46-year old Barbara Schott doesn't remember how the grease fire started. She remembers seeing the horrific burns on her hands and arms, and later, the neat row of stitches on her thigh where surgeons had taken skin grafts to repair her hands. And she says she will never forget the painful months of treatment that followed.
"It was pure agony, having bandages changed, the wounds cleaned, flexing my fingers so that the scars wouldn't freeze up the joints," recalled Schott. "Even though you know it has to be done, and the nurses and doctors are doing everything they can to make it easier -- when it comes time for that appointment, every fiber in your body is in panic mode and wants to run the other way."
Each year, 1.1 million people in the United States suffer burns that require medical attention, many of which, like Schott, will need to undergo multiple skin grafts along with months and possibly years, of treatment.
"Severe burns are both physically and emotionally different from other types of traumatic injuries. Burns cause an inflammatory response in the area that houses the pain receptors. These nerves are continually re-stimulated as wounds heal and undergo treatment," said J. Kevin Bailey, MD, a burn surgeon at the Comprehensive Burn Center at The Ohio State University Wexner Medical Center. "Besides the pain, deep scars are disfiguring and uncomfortable, pulling on healthy skin and limiting movement. It's a long-term healing process that is mentally and physically challenging."
Dr. Bailey is now working with two different research teams to address both of those challenges. But unlike some types of research, their discoveries aren't decades away from reaching patients. By using therapies already approved by the FDA, the scientists hope their innovations can be efficiently and easily translated into a clinical setting.
Patient-controlled anxiolytics could help providers feel calmer, too
Burn wounds require frequent dressing changes and debridement, a painful procedure that removes dead tissue from injury sites. Most patients will receive pain medication to help ease the procedures, but the efficacy of these medications can be undermined by the "wind-up phenomenon."
"It's a complex and poorly understood set of physical and mental symptoms where patients experience high levels of anxiety in the days and minutes leading up to a procedure. These feelings appear to intensify the pain response and make pain medications less effective," said Linda Chlan, PhD, RN, FAAN, distinguished professor of symptom management research at Ohio State's College of Nursing.
To determine the need for anti-anxiety medications, nurses will typically rely on patient feedback, observed patient behavior or physical signs like increased heart rate. However, these are not always accurate measurements of anxiety. Furthermore, nurses can also have become anxious in anticipation of treatment because they know the patient is going to experience pain at their hand. "It's a vicious cycle of pain and anxiety for burn patients and healthcare providers," said Dr. Chlan.
In an effort to stop that cycle, the research team turned to the results of an earlier study conducted by Dr. Chlan which allowed critically ill patients on mechanical ventilation to self-administer a sedative called dexmedetomidine. Dexmedetomidine is frequently used in the intensive care unit (ICU) because it is short-acting and does not depress respiratory function, which is common with other sedative medications.
In Dr. Chlan's study, ICU patients gave themselves pre-measured doses of dexmedetomidine via a monitored IV-fusion pump if they started to feel anxious. The study, published in Chest, showed that patients were able to safely self-administer the medication and were satisfied with their ability to manage anxiety. ICU nurses in the study also said they were satisfied with the results of the patient-controlled-sedation (PCS) for individual patients.
Supported by a grant from Ohio State's Center for Clinical and Translational Science, the research team has just embarked on similar pilot study with burn patients self-administering dexmedetomidine during dressing changes.
"Our hypothesis is that patient controlled anxiolysis (PCA) will improve the patients tolerance of dressing changes and improve both pain and anxiety control in the short term. Long term benefits could include the prevention of psychological complications such as PTSD," said Dr. Chlan.
After completion of the pilot study, the research team hopes to publish the results with the eventual goal of pursuing a larger, randomized controlled study that can provide the kind of data needed to support the use of PCA with dexmedetomidine in a clinical setting.
Dr. Bailey is also hopeful that PCA can soon join the toolbox of personalized anti-anxiety and pain blocking techniques that patients currently use at Ohio State's Burn Center, including controlled breathing, guided imagery, virtual reality and music intervention.
In addition to Drs. Chlan and Bailey, the research team includes Larry M. Jones, MD, director of Ohio State's Burn Center, Rebecca A. Coffey, MSN, CNP, also with Ohio State's Burn Center, Clinical Nurse Specialist Kristin A. Calvitti, MS, RN, ACNS-BC, CMSRN, and Claire V. Murphy, PharmD, BCPS a Specialty Practice Pharmacist, Burn/Surgical Critical Care.
Laser burns holes into scars to regenerate skin
The physical scars caused by severe burn injuries are as long-lasting as the psychological ones, and much more visible. Deep tissue burns and skin grafts can change the skin's flexibility and restrict movement, particularly around joints. "The gold standard for these patients is to conduct additional surgeries or skin grafts to release "locked" tissue so it can flex and stretch again," said Dr. Bailey. "There aren't really any other options."
However, for nearly twenty years, cosmetic surgeons and dermatologists have used lasers to improve the texture and appearance of small scars. Considered a cosmetic procedure, laser resurfacing is not reimbursed by insurance companies. Data around its efficacy and mechanism of action are sparse and the study of lasers to treat severe burns has been limited.
For Dr. Bailey, the cosmetic effect of lasers to reduce scar thickness and discoloration has always offered a tantalizing look at a potential treatment for severe burns. Some types of cosmetic lasers punch hundreds of microscopic holes into tissue, not only causing it to physically collapse but possibly triggering genes to go into healing mode. Dr. Baily conducted an initial study using lasers to help reduce contracture of skin grafts in burn patients, and results confirmed that he was onto something.
"It sounds counter-intuitive to use a laser to burn tissue to help burn injuries, but we saw improvement in healing," said Dr. Bailey. "These lasers allow us to create a microscopic wound never before seen in nature. We think the laser coaxes the body to respond like it would to a lesser type of injury, triggering messages that cause skin to regenerate instead of create more scar tissue."
However, before insurance companies will consider reimbursing their use, Dr. Bailey says he will need proof that they work and details about how they work. Supported by a grant from the CCTS, Dr. Bailey is partnering with Ohio State biomedical engineer Heather Powell, PhD, to gather that evidence. Powell is a past recipient of a CCTS pilot grant researching burn wound repair, providing essential insights to support Dr. Bailey's hypotheses. As a first step, they have created a novel animal model that replicates the response of human skin to severe burns, skin grafts and laser therapy.
"This new animal model is allowing us to generate and gather data that we've never had access to. We're testing the best laser type, optimal window of therapy, use of concurrent medications that prevent scarring, molecular inflammatory responses," said Dr. Bailey. "All these different parameters that will help us deliver the best therapy to the right patient at the right time."
Drs. Bailey and Powell are gathering their initial animal model data now and aim to publish their results in the next six months. "Ultimately, I hope to prove that the use of lasers along with early skin grafts can dramatically reduce the development of contractures and the need for additional surgeries," said Dr. Bailey. "We'll improve outcomes and access. And it's being done with technology that's already sitting in doctors' offices."
Materials provided by Ohio State University Center for Clinical and Translational Science. Note: Content may be edited for style and length.
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