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Hospital acquired infection (HAI) is an infection that is acquired when the patient is admitted to a hospital or a health care facility for any reason other than that infection. The infection should not have been present or incubating prior to the patient’s being admitted to the hospital.

Sites of hospital acquired infections:

  • Burns and wounds: When a burn injury happens, the skin barrier will be broken and the body will become more vulnerable for all kinds of infections not only hospital acquired infections; this may as a result increase the risk of sepsis and septic shock.
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Treatment of severe burns is still one of the challenging issues for physicians and necessitates the collaboration of a multidisciplinary team due to the magnitude of the injury. Many patients with serious burns require ICU admission for their management in order to minimize morbidity and mortality. Despite the modern advances in the treatment of burns, still the mortality rate is high in patients with extensive burns with infection being a major cause of death. (Thompson, Herndon, Abston and Rutan, 1987) found that early excision of dead tissue (burn eschar) decrease the incidence of invasive burn infection and sepsis, improves the patient’s outcome and decreases the duration of hospital admission.

Burned patients are also at higher risk of developing infection and sepsis from catheters and central lines. A central line is a long, thin, soft plastic tube that is introduced through a small cut in the skin into a large vein to administer fluids, blood products, nutrients and medications over an extended period of time. It is often placed in patients who require care in the intensive care unit to provide nutrition, medication and fluids. Infection can be one of the complications associated with the use of a central venous line which can be caused by bacteria and/or fungi. Other complications may include bleeding, pain, blockage, kinking or shifting of the line, air embolism and lung collapse.

As the central venous line is introduced through an opening in the skin, bacteria can grow in this line making the patient more susceptible for blood born infection. Infections associated with a central venous line can be very serious as the bacteria causing these infections can multiply and spread quickly to the entire blood stream causing septicemia which can be fatal.

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Diabetes mellitus (DM) is a disease with an increasing incidence worldwide including the US. It is expected to reach 15/1000 in the United States by the year 2050. Most burns in patients with diabetes are due to contact with hot objects or scalds. Patients with diabetes especially if uncontrolled are usually associated with poorer prognosis with more complicated and longer hospital stay compared to healthy people and need special attention as they will form a large percent of burn center and hospital admission in the future.

Diabetes mellitus is a chronic disease that has many complications, among which is the effect of diabetes on the blood vessels leading to damage, narrowing and/or blockage of the blood vessels, leading to peripheral vascular disease (PVD) that results in the alteration of blood perfusion and subsequent reduction in the oxygen and nutritional delivery to the tissues which will affect wound healing.

Diabetes can also affect the nerves leading to nerve damage (diabetic peripheral neuropathy); nerves affected by the disease are usually responsible for temperature, pressure, texture and pain sensation. The nerves of the lower legs and feet when affected can lead to insensitivity to temperature and pain in the legs and feet and patients may experience numbness and tingling sensation in these areas.

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Bedsores or bed ulcers are areas of ulcerated or damaged skin that happens when the skin and underlying tissue over a bony prominence is compressed between that bony prominence and an external surface for a prolonged period of time, the unrelieved pressure on the skin and underlying tissue will lead to compression of the blood supply to that area. As a result of the decreased blood supply and oxygen the skin begins to die forming an ulcer. Friction of the skin created by the body sliding over a bed sheet, etc contributes also to the skin injury and the formation of ulcer, too much moister such as sweat and urine may also contribute to the formation of an ulcer. Although pressure ulcers can happen anywhere in the body, the hips, heals and buttocks are common sites.

Risk factors:

  • Persons at a high risk of developing pressure ulcers are those who are immobile due to an injury or an illness such as third  degree burns. Any injury or illness that leads to immobility or causes the patient to be bedridden for a long time will increase the risk of pressure ulcers.
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Compartment Syndrome:

A compartment is defined as a closed space of nerves, muscle tissue and blood vessels. This space is surrounded by fascia (thick layer of tissue) that doesn’t stretch. When the pressure inside the compartment increases from any cause and if the pressure increases substantially, this may lead to the compression of the nerves, blood vessels and muscles inside the compartment. The result may be impaired blood flow and reduced oxygenation that may result in muscle and nerve damage. Compartment syndrome most commonly involves the forearm and lower leg although it can occur in other places.

In third degree burns the pressure increases due to fluid retention and edema (swelling) causing compression of muscles, nerves and blood vessels which will lead to ischemia (reduction in blood flow) and necrosis (death) of tissue if not managed quickly.

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Third degree burns are burns that causes injury to all  layers of the skin (epidermis, dermis and subcutaneous tissue), it may also damage the muscles and bones. These burns are serious and may result in extensive scarring as well as other injuries and limitations. Third degree burns are vulnerable for  many complications, some of which are due to  the burn injury itself while others are due to the reaction of the body during treatment and healing process.

Complications may include:

Burn Infection:

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During the recovery process, burned patient begins to heal both physically and emotionally. Some patients and depending on the severity of the burn injury (second and third degree burns) will go through painful procedures and treatments and start to be aware of the impact of the injury and how their injuries have changed their lives as some may lose loved ones and some may lose everything they have worked for.

Patients in this stage may experience sleep disturbance due to many factors including being in a hospital environmental with the lights and the staff awakening them for medication and vital signs checking. Anxiety and depression as a result of the burn also play a role in sleep disturbance so as nightmares, agitation and pain for the burn injuries. Psychological issues (pre-burn) such as depression may have an adverse effect on the outcome of the patient. These patients may stay in the hospital for a longer time and may have more severe psychological consequences after the injury.

Anxiety and depression counseling may be helpful to reassure the patient that after a trauma like this, it’s not uncommon to experience these symptoms and these symptoms may disappear on their own with time. Sometimes medication may be needed in addition to counseling.

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Nutritional support is considered as a critical component in the treatment and wound healing of patients suffering from burn injuries (second and third degree burns). The aim of the nutritional support is to provide enough nutrients and supplements either enteral (feeding using the gastrointestinal tract such as oral or feeding tube) and/or parenteral (intravenous infusion) to meet the body demands in response to the metabolic changes that happen in moderate to severe burns. It have been shown that the early introduction of enteral feeding in the burned patients is vital for survival (Rodriguez et al, 2011).

When a burn happens and depending on the severity of the burn, the body react to the injury by increasing the production and secretion of certain hormones which in turn cause an increase in the metabolic demand (hypermetabolic response) that will result in the need of more nutritional support which may sometimes be accompanied by alteration in the carbohydrate, protein and fat breakdown.

The nutritional needs of the patient can be assessed in many ways taking into consideration many factors including the age of the patient, body weight, the percentage of the body surface area burned among other factors. The Curreri formula is used for adults and children. The Harris-Benedict formula is used for adults and the Galvaston formula used for children. Dietitians and treating doctors will assess, monitor, and adjust the nutritional needs frequently as the patient’s condition improves or deteriorates.

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Treatment may not stop itching completely but help in decreasing the severity of itching. Some patients may need more than one treatment option depending on the intensity of itching and the quality of life affected. Your treating physician or care provider will determine the best treatment for you.

Treatment may include:

1- Oral medications:

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Itching is the feeling or sensation that leads to the desire to scratch. Itching is a normal part of the healing process and most patients recovering from burn injuries experience itching at some point during their recovery. The itching sensation happens due to the activation of sensory neurons that have their peripheral nerve endings situated on the surface of the skin (Stein, 1983).

There prevalence of itching to happen post burn is high; it initially affects more than 90% of burned patients (Carrougher et al, 2013). When the skin is burned, the oil glands (Pilosebaceous glands) location in the skin will be damaged. These gland are responsible for secreting an oily material (sebum) that lubricates the skin and keep it moist. As a result of the lack of these glands in the healing and scar tissue, the skin will be dry leading to the sensation of itching that can be problematic and distressing to the patient.

The severity of itching varies from one patient to another; the frequency of itching and its intensity may not be related to the severity and size of the burned area. Itching may be so severe that it may interfere sleeping, eating, working, moving and the quality of life of the patient. Anything that increases the temperature of the body may lead to an increase in the itching sensation (due to an increase in the histamine release which is one of the mediators of itching) such as physical activities including sports and exercise.

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