, with important implications for both practice and research. In one RCT, the mean healing time was 19.7 days in those patients treated with HBOT versus the control group(mean: 19.7 versus 43.8 days. Adverse events (pulmonary barotrauma, drug reactions, injury or death related to chamber fire) however were also reported from the treatment group.
3 Hyperbaric oxygen therapy Quality Indicator
 Type: Systematic review
Saunders PJ. Hyperbaric Oxygen Therapy in the Management of Carbon Monoxide Poisoning, Osteoradionecrosis, Burns, Skin Grafts, and Crush Injury. International Journal of Technology Assessment in Health Care 2003; 19(3): 521-5.
Review concludes that there is no convincing evidence that HBO2 is of benefit for the treatment of CO poisoning (severe or moderate), osteoradionecrosis, burns, skin grafts, or crush injury, and there is no case for a unit in the West Midlands region.
4 Lidocaine treatment Quality Indicator
 Type: Systematic review
Wasiak J, Cleland H. Lidocaine for pain relief in burn injured patients. Cochrane Database of Systematic Reviews 2007, Issue 3.
Study shows poor quality of RCTs and CCTs as there were no clinically relevant outcomes. Despite this, however, the review clearly states what it would have proceeded to do had better studies existed, and provides important implications for research.
5 Photodamaged skin Quality Indicator
 Type: Systematic review
Samuel M, Brooke RCC, Hollis S, Griffiths CEM. Interventions for photodamaged skin. Cochrane Database of Systematic Reviews 2005, Issue 1.
This study examines a large scope of interventions pertaining to photodamaged skin, and has included a large number of RCTs. There is conclusive evidence that topical tretinoin improves the appearance of mild to moderate photodamage on the face and forearms, in the short term. However, erythema, scaling/dryness, burning/stinging and irritation may be experienced initially.
6 Toxic epidermal necrolysis Quality Indicator
 Type: Systematic review
Majumdar S, Mockenhaupt M, Roujeau J-C,Townshend A. Interventions for toxic epidermal necrolysis. Cochrane Database of Systematic Reviews 2002, Issue 4.
No reliable evidence for the benefits of thalidomide treatment. Treatment with thalidomide was not shown to be effective and was associated with significantly higher mortality rates then placebo. The study was terminated as the mortality on the treatment arm was 83% compared to 30% on the control arm (relative risk 2.78, 95% CI 1.04-7.40).The study highlights contradictions in evidence and need for better RCTs.
7 Carbamazepine Quality Indicator
 Type: Systematic review
Wiffen PJ, McQuay HJ, Moore RA. Carbamazepine for acute and chronic pain. Cochrane Database of Systematic Reviews 2005, Issue 3.
Study highlights the need for better RCTs, and concludes that there is insufficient evidence to promote the use of carbamazepine for acute pain due to the small trial size. Two studies however did show NNT of effectiveness of 1.8 (95% Ci 1.4-2.8)
8 Early enteral nutrition Quality Indicator
 Type: Systematic review
Wasiak J, Cleland H, Jeffery R. Early versus delayed enteral nutrition support for burn injuries. Cochrane Database of Systematic Reviews 2006, Issue 3.
This review highlights the need for more evidence pertaining to this subject using larger sample size and more rigorous methodology. The evidence recovered from 3 studies concerning the benefit of early enternal nutrition support on standardized clinical outcomes including LOS and mortality were inconclusive
9 Early enteral nutrition Quality Indicator
 Type: Systematic review
Marik PE, GP Zaloga. Early Enteral Nutrition in Acutely Ill Patients: A Systematic Review. Critical care medicine 2001: 29(12): 2264-70.
The results indicate that early feeding decreases infectious complications (p = 0.00006) and length of stay (p = 0.002). There results however should be interpreted with caution because of the significant heterogeneity between studies.
10 Early enteral nutrition Quality Indicator
 Type: Systematic review
Wasiak J, Cleland H, Jeffery R. Early Versus Late Enteral Nutritional Support in Adults with Burn Injury: A Systematic Review. Journal of Human Nutrition & Dietetics 2007; 20(2): 75-83.
In this systematic review of RCTs and CCTs, the quality of the individual studies was poor and the findings inconclusive. As a result, more well-designed studies are required to explore the benefits of early enternal nutritional support.
11 Silicone gel sheeting Quality Indicator
 Type: Systematic review
O’Brien L, Pandit A. Silicon gel sheeting for preventing and treating hypertrophic and keloid scars. Cochrane Database of Systematic Reviews 2006, Issue 1.
This is a good systematic review of RCTs and quasi RCTs, non-randomized trials. No differences were found between treatment with silicon gel sheeting versus control for improvement in scar colour, appearance, elasticity or relief of itching or pain in persons with keloid or hypertropic scars. Generally the reviewed studies were of poor quality indicating the need for further rigorous investigation of this topic.
12 Topical negative pressure Quality Indicator
 Type: Systematic review
Wasiak J, Cleland H. Topical negative pressure (TNP) for partial thickness burns. Cochrane Database of Systematic Reviews 2007, Issue 3.
Review examined studies measuring the rate of change in wound area and adverse treatment events. One study reported a significant difference in burn size at day 3 (p < 0.09) and day 5 (p < 0.04), but none by day 14. No conclusive evidence was recovered. As a result, this study highlights the need for better quality RCTs on TNP as sample size was limited and the methodology to detect differences was inadequate.
13 Tramadol Quality Indicator
 Type: Systematic review
Hollingshead J, Dühmke RM, Cornblath DR. Tramadol for neuropathic pain. Cochrane Database of Systematic Reviews 2006, Issue 3.
Data shows that tramadol is an effective treatment for neuropathic pain. Four trials showed that with tramadol treatment compared to placebo showed the NNT to reach at least 50% was 3.8 (95% CI 2.8-6.3).
14 Immunonutrition Quality Indicator
 Type: Systematic review
Montejo JC, Zarazaga A, Lopez-Martinez J, Urrutia G, Roque M, Blesa AL, Celaya S, Conejero R, Galban C, Garcia de Lorenzo A, Grau T, Mesejo A, Ortiz-Leyba C, Planas M, Ordon~ez J Jimenez FJ. Immunonutrition in the Intensive Care Unit. A Systematic Review and Consensus Statement. Clinical Nutrition 2003; 22(3): 221
This well-conducted systematic review contains important, detailed recommendations for future studies and systematic reviews illustrating the improvement in infection rate and length of hospital stay with pharmaconutrients. The use of diets enriched with pharmaconutrients could be recommended in ICU patients requiring enteral feeding. More investigation are however required in order to target the appropriate population of patients that can benefit from this nutritional therapy
15 Honey wound dressing Quality Indicator
 Type: Systematic review
Moore OA, Smith LA, Campbell F, Seers K, McQuay HJ, Moore RA. Systematic Review of the use of Honey as a Wound Dressing. BMC Complementary & Alternative Medicine 2001
This review highlights the lack of high-quality studies. Nonetheless, the potential benefits of honey treatment for wound healing and infection rates have been elucidated, but these findings are inconclusive.
16 Early excision of burns Quality Indicator
 Type: Systematic review
Ong YS, Samuel M, Song C. Meta-Analysis of Early Excision of Burns. Burns 2006; 32(2): 145-50.
Detailed systematic review with specific conclusions stating that patients receiving early excision treatment had significantly higher blood transfusion requirements (SMD 1.65 95% CI 0.51-2.80), but shorter hospital stays (WMD 8.89, CI 14.28-3.5). The need for better studies is however communicated as a number of out comes (wound healing time, duration of sepsis, operating room hours and long term morbidity) could not be pooled because of differences in outcome definition or the absence of relevant data.
17 Cerium Nitrate Treatment Quality Indicator
 Type: Systematic review
Garner JP, Heppell PSJ. Cerium Nitrate in the Management of Burns. Burns 2005; 31(5): 539-47.
This systematic review examined the benefit of cerium nitrate as a topical treatment for cutaneous burns. Data showed reduced mortality and morbidity by 50% in the treatment of severe burns. This benefit is derived from its ability to bind and denature the lipid protein complex liberated from burnt skin. The methodology of this study however, was poor and requires improvement.
18 Exogenous erythropoietin Quality Indicator
 Type: Systematic review
MacLaren R, Gasper J, Jung R, Vandivier RW. Use of exogenous erythropoietin in critically ill patients. Journal of Clinical Pharmacy and Therapeutics 2004; 29: 195–208.
rHuEPO reduces the need for transfusions. However, defining an optimal dosage regimen, identifying patients most likely to respond to rHuEPO, and determining risk factors for ICU associated anemia would provide information for appropriate rHu- EPO utilization.
19 Silicone Quality Indicator
 Type: Systematic review
Fette A. Influence of Silicone on Abnormal Scarring. Plastic Surgical Nursing 2006; 26(2): 87-92.
The study quality was not considered, although the methodology was poor and overall evidence low. Despite this occlusive silicone cream treatment versus petroleum jelly was successfully tested in split and full-thickness skin grafts, resulting in significantly less pigmentation and hardness (78%), less marginal scar hypertrophy (37%), redness (26%), and in an even narrower marginal scar (22%). Nonetheless, a reliable and validated animal model would be essential for further well-structured research.
20 Keloids and Hypertrophic Scars Quality Indicator
 Type: Systematic review
Leventhal, D, Furr M, Reiter D. Treatment of Keloids and Hypertrophic Scars. Arch Facial Plast Surg. 2006; 8:362-368.
Review examined studies that measures success rate of various therapies and found a mean rate of 60% from all the studies. Additional research needs to be done to determine whether factors such as location, depth and duration of lesion, patient ethnicity, or prior response to therapy have any influence on treatment outcome.
21 Prevention of Pressure Sores Quality Indicator
 Type: Systematic review
Gordon MD, Helich MM, Helvig EI, Marvin JA, Richard RL. Review of Evidence-Based Practice for the Prevention of Pressure Sores in Burn Patients. J Burn Care Rehabil 2004; 25: 38-410.
This systematic review examined the current evidence of practice in nursing, nutrition, and rehabilitation as it pertains to the prevention of pressure sores after burn injuries. They found insufficient data necessary for the characterization of nutrition assessment standards to prevent and treat pressure sores in burn patients It was however found that patient positioning is thought of as a physical approach to the prevention of burn scar contracture. Final research questions were generated towards the uultimate goal being the development of evidence-based practice guidelines.
22 High release nanocrystalline silver dressing Quality Indicator
 Type: RCT
Huang Y, Li X, Liao Z, Zhang G, Liu Q, Tang J, Pang Y, Liu X, Lou Q. A randomized comparative trial between Acticoat and SD-Ag in the treatment of residual burn wounds, including safety analysis. Burns 2007; 33(2):161-166.
In this well designed multi-centre RCT comparing Acticoat with SD-Ag, a non-significant trend toward Acticoat having shorter healing time was detected. As well, this study suggests significant evidence supporting the efficacy of Acticoat in bacterial clearance.
23 High release nanocrystalline silver dressing Quality Indicator
 Type: RCT
Muangman P, Chuntrasakul C, Silthram S, Suvanchote S, Benjathanung R, Kittidacha S, Rueksomtawin S. Comparison of efficacy of 1% silver sulfadiazine and Acticoat for treatment of partial-thickness burn wounds. Journal of the Medical Association of Thailand 2006; 89(7): 953-958.
Study confirms the advantages of Acticoat as a less painful alternative to wound care. Average pain scores in patients treated with Acticoat (4 ± 0.6) were significantly lower then those treated with 1% Ag-SD (5 ± 0.7). There were however no significant difference between wound and LOS between both groups (p > 0.05). The 1% AgSD treatment group received more split thickness skin grafts compared to patients treated with acticoat, but this was not significant (p = 0.32).
24 Silver Sulfadiazine Treatment Quality Indicator
 Type: RCT
Mashhood AA, Khan TA, Sami AN. Honey compared with 1% silver sulfadiazine cream in the treatment of superficial and partial thickness burns. Journal of Pakistan Association of Dermatologists 2007; 16(1): 14-19.
This is a RCT that explores the benefits in terms of healing rate, pain relief and bacterial clearance from honey treatment in comparison to 1% silver sulfadiazine. Patients treated with honey had their burns healed completely by 4 weeks versus 6 weeks in the 1% silver sulfadiazine group. As well, all patients in the treatment group were pain free by 3 weeks, while in the 1% silver sulfadiazine group this took 4 weeks. It took 3 weeks and 5 weeks for a positive swab culture from the wound to get sterile with honey and 1% silver sulfadiazine respectively.
25 Surprathel skin substitute Quality Indicator
 Type: RCT
Uhlig C, Rapp M, Hartmann R, Hierlemann H, Planck H, Dittell KOKI. Surprathel- An innovative, resorbable skin substitute for the treatment of burn victims. Burns 2007; 33(4): 221-229.
A good preliminary study examining the benefits of Surprathel in comparison to conventional paraffin gauze or Omiderm indicating that there was significantly less pain with Surprathel than with paraffin gauze or Omiderm. Surprathel is a porous membrane and its described production course guarantees a nearly symmetrical cross-section of the membrane with an interconnected structure of pores.
26 Suprathel skin substitute Quality Indicator
 Type: RCT
Schwarze H, Kuntscher M, Uhlig C, Hellmann H, Prantl L, Noack N, Hartmann B. Suprathel, a new skin substitute, in the management of donor sites of split-thickness skin grafts: Results of a clinical study. Burns 2007; 33(7):850-854.
This two-centre RCT demonstrated the medical benefits of Suprathel on wound healing, patient comfort and ease of care. Suprathel® represents an absorbable, synthetic wound dressing with properties of natural epithelium. Suprathel treated patients had a significantly lower pain score, and as compared to Jelonet had better plasticity and attachment to wound surfaces (p = 0.0002). There was no significant difference between Suprathel and Jelonet with regards to healing time and re-epithelization (p = 0.5). The material effectiveness contributes to the reduction of overall treatment cost.
27 Cultured skin substitutes Quality Indicator
 Type: RCT
Boyce ST, Kagan RJ, Greenhalgh DG, Warner P, Yakuboff KP, Palmieri T, Warden GD. Cultured skin substitutes reduce requirements for harvesting of skin autograft for closure of excised, full-thickness burns. Journal of Trauma-Injury Infection & Critical Care 2006; 60(4): 821-829.
The data obtained from this prospective study suggests that cultured skin substitutes (CSS) consisting of autologous cultured keratinocytes and fibroblasts that attaches to collagen-based sponges provides medical benefits and reduced complications for closure of burn wounds greater then 50% TBSA. The ratio of closed wound: donor skin areas for CSS at post-operative day 28 was significantly greater than for conventional 4:1 meshed autografts (p < 0.01). The percentage of total body surface area closed with CSS at post-operative day 28 was significantly less then AG (P < 0.05).
28 Cultured autologous keratinocytes skin substitute Quality Indicator
 Type: RCT
Magnusson M, Papini RP, Rea SM, Reed CC, Wood FM. Cultured autologous keratinocytes in suspension accelerate epithelial maturation in an in vivo wound model as measured by surface electrical capacitance. Plast. Reconstr. Surg. 2007; 19(2): 495-499.
This double-blinded, RCT analyzes the difference between cultured epithelial autografts and Dulbecco's Modified Eagle's Medium for the treatment of acute wounds. A statistically significant difference in surface electrical capacitance observed in the cultured epithelial autograft compared with the Dulbecco's Modified Eagle's Medium treated wounds at 5 days (p = 0.012) and 7 days (p = 0.036). It demonstrates that healing rate increased with the cultured epithelial autograft treatment.
29 Intensive rehabilitation therapy Quality Indicator
 Type: RCT
Okhovatia F and Zoubine N. A comparison between two burn rehabilitation protocols. Burns 2007; 33(4): 429-434.
This group match clinical trial examines the feasibility and efficacy of a more intensive burn rehabilitation therapy that proves more effective for preventing burn contractures then ordinary rehabilitation protocol and a trend toward shorter LOS. Due to the immobilization with ordinary rehabilitation protocol there was a 67% increase in burn scar contracture in group I (p < 0.01). here was no significance difference between groups (p > 0.05) for thrombosis and duration of stay in the hospital. Despite this insignificance, additional BRT releases patients 4 days earlier from the hospital, which helped reduce hospital costs.
30 Early enternal resuscitation and feeding Quality Indicator
 Type: RCT
Venter M, Rode H, Sive A, Visser M. Enternal resuscitation and early enternal feeding in children with major burns- Effect of McFarlane response to stress. Burns 2007; 33(4): 464-471.
This paper discusses the benefits of early resuscitation and enternal feeding in young infants and children for improved healing of major burns with reduced hormonal stress. The ER and EEF group showed an anabolic response with significantly higher insulin concentrations (p = 0.008) and insulin: glucose ratios (p = 0.043). Growth hormone concentration were significantly higher in the LEF group (p = 0.03).
31 Xenogenic acellular dermal matrix Quality Indicator
 Type: RCT
Fang X, Shen R, Tan J, Chen X, Pan Y, Ruan S, Zhang F, Lin Z, Zeng Y, Wang X, Lin Y, Wu Q. (2007). The study of inhibiting systematic inflammatory response syndrome by applying xenogenic (porcine) acellular dermal matrix on second-degree burns. Burns 2007; 33(4): 477-479.
This study indicates that use of xenogenic acellular dermal matrix versus bedtime ointment gauze in patients with second-degree burns results in lower CRP levels indicating less SIRS.
32 Trace element supplementation Quality Indicator
 Type: RCT
Berger MM, Baines M, Raffoul W, Benathan M, Chiolero RL, Reeves C, Revelly JP, Cayeux MC, Senechaud I, Shenkin A. Trace element supplementation after major burns modulates antioxidant status and clinical course by way of increased tissue trace element concentrations. Am.J.Clin.Nutr. 2007; 85(5): 1293-1300.
Randomized, placebo-controlled trial that examines the benefit of TE supplementation after major burns leading to reduced number of infectious complications and better wound healing. The number of infections was significantly lower in the TE group (p = 0.015) as a result of a reduction in pulmonary infection in the TE group (p = 0.03). Wound healing was improved in the TE group with lower requirements for re-grafting (p = 0.02).
33 Fenofibrate Quality Indicator
 Type: RCT
Cree MG, Zwetsloot JJ, Herndon DN, Qian T, Morio B, Fram R, Sanford AP, Aarsland A, Wolfe RR. Insulin sensitivity and mitochondrial function are improved in children with burn injury during a randomized controlled trial of fenofibrate. Ann. Surg. 2007; 245(2): 214-221.
This double-blind, placebo-controlled randomized trial examines the drop in glucose concentrations following fenofibrate treatment and suggests that it is effective as a new therapy for treating insulin resistance following severe burn injury. Average daily glucose concentration in the fenofibrate group was less then the control group (p = 0.003).
34 Silicone gel sheeting Quality Indicator
 Type: RCT
Li-Tsang CW, Lau JC, Choi J, Chan CC, Jianan L. A prospective randomized clinical trial to investigate the effect of silicone gel sheeting (Cica-Care) on post-traumatic hypertrophic scar among the Chinese population. Burns 2006; 32(6): 678-683.
This study offers a comprehensive analysis into the addition of silicone gel sheeting (SGS) treatment to post-traumatic hypertrophic scar protocol among Chinese individuals as it was effective to reduce thickness, pain, itchiness and pliability of the scar. Scar thickness was significantly less in the SGS group than in the MT group at 2 months (p = 0.008) and 6 months (p < 0.001). There was no statistically significance between pain and itchiness between the two groups. The scars in the SGS group became softer, more pliable and the improvement between the two groups were significant in 2 months (p = 0.008), 4 months (p = 0.004) and 6 months (p < 0.001).
35 Negative pressure closure Quality Indicator
 Type: RCT
Llanos S, Danilla S, Barraza C, Armijo E, Pineros JL, Quintas M, Searle S, Calderon W. Effectiveness of negative pressure closure in the integration of split thickness skin grafts: a randomized, double-masked, controlled trial. Ann. Surg. 2007; 244(5): 700-705.
This randomized, double-masked, controlled trial examines the benefits of negative pressure closure (NPC) for both healing, as it diminishes the loss of split thickness skin grafts (STSG) area, and decreased hospital stay. The medium loss of STSG in experimental NPC patients was 0.0 cm² versus 4.5 cm² in the control group (p = 0.001). The medium hospital stay was 13.7 days in the experimental NPC group versus 17 days in the control group (p < 0.001).
36 Enteral arginine supplementation Quality Indicator
 Type: RCT
Marin VB, Rodriguez-Osiac L, Schlessinger L, Villegas J, Lopez M, Castillo-Duran C. Controlled study of enteral arginine supplementation in burned children: impact on immunologic and metabolic status. Nutrition 2006; 22(7-8): 705-712.
This double-blind, randomized, placebo-controlled trial investigates the potential benefits of using arginine-supplemented diets on burned children to improve mitogen-stimulated lymphoproliferation. Responses varied between the two groups on day 7 as the experimental group showed 144% increase in lymphoproliferation response (p < 0.05) while the control group only showed a 56% increase. Both groups however returned to normal baseline levels by day 14.
37 Glutamine granule-supplemented enteral nutrition Quality Indicator
 Type: RCT
Peng X, Yan H, You Z, Wang P, Wang S. Glutamine granule-supplemented enteral nutrition maintains immunological function in severely burned patients. Burns 2006; 32(5): 589-593.
This double-blind, RCT study examines the benefit of glutamine granule supplement to help heal and build immunological function in a severally burned patient. Wound healing was better and hospital stay days reduced in the glutamine group (46.59 ± 12.98 days versus 55.68 ± 17.36 p < 0.05). There was no significance difference between groups (p > 0.05) for thrombosis and duration of stay in the hospital.
38 Growth Hormone Quality Indicator
 Type: RCT
Przkora R, Herndon DN, Suman OE, Jeschke MG, Meyer WJ, Chinkes DL, Mlcak RP, Huang T, Barrow RE. Beneficial effects of extended growth hormone treatment after hospital discharge in pediatric burn patients. Ann. Surg. 2006; 243(6):796-801.
This double-blinded RCT conveys how rhGH treatment can markedly improve recovery, body composition, body function and hormone metabolism in severely burned children following hospital discharge and with fewer reconstructive procedures then with the placebo. rhGH treatment significantly improved height, weight, muscle strength, lean body mass, bone mineral content and cardiac function (p < 0.05) the number of operative reconstructive procedures was significantly lower in rhGH treatment group (p < 0.05).
39 Topical morphine Quality Indicator
 Type: RCT
Welling A. A randomized controlled trial to test the analgesic efficacy of topical morphine on minor superficial and partial thickness burns in accident and emergency departments. Emergency Medicine Journal 2007; 24(6): 408-412.
This placebo-controlled RCT examined the potential benefits of topical morphine on superficial burns and chronic inflammatory wounds and found it to be ineffective. There were no significant differences between the pain scores found among the three treatments (p = 0.217, but the morphine group was administered the greatest amount of analgesia.


Enablers for practice

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