E43 Masterclass with Sarvesh Logsetty On Burns

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Chad Ball  00:00

This week on Cold Steel…

Sarvesh Logsetty  00:03

The thing that appealed to me the most about it was the whole idea of a team. It’s a team approach to everything else that is an ongoing component from the acute burn care to the chronic and the scar management and getting people back in to work. It’s very different than the other aspects of surgery that I do. You know, the appys (appendectomy) and the gall bladders and things like that, where it’s kind of like, okay, great. Your appendix is in the bucket.

Chad Ball  00:36

Welcome to Cold Steel, the Canadian Journal of Surgery podcast with your hosts Ameer Farooq and Chad Ball. The goal of the CJS podcast is threefold. The first is to highlight the best research currently being completed by Canadian surgeons. Second is to offer educational topics for both surgeons and trainees alike. And most importantly, the third goal is to inspire discussion, thoughts, creativity and career development in all Canadian surgeons. We hope you enjoy it.

Ameer Farooq  01:17

In this episode, we get all fired up about burn care. Dr. Sarvesh Logsetty is a burn surgeon at the University of Manitoba. In this episode, we talk about training pathways for burn surgeons, burn resuscitation, operative management of burns, and finally, about Dr. Logsetty’s innovative research into burn wound management.

Chad Ball  01:37

First of all, we know how busy you are. And we see that to all our guests because it really is true, but we’d like to thank you so much for being on Cold Steel today. You know, there’s there’s a couple of different styles of podcasts as as you as you know, from our chat, and we’re hoping that this one could surround the concept of burn care in in a CME style. And there’s certainly no one else, you know, without question, at least in Canada and probably North America that comes to my mind more quickly than the you when it comes to burn expertise. But before we launch into that, I was wondering if you could tell our listeners who maybe don’t know you as well as we do, where you grew up, what your training pathway was, how you ended up in Winnipeg, and why a burn surgeon?

Sarvesh Logsetty  02:24

Well, Chad, thank you very much for the privilege of being on the podcast, it was an honor. It you know, your accolades are, you know, they’re kind. But there are a lot of people that I I there have been my mentors and any achievements I have is because of the the giants that have helped me along the way and still are taking care of burns and in a way more than I do. So thank you for your your statement though. I started in Edmonton as I grew up there, and I went to medical school at the University of Alberta, and wanted to do general surgery. So I ended up at the University of Toronto for general surgery. And I always wanted to do some overseas work and global channels, like global surgery. And after I finished my general surgery residency, I realized that, you know, our current residency is not adequate to train people who have come you know Third World surgeons. So I spent a year and created a fellowship for myself where I was doing C-sections and some cranis (craniectomy) and a bit of vascular surgery and orthopedic surgery and learning how to do ORAF’s and things like that. And one day, I was walking down the hallway and ran into a former senior resident of mine who mentored me previously Joel Fish, and I said, Hey, Joel, what are you doing here? and Joel says, oh, I’m head of the burn unit. So I said, burns, oh, my God, that’s an area that I completely did not think about when I was planning my year. And then said, hey, can I come work with you. And Joel is an incredibly enthusiastic and energetic individual who just instilled in me a sense of wonder about burn care. And the thing that appealed to me the most about it was the whole idea of a team. It’s a team approach to everything else that is an ongoing component from the acute burn care to the chronic and the scar management and getting people back in to work. It’s very different than the other aspects of surgery that I do, you know, the appys (appendectomy) and the gall bladders and things like that, where it’s kind of like, okay, great. Your appendix is in the bucket. See you later.

Ameer Farooq  04:40

We really, as Dr. Ball said, we really wanted to take this opportunity to go deep, talking about burn care. And from a high level perspective, from a system level perspective, can you talk to us about who generally takes care of severe burns in Canada and how does that really compare to the US?

Sarvesh Logsetty  05:00

The model in Canada for the most part is burns taken care of by plastic surgeons, with the critically injured burns taken care of in conjunction with intensivists. And there’s mostly been the plastic surgeons who are involved. There’s in the recent past has been sort of an increase in the presence of general surgeons. I was the first one in Canada as a general surgeon who developed a career in burns. And in now we have two or three younger individuals that are going down that pathway. And that stems from the American model of burn care, where about half of the burns are taken care of by plastic surgeons and the other half are taken care of by general surgeons who started off with an interest in trauma and ended up being burned surgeons or general surgeons who, for various reasons, have mentors and exposure decided they wanted to be a burn surgeon period. My sort of career burn surgery was that after I met Joel, I, he offered me a fellowship a formal fellowship in the burn unit in Toronto. So I did a year there. And while I was there, the folks in Seattle, which at that time was the mecca for burn care, heard about me and said, Hey, Sarvesh, do you want to come work with us for a year? And, you know, when you get called from up on how you say, yes, you don’t think about what it means afterwards. And I have to say, it was one of the best years of my life in terms of burn care, incredible exposure. And they do things very differently in the States as a system than we do in Canada. So it was quite an eye opener.

Chad Ball  06:36

It’s it’s so interesting to hear you describe that Sarvesh. You know, my experience in the in the US doing trauma and critical care, as the first couple of fellowships was going to the American Burn Association meeting one time interacting with the head of the burn unit there, which was a gentleman Walt Ingram, who was really, really an interesting guy, you know. He had been an aerospace engineer at NASA for at Johnson Space Center for a dozen years before going back into medicine, and then surgery, and then burn care. And my, my sort of overwhelming observation was that it seemed to be that these big American programs had, and maybe it’s typical, I don’t know, they had one sort of person that really ate, slept and lived that burn unit and provided, you know, exemplary and incredibly dedicated care.

Sarvesh Logsetty  07:30

And that that really is part of it. You know, if you think about burn units in the States or in Canada, they tend to be individual driven. There are a lot of dedicated people that are part of it. There it is a team. But in terms of the burn surgeons, it tends to be like leaders like in Seattle at the time that I was there was Dr. David Heimbach, who was, you know, one of the giants. And his partners were Lorne Engrav and Nicole Gibran who themselves are giants in burn care as well. But it’s just by virtue of the way things are they tend to get associated with that. I think it’s a bit like that in the trauma world as well, you know, your time in Atlanta and so on, right? You think about the people, think about the mentors, because they’re the ones who kind of lay the path that everyone follows.

Chad Ball  08:22

Yeah, it’s so true. Sarvesh, what would your recommendation be for somebody say, in Winnipeg, or in Calgary, who was in a general surgery residency, and wanted to pursue burn care in 2020, as a fellowship, or as a career. What what sort of career path should they take? Or what makes the most sense in the current day and age?

Sarvesh Logsetty  08:43

I think in today’s day and age, there would be two pathways that I would suggest if yes, a general surgeon was interested in doing burns. One of which is to do critical care. And that way, you could approach burns from the aspect of being an intensivist, who did burns, which would be fantastic. And the other approach is to do it from the perspective of being a trauma surgeon who does burns, where you end up by incorporating the burns into your standard trauma care, which also I think is a reasonable pattern of practice.

Ameer Farooq  09:18

Okay, and I think it’s time for us to dive into case scenario and really benefit from your expertise about burns. So I’ll give you an example from someone that we had not too long ago when I was on call. We had a 35-year-old male who was trying to stay warm in his trailer and as something that probably happens in in Winnipeg as well as in Calgary, they often are using the the gas heaters, and unfortunately lit himself on fire and was severely burned. So we got to page level one trauma, heart rate of 110, blood pressure 90 over 60 eta 10 minutes. How do you approach that patient In the trauma bay, and how do you even mentally prepare the team?

Sarvesh Logsetty  10:05

I think that the important thing to remember is that all of these individuals are still trauma. And they have to be assessed as a trauma using standard HLS protocols. The only change is that burn changes how you’re going to manage their fluids somewhat. And you know, one of the unique things about our situation in Canada is that you can have this 35-year-old who’s injured with a high temperature thermal injury, who may be hypo thermic, when they hit your door, right, it occurs everywhere, but more so when you have a minus 35 degree environment that you’re working in. And this person may have been doused in, you know, water at the environment. And he may have been cold to start off with, which is why he turned on the heater and was trying to heat up his environment in the first place. And so you have to make sure that you’re not overly exposing them that you’re assessing all the things that you normally would so start off with your airway, and make sure that you know, there’s a was, is there a risk of inhalation injury? Should you be thinking about intubating this person early? What if they’re in a closed space or closed environment? What’s their risk of carboxyhemoglobin? There’s a lot that’s written on things like cyanide and finite toxicity. But the reality is that there’s little to no evidence that any of the cyanide toxicity kits are of any value that they change any outcomes. And most of the times when you try to measure cyanide, most institutions take over a week to get the results back, because you have to send them out to get them done. So there’s literally no solid evidence that says that you should correct somebody cyanide.

Ameer Farooq  11:41

I wanted to pick up on that, that that airway piece because in my in the few times that I’ve had burns come in a while I’ve been on call. It’s certainly not always straightforward decision as to should we intubate this patient or not. So what are the factors that go into your decision making about intubating a patient or or evaluating them more closely, let’s say without bronchoscopy.

Sarvesh Logsetty  12:09

A lot of it comes from the history of what the individual has and a bit of the physical examination as well. If someone tells me they’ve had a flash injury, then most of the time you can get away with at least observing them doing a better examination during an oropharyngeal examination, especially if there’s a smaller burn. The classic textbook answer the exam answer for cinch facial hairs and face burns and things like that are you know, they’re very soft and haven’t really held up over time. Although there’s there’s still the correct exam answer for the. The bigger issues are how much fluid are you going to give these individuals as your resuscitating them. If there’s someone that you can back off on the fluid, and the reality is, is that you don’t need to resuscitate burn, in the absence of other things going on. If it’s under 15 to 20%, you can get away with maintenance fluid and not have to give them any Parkland or anything else. And if you can stay away from over-resuscitating them and giving them a ton of fluid, sometimes they won’t get that edema in their airway. And they won’t get that reaction. So you like I say you have a bit of time, so you can try and figure them out. The big challenges are in our environment is the whole transport, right? If somebody is over two to four hours away in terms of transport, sometimes it’s a better idea to get them intubated for safety, because you don’t know what’s going to happen on the road. And you don’t know how they’re going to respond, then it is to sort of leave them and watch them. But if they’re an environment, we have an anesthetist in house and you have people who are experienced in assessing things, and maybe you can, you know, back off on integrating them immediately.

Ameer Farooq  13:47

So how does that play out with you and your EMS? Are you are they calling you and you’re giving them advice over the phone based on what they tell you? Or how does that decision play out?

Sarvesh Logsetty  13:57

From an EMS perspective in the city, the patch in with our emerge, and we communicate with our emerge team pretty regularly. And I’ve given the emerge talks, at least two or three talks over the last few years on how to manage burns and with a focus on inhalation as part of it. And we have you know, I’m available 24/7, regardless of whether I’m in the country or not people know that. So they’ll call me if there’s any questions.

Ameer Farooq  14:25

Does it matter to you? So first of all, I just want you to explain in case or, you know, we have junior residents or medical students listening to this, what what’s a flash injury? And does it matter to you in terms of the mechanism of the burn? So let’s say, you know, is it different from electrical injury versus, you know, a house fire versus as you see a flash injury in does that play a role at all in how you initially manage these patients?

Sarvesh Logsetty  14:54

So I joke that I’m from Alberta, and as an Albertan, we like to barbecue even in the middle winter. And oftentimes, I’ll be kind of barbecue something a little winter. And you know, those little starters that are on the barbecue, right? They don’t, they’re probably invented by a burn surgeon to be honest because they don’t work properly. And now you can just imagine me sitting there and dead of winter over this barbecue going click, click, click going, I wonder if the starters working, sticking my head over it right? And it goes, and you get the flash burn, right. That’s the flash of flames that comes up can be high intensity, you get some facial burns, you get some cinch nasal hair, but it’s very quick, it’s very short. It’s very instantaneous. So there’s very little smoke, there’s very little particles there’s very little bits of the chemicals and everything else, partial product of partial combustion. So from that perspective, it’s a flash burn is less likely to require intubation, even though the burn itself can look dramatic. And those are people that have like peeling skin all over their face, and then may have corneal abrasions and things like that as compared to somebody who is asleep on their couch and luckily, we see this less and less because of self extinguishing cigarettes and so on, but fell asleep, smoking, and their couch catches a little fire and they’re like, I couldn’t find my door. It was too smoky. Right. And those are the kinds of people that even if they don’t have any face burns, you’re gonna be, okay, you’re going to be at risk. And especially if they have a bigger burn from a total body surface area or TBSA perspective. If they’re over 20 or 30%, then you get a synergistic effect on the edema that results in the airway and in the lungs, from just the inhalation injury alone. So the burn and the inhalation injury add to each other. And by doing that, you end up with more likelihood if requiring intubation.

Ameer Farooq  16:57

I think that that segues perfectly to actually talking about how you assess the burns themselves. Again, recognizing that this podcast is going to be listened to by trainees at all levels, maybe you could start from just a basic, you know, textbook kind of assessment of burns, and how to assess total body surface area injury.

Sarvesh Logsetty  17:22

Sure, so let’s start off with the degrees of burns. So in the old language we used to talk about first, second and third degree burns. And everyone still uses that quite a bit because it’s arrived everywhere and patients seem to understand it, and so on. But the we’re trying to move away from that we’re trying to use superficial, partial thickness and full thickness as the language because that actually tells you what’s going on. superficial burn just involves the epidermis, by definition doesn’t go beyond the epidermis, it’s painful, it’s erythematous, there is no blistering at all. And if you sort of scrape your thumb across it, the skin doesn’t peel away or slough. It’s all intact. That’s like a bad sunburn. And those you don’t include in your TBSA don’t include them in your calculations. The next is on the other side to the other extreme is a full thickness injury which goes all the way through the epidermis all the way through the dermis. And that injury, if it’s bigger than the size, roughly a toonie is going to require some sort of excision and grafting or closure of some sort. And those are guys that should probably go to the burn unit, you know, sooner rather than later. And they are really high risk of infection because literally you’ve got a piece of dead tissue there, you know exposed to the bacteria, exposed to the environment, with no blood supply. So you know, as soon as bacteria get onto it, they’ll just it’s media for them. And in between you have the partial thickness injury and the best way to think about the partial thickness injury is to divide it into two. There’s a superficial partial thickness which is kind of in the top, third or so of the dermis. This is an area that has minimum a product or dead tissue. So the risk of infection is relatively low. This is an area that usually heals as soon as that dead tissue kind of self-sloughs and sort of self debride and the body will get rid of that over time and the body will heal underneath that and the epi the epithelium migration the epidermal cells from the hair follicles of the sweat ducts and will grow across that area. And that’s the same as if you create a donor site when you do the split thickness skin graft and will heal and to be honest, if you don’t you could we all put antimicrobial dressings on there, but you probably don’t need to for these. The blood supplies fantastic, the amount of dead tissue is minimal. The risk of scarring is very, very low. It’s hard to say what the pigmentation will do, but people don’t get the thick raised hypertrophic scars that you can with a deeper partial thickness injury. The superficial partial thickness injuries, they have blistered. They’re moist because there’s good blood supply. There’s good capillary leak, that’s going to happen. These are weepy, they’re erythematous. They’re homogenous. And if you touch them gently, they will blanch because of the vascular dilatation that’s occurring in that space. And then as the burn gets deeper you get into the dermis you get further further, you have more dead tissues, so you have more and more burden of area that can become infected. You have a risk of, you know, inflammatory response that if you allow it to heal, and it takes more than two to three weeks, the scar they’re going to get is going to be worse than any scar I can create surgically for the most part. And those are the areas that you really do need a good topical antimicrobial on because there is enough of a burden of dead tissue that’s there, that if you don’t prevent the infection, you don’t have the opportunity to give the person time to heal a little bit so you can figure out if they really do need the surgery or not. And those ones they tend to be drier, they tend to be more pale. And occasionally you’ll see them where they’ll look like they’re bright red, but if you touch it, they’re not they don’t blanch and that’s because the subdermal basket or plexus has been damaged by the heat, there’s been a little bit of vascular leak that’s occurred. And because it’s in the interstitial space, it doesn’t blanch, right, that’s compared to the vasal dilatation that occurs in the superficial partial thickness injury. So those those are the burns that you should put them into topical antimicrobials, get them to burn surgeons sooner, so they can decide whether or not this person needs to have surgery sooner or not.

Chad Ball  21:37

Sarvesh I was hoping that we could delve in to a little bit about fluid resuscitation and in burns and I I bring that up with the obvious moniker that, you know that’s for us. that’s a pasture full of sacred cows and a lot of dogma. For you where does fluid resuscitation, fluid maintenance, colloids versus noncolloids and then you of course, leading into if it’s managed poorly, abdominal compartment syndrome, where does that all fit for you?

Sarvesh Logsetty  22:08

The fluids, you know what I’m lucky enough that I’m part of the ABLS, the Advanced Burn Life Support Group at the American burn Association, and I helped rewrite the ATLS chapter for both the 9th and 10th edition of the ATLS. So I’ve had a lot of discussion with people who, again, are wiser and have some, some great knowledge on this. And I think the reality is nobody has a firm answer on any one individual. But there are a couple of things that are coming down the pipeline that I think are important to discuss. The big one is that we’re trying to get everyone to back off on the fluid. Right now, we’ve been kind of sitting at Parkland as being four cc’s per kilogram per percent. And everyone’s kind of like Okay, great. And there’s been a what’s been called a fluid creep by Basil Pruitt and others, and people are like more fluid will be better. The reality is it isn’t. And the original Parkland is really described as two to four cc’s per kilogram per percent. And the bigger the burn is, the presence of an inhalation injury, and tends to ask to drive the fluids to the higher side versus a smaller burn somebody who’s you know, nutritionally replete without an inhalation injury tends to be on the drier side. So what we’re really trying to encourage everyone to do is to start focusing more on what the urine output is doing, and staying on the drier side of the urine output. So historically, we’ve talked about point five to one cc per kilogram. We’re even you know without a lot of randomised trials or anything else, but the wind is staying tight to that point five CCS per kilogram per hour, in an adult, even a little bit on the lower side of that if, if you can pull that off. For sure, don’t chase hemoglobins, don’t chase  hematocrit. They will, heme or concentrate they will, but you can’t correct it, the more you crank fluid in there, the more it will leak out and you won’t be able to correct that and you’ll end up causing a lot more trouble if you give them more. The big thing that I would advocate your learners to take a look for is that Kevin Chung, who’s an intensivist out of San Antonio on the military base there which is probably the world’s best Center for Learning critical care of burns in today’s day and age in a lot of ways. They wrote a paper and sort of justify not justified but they did a computer modeling off a number of different burns based on this and they’ve come up with something called the rule of 10s. Or basically you take the size of the burn, multiply it by 10 and that’s your percent that’s your cc rate per hour that you’re going to start off. And then titrate to the urine output.

Ameer Farooq  25:03

So this is different. When you say rule of 10. Do you mean actually take the physical size? We’re not talking about like, the rule of nines where you’re talking about 9% for an arm, 18% for like this is this is the actual size of the, the burn is that right?

Sarvesh Logsetty  25:18

Correct. So you estimate your burn size to the nearest 10, then you multiply it by 10. And that’s your initial cc per hour rate. And then you have 100 cc’s per hour for every 10 kilograms over 80.

Ameer Farooq  25:35

This is a pretty dramatic difference in than what the Parkland formula would say in terms of fluid like that’s like, you know, a third of the amount of fluid potentially easily, that you’d be giving someone if you’re if you’re taking sticking to a point five cc per kilogram times TBSA.

Sarvesh Logsetty  25:58

Well, what they showed with their community computer modeling is that it the Parkland formula is, is great as an overall formula. But it isn’t very accurate when you use it to predict an individual, it fits for groups. And the rule of 10s does the same thing. So they they’re pretty reasonable. And the rule of 10s actually was able to map the urine output just as well as a Parkland did in terms of how well that resuscitated individuals. So from that perspective, they they’re not that far off, to be honest. It’s just your way of approaching it. And the other big thing that’s coming in that we’re getting rid of this, do half in the first eight hours and do the rest in the next 16. Because the body doesn’t sort of suddenly shut itself off, at eight hours from the infantry response or shift it, it this gradual change over time. So if you’re paying attention to the urine output on an hourly basis, you you are more likely to be able to titrate that fluid in a more physiologic way, then suddenly taking somebody from 800 cc’s an hour to 400 cc’s an hour and wondering why their blood pressure just tanked.

Ameer Farooq  27:13

Really requires you to be much more diligent in terms of monitoring these patients, not just, you know, setting a rate and then, you know, letting it ride, you really have to just be on those patients and watch them every hour and see how they’re doing.

Sarvesh Logsetty  27:31

Yeah, and that’s part of the biggest difference between burn surgeons versus I think nonburn surgeons, so to speak, taking care of burns, is that if I get a big burn that’s in hospital, say 70 or 80%, the nurses know that every two hours or three hours, I’ll be calling them, you know, two or three in the morning and going, Hey, what’s your note? What what are we doing? You know, how much are you giving them. And the other thing that’s really important to remember, resuscitating burn patients is unless they’re hypotensive, don’t give them boluses. The boluses will just leak out, they have huge capillary leak, it’s massive. And all you do is compound the edema and make it worse, and you will be able to get them any better. So if they’re, if they’re, you’re not pleased, okay, give them high vasopressor to try and maintain their blood pressure, if you’ve given them enough fluid, right? Like, it’s, it’s the fine balance, you don’t want to sit there and say, Okay, great, you know, run the tank empty and try to give them a bunch of a bunch of inotropes or vasoplegic agents. But at the same time, if the tank is full, don’t keep trying to fill the tank to make the pressure better, or to make the kidneys, you know, pee more than one cc per hour per kilogram per hour.

Ameer Farooq  28:56

Does it matter to you what kind of IV fluids to use it? As Dr. Ball was kind of asking or alluding to, does it matter a colloid, crystalloids,  you know, some of the synthetic agents, how do you think about that?

Sarvesh Logsetty  29:11

So so let’s start off with the colloid versus crystalloid sort of issue. You know, I’ve been around long enough that I remember when albumin was like, the greatest thing since sliced bread. And then suddenly, there were a couple of reviews that came out and everyone said that albumin is the worst thing that you could ever give anybody. And there was one point where to give a unit of albumin you have to get consent from, you know, the patient, their loved one, their lawyer, their next of kin and the Pope. And now we’re kind of back to well, you know, maybe it’s not, you know, it’s okay. So the reality is, in the first, at least 12 hours, there’s a lot of physiologic evidence and animal studies that show that the capillary leak is so big, and the capillary permeability is so large that the colloids that we have will just leak straight out. And there’s no real point in giving it. Having said that there are some notable resuscitation formulas that exist where they start resuscitating with fresh frozen plasma, or stored plasma or fresh plasma, immediately, and that’s what their resuscitation is based on. And, you know, they haven’t necessarily shown that their outcomes are so much worse than anyone else’s. North American Standard is to use Ringer’s lactate, because it’s slightly less acidic than normal saline. The one of the major Shriners burn units has traditionally added an amp of bicarb to their Ringer’s lactate, if they’re doing a large volume resuscitation. It serves two purposes, one of which is it makes it slightly hypernutrimic, and also gives you a little bit of better off of buffering capability and less acidic solution over time, so that you don’t make the patient go into a metabolic acidosis from your resuscitation. So if we’re doing large volumes of fluid, I will generally resuscitate with ringers lactate with one amp of bicarb per liter. And after about 12 to 18 hours, and have to be honest that I started at 24 hours and I keep dropping my timeline. And now I’m at 12 hours, if I’m still giving them massive amounts of crystalloid. I will add in 25% albumin as an infusion, not as a bolus, but as an infusion. And when I first started doing that, I used to do this fancy calculation where I’d be like, okay, what’s a Parkland? And and how much in excess of parkland am I giving and divide it by five, blah, blah, blah. But then I realized and my pharmacist told me, well, the 25% albumin comes in an 100 cc bottle. And after four hours, we have to throw it out. So I’m like, oh, okay, well, when they’re 25 cc’s an hour, though. Right? Why waste resources, they need a little bit of albumin, they need some noncardiac load. So I went 25% at 25 cc’s an hour.

Ameer Farooq  32:02

I just love how something that we think is such a simple concept like IV fluids is still continues to be something that evolves. And hopefully we continue to get better at. And that’s I think that applies to burns. And it clearly also applies to resuscitation and trauma with the whole advent of whole blood, etc. So I think this is such a fascinating topic. Let’s move on to talking about some other issues in the ICU. So if we go back to our patient, who let’s say gets intubated, it’s clear that he is critically ill. How are you thinking about this patient? Let’s say early on in the first 24 hours in the ICU, besides the fluids, what other kinds of issues are you already thinking about? And then beyond the first 24 hours, what are the key things that you think need to happen in the in the intensive care unit?

 

Sarvesh Logsetty  32:57

So I think the first 24 hours is mainly the resuscitation trying to make sure that number one, have you recognized the true extent of this person’s burden injury? Are you or is your TBSA estimation accurate? Did your assessment of the depth make sense? Is the person responding like they have an inhalation injury or not? And most of these individuals, as you noticed, and identified earlier, are have other issues going on? So this 35-year-old who was in a trailer was not to be prejudicial, or anything else. But was this a meth lab that blew up? Was this homicide and somebody had beat him up beforehand? Are there other things that we need to be considering in this individual? Are there drugs, is there alcohol, that kind of thing that need to sort of be taken into account? And in any other any individual at all is the other questions about what are their comorbid status? What’s their comorbid status? Do they have diabetes, do they have any other issues? Our standard dressings have migrated from being twice daily, which is what Flamazine used to be, or even three times a day to, we do polysporin and adaptive dressings Monday, Wednesday, and Friday, or we do Acticoat which is silver nanocrystalline dressing, every Monday, Wednesday, and Friday or Monday and Thursday if they’re healing really well and don’t need anything. And from that perspective, you know, it’s then the other burn stuff. So make sure that they get the nutrition started early. And usually we just use NG tubes. You don’t really need NJ for majority of individuals. And we don’t use prophylactic antibiotics because, you know, if the skin’s dead, there’s no blood getting to it so there’s no antibiotic getting to it. It’s the antibiotics got to come from the outside. And you know, make sure they’ve got their tablets up to date things along those lines, all burn patients are coagulopathic. So they all need to be on some sort of anticoagulation prophylaxis. It’s a little bit controversial about whether or not you should be doing b.i.d or t.i.d dosing. Partly because the volume of distribution in the burns is so high. And there’s a lot of evidence from antibiotic studies and other medication studies that their volume is, is that anywhere up to twice what other individuals volume of distribution is. So I don’t think it’s unreasonable to give your heparin adult parent twice a day, if that’s what you want to do. Or three, three times a day, if that’s what you want to do.

Chad Ball  35:40

Sarvesh, you’ve always been a really innovative thinker and an innovative guy overall. I’m just curious, without blowing any of your patents or any of your, your nonpublic work, where you know, the topic of burn coverings or burn dressings, where is that going in the future for us all?

Sarvesh Logsetty  35:57

I think there’s a couple of different things to chat about from that perspective. And this is, you know, really just my opinion, but the the standard of burn here today is early debridement, in some form or the other. And in a big burn, if it’s a small burn, you could wait weeks, you know, that’s fine, it doesn’t matter. But in a big burn, so anything over 20 or 30%, they really should hit the operating room within about 72 hours, before the inflammatory response really starts to kick in. And before there’s a risk of infection or anything else. And the idea is to get rid of that burn. So the first innovation that I see coming down the pipeline in the next five to 10 years, is going to be the enzymatic or nonsurgical debridement of woulds. And there’s a couple of different products that are out there, one of which is based on pineapple enzymes, another one, which is a surfactant. And there’s a couple of other interesting ones that are in evolution. And I think that really what’s going to happen is that people gonna come in the door, the first dressing change that’s done in the burn unit is one of these enzymatic substances is going to get put on their would. There, you’re going to watch them for two or three days to see how much of that just debrides and lifts off. And if it debrides all the way down to fat, then you know that this person needs a skin graft. If it debrides down to a little bit of dermis. And then you you know, you might say, Okay, let’s wait and see what they do. And that’s going to be a huge game changer, because instead of rushing everybody to the OR to get rid of this dead skin and inflammatory response, you’re going to put this product on them, they’re going to autodebride through this chemical debridement or enzymatic debridement. And I think that the inflammatory response will be lower, their overall scoring will be lower than the amount surgery they need will be lower. I think that those are huge, huge factors. And then the other part that will go hand in hand and this is you know, as, as you alluded to Chad, you know, I’m working in a lab with a very brilliant scientist by the name of Song Liu. And we’ve been working on trying to create new burn dressings. And one of the things we’re trying to do is come up with a dressing that is both a responsive dressing so it stays inert until the bacteria are present. And then as a bacteria start to grow and start to release some of the enzymes that are specific to those bacteria, it will start to break the bonds and the dressing down. And breaking those bonds will cause the dressing to release antimicrobials, which will kill the bacteria. So from that perspective, you can leave the dressing on for weeks, and you don’t need to look at it. And the other thing is that by within these dressings, we hope to have incorporated a color changing indicator so that what happens is the dressing will turn red or green or whatever color and once it changes color, you know that that area of the dressing has growth of bacteria underneath it. And so you can cut out that part of the dressing, you can take a look at that area. If you need be, you can do whatever management you need on that area of the wound, and replace the dressing and there’s no need to take off the rest of the dressing, you can just leave the rest of it intact until the body itself heals up. And I think that you know combinations of things along those lines with the enzymatic debridement and so on will change the way we approach burn wounds. Especially partial thickness ones.

Ameer Farooq  39:30

That is so cool. And I think we need to watch this space closely and I’m so excited to see where all that research goes. I would like to touch briefly on the operative management of these burns. Especially because I think myself included a lot of general surgery residents or residents not in let’s say not in plastic surgery may not have the same kind of exposure to burn surgery. What are the principles of during performing these operations? And what are sort of the goals in the operating room?

Sarvesh Logsetty  40:13

The I think the, the main principle that somebody should adhere to is don’t take away more than you need to in terms of the removal of the dead skin, but take away everything you do need to take away. So excising, you know partial thickness burn, and still leaving a layer of dead tissue behind and trying to skin graft on that is about as useful as skin grafting onto a table. The skin grafts are not going to be not going to vascularized, you’re going to end up losing it, you’re going to end up creating a donor on this person that they didn’t need, and you’ll make them sicker for no reason. So it’s that fine balance between taking too much, where you’re making a wound that is going to have a worst scar and is going to have worse problems or not taking enough and end up having to do the surgery again. And that’s, that’s something that you have to be cautious about. And trying to figure out where you’re going to go with those, I have to honestly say that even at this time in my career, I still have times where I’m like, I don’t really know what the right depth on this individual is. And that’s why I’m excited about these enzymatic debridement and nonsurgical debridement. Because, you know, they’re, they’re going to help with that a lot. The second part of it is making sure that when you are harvesting your skin or putting it in place that you you’re thinking about how the patient’s going to move how the scars are going to form, think about anatomical lines, and trying not to put seams across a joint or in a way where if it does contract and all graft seems contract, unfortunately, that you don’t create a band, you know, in the antecubital region, for example, or behind someone’s knee, so they’re gonna have trouble, like, you know, extending those joints. And then the last thing is to think about, you know, what are the things that are going to impede your ability for that skin graft to heal? You know, does this person need better nutrition, and should you give them better nutrition before you take them to surgery. As I get older, and you know, get a little bit more gray hairs, I start, I feel that a lot of our patients have poor nutritional status coming into surgery. And, you know, you can’t expect people to, you know, make sticky proteins, as Mr. Hamilton would say, if you if they don’t have new proteins to start off with. So trying to optimize nutrition, before surgery, and even after surgery are important parts of it, try to make sure that you better minimize shear, and try to make sure that you know you’re not taking unnecessary steps and managing the care of the patient. And for me, part of that is trying to minimize things like blood loss. We do a lot of subcutaneous tumescence with epinephrine solution. A while back, I wrote a paper on phenylephrine as an alternative, it has less central effects. So you know, it’s an unreasonable thing to do. And it’s important to sort of keep track of like the amount of fluid and the temperature that’s going on with the patients during the surgery. It’s not as simple as you know, letting your anesthetist do their thing, you kind of operating it’s the same way that if you haven’t made your trauma, you should be communicating with your anesthetist at all times, you know, what’s the ask, what’s the pH in this patient? How are they doing? What’s their clotting like? What’s, you know, what’s their blood pressure? Do you think that we have time to do some more stuff? Or should we be backing off and just doing damage control? It’s an ongoing communication.

Ameer Farooq  43:59

I think that the the last part of this that I wanted to touch on is sort of the reconstructive side of this. And I think part of that is talking about skin grafts when when would you consider doing skin grafts and in general, again, principles of abusing skin grafts. And then beyond that, what is the rehabilitation look like for these patients in terms of getting them back to a functional status, where they can leave the hospital and and try to return back to their former quality of life and function.

Sarvesh Logsetty  44:35

I’d like to say that, you know, while we have a pretty good track record of giving people back to their level of function that they had before. It’s you know, not always 100% for sure, but most people should be able to do what they were doing prior to the burden injury from a physical perspective. They there are some individuals who for reasons, I still don’t understand scar more aggressively. And just they no matter what we do, no matter what we try, they’re very compliant, but their range of motion is sucks. They’ve got horrible hypertrophic scars. And I know it’s it’s a huge challenge for those individuals. But the majority of individuals, I think that we can do pretty well. And especially if you have a smaller burn, and we can put some sheet graft instead of mesh graft down, a lot of the time, some of those areas are not very noticeable, and I’ve grafted a few people’s hands, where unless you look closely, you will know that their hands are grafted. You know, and this is the concept concept of burns is a team that takes another step entirely. In hospital without the dietitians and nurses, the you know, the social workers to help everybody and so on, we you know, that it’d be a horrible time for the burn survivors. And they’re getting home, it’s the OTs and PTs getting them back into their work, and having those dedicated individuals who know what to look for and aren’t afraid to, to push the patients who are needed and know where to back off where they need some time to recuperate. It’s those things that are I think, what drew me to this in the first place is the people that are dedicated to this. The other parts of it that we’re trying to explore understanding how to get people back to work, and how to get people re-engaged with their workplace. And I have to say that one of my frustrations is the concept that you have to be 100% before you can go back to work. And, you know, I understand why that is from a safety perspective and everything else. But people don’t get back to 100% if they’re sitting around at home, it just doesn’t happen. That’s like telling a hockey player that’s, you know, an NHL level hockey player that he’s going to go back to being an NHL level hockey player by staying at home. You know, people need to be engaged.

Ameer Farooq  47:08

One of the questions that we ask all of our guests, when they come on the podcast is if you’re able to go back and give yourself advice as a trainee, knowing what you know, now, what would that advice, advice be whether it’s about looking after burned care, or burn patients specifically, or just generally some advice about your career and training?

Sarvesh Logsetty  47:34

It’s a great question. And I think that the advice that I would give myself is something that I think Chad and I have discussed a few times. And that’s whatever you do, keep it fun. Because the moment it stops being fun, it becomes work. And work isn’t fun.

Ameer Farooq  48:10

You’ve been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you’ve liked what you’ve been listening to, please leave us a review on iTunes. We’d love to hear your comments and feedback.  So feel free to email us at podcast.cjs@gmail.com or connect with us on Twitter @CanJSurg. Thanks again.