Study design. The authors conducted a retrospective, matched cohort study.
Setting. The study was completed at Assaf Harofeh Medical Center, Zerifin, Israel, and it was approved by the medical center’s institutional review board.
Selection criteria. The authors retrospectively obtained patient record data from January 31, 2008, to March 30, 2013. Pediatric patients with burns under 18 years of age who suffered mainly from partial-thickness burns > 1% total body surface area (TBSA) and required hospitalization in the Pediatric Surgical Department were included. Patients were excluded if they required surgery during hospitalization, were transferred to a tertiary burn center, or received treatment different from the topical burn dressing protocols compared in the present study. Overall, 40 patients were included in the control group and 40 in the SCD group.
Variables and data measurement. Baseline variables collected from each patient’s medical record consisted of age, gender, cause of burn, location of burn, and percent TBSA (%TBSA) at admission. Group matching was done using age, gender, and TBSA. Outcome variables documented per case included daily frequency of dressing changes, analgesic administration rate, type and dosage of analgesics, duration of hospitalization, infection of burn site during hospitalization, and adverse reactions to the dressing used. Possible confounding variables used for statistical analysis included age, sex, weight, ethnicity, TBSA, and burn cause; their potential effects were examined using a multivariate analysis.
Standard dressing protocol. Standard burn treatment included burn irrigation with 0.9% normal saline. Next, wet gauze soaked in 5% mafenide acetate solution was applied directly to the wound and covered with Vaseline Petroleum Gauze (Medtronic, Dublin, Ireland). The burn irrigation, mafenide acetate, and dressing were applied twice daily. Topical Synthomycine 3% (Teva Pharmaceutical Industries, Petah Tikva, Israel), used for more delicate areas such as the face, was administered twice daily. Petroleum gauze alone was preferred for areas with superficial partial-thickness burns.
Silver-coated dressing protocol. The SCD was introduced in the authors’ medical center in 2007. It is generally placed on partial-thickness burns following initial debridement in the emergency room (ER), and then covered with a nonocclusive secondary gauze dressing. Occasionally, the SCD was not placed immediately after debridement in the ER, but rather placed 1 or 2 days into hospitalization. The dressing was left adhered for about 1 week. Patients receiving a SCD were released with their existing closed dressing. Need for continued hospitalization was assessed by a plastic surgeon on a day-by-day basis based on the patient’s vital signs, subjective pain level, clinical burn appearance, and wound dressing capacity. Following discharge, patients in each group were given a follow-up appointment at the Plastic Surgery Outpatient Clinic 3 days later, where areas of early SCD detachment were removed. The remaining adherent SCD was left untouched until it spontaneously dissociated.
Analgesic treatment protocol. Standard burn treatment protocol included the use of analgesic medications and dressing changes for both groups. Analgesics used included acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids. Specific drugs and dosages included paracetamol 15 mg/kg, ibuprofen 10 mg/kg, oxycodone 0.1 to 0.2 mg/kg, and tramadol 1 mg/kg (max dose/6 hours did not exceed 50 mg). Generally, opioids were administered prior to dressing changes, whereas paracetamol and NSAIDs were given upon patient or parental request. Level of pain was assessed by the parents using the visual analog scale,26 and the dose of analgesia was adjusted accordingly.
Sample size calculation. Sample size was calculated using G*Power Statistical Power Analysis Version 3.1.4 (Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany). An average opiate daily dose of 0.2 mg with a standard deviation ± 0.15 mg based on previous hospitalization data was assumed. Sample size was calculated for alpha = 0.05 and power = 80%. To find a 50% decrease in average opiate daily dose, 37 cases in each group (based on the t-test) were needed. The authors added 10% for potentially unaccounted cases to the goal sample and reached 40 cases in each group.
Statistical methods. Statistical analysis was conducted using SPSS software Version 18 (SPSS Inc, Chicago, IL). Continuous variables were presented as averages and standard deviations and were compared using the independent Student’s t-test. Differences in categorical variables were calculated with Pearson’s chi-squared test or Fisher’s exact test. Multivariate analysis was performed using a linear regression model to assess independent predictors of outcome variables and control for potential confounders.