Variation in acute fluid resuscitation among pediatric burn centers

BackgroundAccurate resuscitation of pediatric patients with large thermal injury is critical to achieving optimal outcomes. The goal of this project was to describe the degree of variability in resuscitation guidelines among pediatric burn centers and the impact on fluid estimates.MethodsFive pediatric burn centers in the Pediatric Injury Quality Improvement Collaborative (PIQIC) contributed data from patients with ≥15% total body surface area (TBSA) burns treated from 2014 to 2018. Each center's resuscitation guidelines and guidelines from the American Burn Association were used to calculate estimated 24-h fluid requirements and compare these values to the actual fluid received.ResultsDifferences in the TBSA burn at which fluid resuscitation was initiated, coefficients related to the Parkland formula, criteria to initiate dextrose containing fluids, and urine output goals were observed. Three of the five centers’ resuscitation guidelines produced statistically significant lower mean fluid estimates when compared with the actual mean fluid received for all patients across centers (4.53 versus 6.35 ml/kg/% TBSA, p < 0.001), (4.90 versus 6.35 ml/kg/TBSA, p = 0.002) and (3.38 versus 6.35 ml/kg/TBSA, p < 0.0001).ConclusionsThis variation in practice patterns led to statistically significant differences in fluid estimates. One center chose to modify its resuscitation guidelines at the conclusion of this study.     

Analgesic use in contemporary burn practice: Applications to burn mass casualty incident planning

BackgroundDetermining the amount of analgesics required will help burn centers improve their ability to plan for a burn mass casualty incident (BMCI). We sought to quantify the amount of analgesics needed in an inpatient burn population. We hoped that assessing the analgesic use in daily burn care practice will potentially help estimate opioid needs in a burn mass casualty incident (BMCI).MethodsWe included patients with burns covering equal to or less than 30% total body surface area (TBSA), admitted from spring 2013 to spring 2015. Patient records were reviewed for analgesics and adjuncts, pain scores, age and TBSA. The doses of the different opioids administered were converted into morphine equivalent doses (MED).ResultsWe enrolled 141 acute burn survivors with a mean TBSA of 8.2 ± 0.6%. The lowest daily average MED per person was 24.6 ± 2.0 mg MED, recorded on the day of injury. The daily average MED per person increased until it peaked at 52.5 ± 5.6 mg MED at day 8 post-burn. Then, it declined to 24.6 ± 3.4 mg MED by day 14. Bivariate regression analysis of average MED by TBSA showed a significant positive correlation (p < 0.001). The analysis of average MED by age showed a significant negative correlation (p < 0001).ConclusionOur study quantified opioid requirements in an inpatient burn population and identified TBSA (positively) and age (negatively) as significant predictors.     

Pregnancy and burns: Guidelines for safe management

BackgroundIThe incidence of burns in pregnancy is very low, therefore little is confirmed in the specific management of pregnant women who are burned.PurposeWe conducted a study to survey the frequency of pregnancy in our patients and evaluate the risk factors of mortality for mother and foetus. Finally we provide recommendations about management of mother and child.Materials and methodsRetrospectively, we surveyed data of our pregnant patients for an 18 year period. All demographic data, gestational age, history of previous pregnancy or miscarriage, diabetes, suicide, number of operations, presence of inhalation injury, TBSA, percentage of burn in abdomen and lower extremity, early excision and outcome of mother and foetus were gathered in a special questionnaire. Uni-variate regression and multi-variate regression were done for mortality of mother and child.ResultsWe treated 89 pregnant patients. Mean (SD) of mother's age and their pregnancy age were 24.08 ± 5.56 years and 19.18 ± 9.24 weeks, respectively. Mean TBSA (SD) was 36 (18%). Median of TBSA was 38 (IQR: 25, 70). Median of TBSA in Abdomen was 8 (IQR: 7, 9). Median of TBSA in lower extremities was 18 (IQR: 9, 34). Nine cases were due to attempted suicide. For 34 patients skin grafting was done. The main cause of death of the mothers was sepsis. The infections were due to Pseudomonas aeruginosa, Acinetobacter, E. coli, Klebsiella and Staphylococcus. In uni-variate regression model, TBSA, gestational week, and burns involving the abdomenwere related to maternal mortality. In multi-variate regression model, TBSA had high influence on maternal mortality, with every percent of burn surface area, the risk of mortality increased by 3.4% (p-value <0.005). In a uni-variate regression, TBSA and abdominal burn was associated with foetal mortality. However, in the multi-variate regression, only inhalation injury and TBSA had association with foetal mortality. Inhalation injury increased foetal mortality up to 16 times (p-value <0.05).ConclusionTBSA burned is the only major risk factor of maternal mortality. TBSA burned and inhalation injury are the main risk factors of foetal mortality.     

A prospective pilot study of the energy balance profiles in acute non-severe burn patients

BackgroundMajor burn patients have been shown to exhibit a hyper-metabolic state of activity which can persist for up to two years after burn. The relationship between total body surface area (TBSA) and resting metabolic rate (RMR) has been investigated in larger burns (≥20% TBSA), however not in non-severe burns (≤15% TBSA). The primary aim of this observational study was to examine the association between the acute effects of burns <15% TBSA with RMR in patients using indirect calorimetry, as well as any potential covariates. The secondary aim was to determine 24-h energy balance.MethodsThe study included data from 39 participants (82% male), all admitted to the State Adult Burn Unit at Fiona Stanley Hospital. Each patient was recruited upon admission and RMR data was collected on day four (± one day) after burn.ResultsThe pooled data bivariate correlation showed a significant relationship between RMR and TBSA (r = 0.435, p = 0.009). A stronger relationship was also found between RMR and TBSA in males (r = 0.634, p = 0.001). Patients recorded a caloric deficit of 116 kcal/day.ConclusionThis study demonstrated that a moderately strong linear association exists between RMR and TBSA in males for burns of ≤15% TBSA. The energy balance data indicated that supplementation of calorific intake for non-severe burns suggests careful consideration.     

Incidence and risk factors for deep vein thrombosis among pediatric burn patients

BackgroundPatients with major burns covering a large total body surface area (%TBSA) fulfill all the criteria of Virchow’s triad, as a sequela of their injury. This places these patients at increased risk for developing deep vein thrombosis (DVT). However, data regarding the incidence of DVT in burn patients are minimal, especially in the pediatric age group. Therefore, the aim of this study is to determine the incidence of DVT in pediatric burn patients, identify possible risk factors for developing DVT, and explore the need for prophylactic treatment.MethodsA retrospective chart review of 95 patients admitted to our Burn Unit was conducted. We included all pediatric patients with second- and third-degree burns admitted to the unit. Exclusion criteria were adult patients, those with first-degree burns and admitted to the unit for <72 h, patients discharged against medical advice, those admitted for elective reconstructive surgery, secondary admissions for non-healing/infected burns, and patients with trauma-induced skin loss. A data collection sheet was utilized.ResultsThe total incidence of thrombosis in our population was 4.2% (DVT, 3.1%; arterial thrombosis, 1.1%). Factors significantly associated with DVT included length of hospitalization (p = 0.012), central venous catheter placement (p = 0.013), and %TBSA (p = 0.004). Unlike adult patients, weight for age (percentile) and body mass index were not significant risk factors for DVT in our patients.ConclusionBurns are a major risk factor for DVT, especially when covering large surface areas (≥40% TBSA) and combined with other factors (i.e., prolonged hospitalization and central lines). Thus, investigations for DVT and prophylactic anticoagulation should be considered for pediatric burn patients with these risk factors, even if they are asymptomatic.     

Lethal triad in severe burns

IntroductionHypothermia, acidaemia and coagulopathy in trauma is associated with significant mortality. This study aimed to identify the incidence of the lethal triad in major burns, and describe demographics and outcomes.MethodsPatients admitted during a 71 month period with a total body surface area burn (TBSA) ≥ 30% were identified. A structured review of a prospective database was conducted. The lethal triad was defined as a combination of coagulopathy (International normalised ratio > 1.2), hypothermia (temperature ≤ 35.5 °C) and acidaemia (pH ≤ 7.25).ResultsFifteen of 117 patients fulfilled the criteria for the lethal triad on admission. Lethal triad patients had a higher median (IQR) abbreviated burn severity index (ABSI) (12 (9–13) vs. 8.5 (6–10), p = 0.001), mean (SD) TBSA burn (59.2% (18.7) vs. 47.9% (18.1), p = 0.027), mean (SD) age (46 (22.6) vs. 33 (28.3) years, p = 0.033), and had a higher incidence of inhalational injury (p < 0.0001) and full-thickness burns (p = 0.021). Both groups received similar volumes of fluid (p > 0.05).The lethal triad was associated with increased mortality (66.7% vs. 13.7%, p < 0.0001). With logistic regression analysis and adjustment for ABSI, the lethal triad was not shown to be a predictor of mortality (p > 0.05).ConclusionBurn patients with the lethal triad have a high mortality rate which reflects the severity of the injury sustained.     

An enhanced recovery after surgery pathway in pediatric colorectal surgery improves patient outcomes

IntroductionEnhanced recovery after surgery (ERAS) pathways in adult colorectal surgery are known to reduce complications, readmissions, and length of stay (LOS). However, there is a paucity of ERAS data for pediatric colorectal surgery.MethodsA 2014–2018 single-institution, retrospective cohort study was performed on pediatric colorectal surgery patients (2–18 years) pre- and post-ERAS pathway implementation. Bivariate analysis and linear regression were used to determine if ERAS pathway implementation reduced total morphine milligram equivalents per kilogram (MME/kg), LOS, and time to oral intake.Results98 (70.5%) and 41 (29.5%) patients were managed with ERAS and non-ERAS pathways, respectively. There was no statistical difference in age, sex, diagnosis, or use of laparoscopic technique between cohorts. The ERAS cohort experienced a significant reduction in total MME/kg, Foley duration, time to oral intake, and LOS with no increase in complications. The presence of an ERAS pathway reduced the total MME/kg (? 0.071, 95% CI ? 0.10, ? 0.043) when controlling for covariates.ConclusionThe use of an ERAS pathway reduces opioid utilization, which is associated with a reduction in LOS and expedites the initiation of oral intake, in colorectal pediatric surgery patients. Pediatric ERAS pathways should be incorporated into the care of pediatric patients undergoing colorectal surgery.Level of evidenceLevel III evidence.Type of studyRetrospective cohort study.     

Clinical characteristics and risk factors for severe burns complicated by early acute kidney injury

BackgroundEarly acute kidney injury (AKI) is a frequent fatal complication of severely burned patients. Although significant progress has been made in fluid resuscitation, intensive care, and renal replacement therapy (RRT) technology in recent years, the incidence and mortality rate in severely burned patients with AKI remains considerable. This study aims to provide theoretical evidence for prevention and treatment by investigating the clinical characteristics and risk factors influencing the incidence and severity of early AKI in severely burned patients.MethodsThis 3-year retrospective, single-center study was conducted in critically ill burned patients admitted to the Burn ICU at Guangzhou Red Cross Hospital of Jinan University. Patients whose age is older than 18 years with ≥30% burned total body surface area (TBSA) were enrolled in this study. Those patients who arrived at our burn ICU > 72 h after injury or died within 48 h from arrival were excluded. Data of 128 patients were studied in the final. Demographic and injury details were recorded. KDIGO criteria were used to assess the incidence and severity of early AKI. Factors influencing early AKI were determined using univariate and multiple logistic regression analysis.ResultsBetween January 2016 and December 2018, Data from 128 critically ill burned patients were available for analysis. The median age was 44.9 ± 16.8 years; 68.8% of the patients were male. The median TBSA% was 60 (IQR, 41.3–80%). According to the KDIGO criteria, 36 patients (28.3%) developed early AKI, as follows: stage 1 AKI, 69.4% (25/36); stage 2 AKI, 13.9% (5/36); and stage 3 AKI, 16.7% (6/36). The incidence of early AKI was associated with TBSA%, full-thickness TBSA%, abbreviated burn severity index on admission (ABSI), inhalation injury, mechanical ventilation, cardiovascular complications, and rhabdomyolysis. Multiple logistic regression analysis indicate that TBSA% (OR = 0.224, p = 0.007), full-thickness TBSA% (OR = 0.254, p = 0.014), ABSI (OR = 18.326, p = 0.009), and rhabdomyolysis (OR = 24.036, p = 0.000) were independent risk factors for the occurrence of early AKI. Significant factors influencing the severity of early AKI included full-thickness body surface area burns, electrical burns, and rhabdomyolysis. Full-thickness TBSA% (OR = 1.437, p = 0.041) and rhabdomyolysis (OR = 5.401, p = 0.035) are associated with mortality. The risk of death due to the occurrence of AKI was 5.407 in the Cox model adjusted for TBSA%, full-thickness body surface area burns, ABSI and rhabdomyolysis. Three patients died, all of whom had stage 3 AKI, accounting for 8.3% (3/36) of AKI patients. The death rate of stage 3 AKI who did and did not receive early RRT was 33.3% and 66.7%, respectively.ConclusionRhabdomyolysis is an independent risk factor for early AKI and closely related to the severity of early AKI in critically ill burned patients. Although with a high incidence of early AKI in severely burned patients, most of them are mild. Early adequate fluid resuscitation, timely and effective escharotomy, reducing the incidence and severity of rhabdomyolysis, most of them can achieve a relatively good prognosis.     

Epidemiology and trend of US pediatric burn hospitalizations, 2003–2016

BackgroundThermal injury is a leading cause of unintentional pediatric trauma morbidity and mortality.MethodsThis retrospective analysis of the 2003–2016 Kids’ Inpatient Database (KID) included children <18 years old with a burn principal diagnosis. The objectives were to describe the trend of US pediatric burn hospital admissions and the patient and hospital characteristics of admitted children in 2016. The trends (2003–2012) and (2012–2016) were evaluated separately due to the 2015 implementation of International Classification of Diseases, Tenth Revision (ICD-10).ResultsThe population rate of pediatric burn admissions decreased by 4.6% from 2003 to 2012, but the proportion of admissions to hospitals with burn pediatric patient volumes ≥ 100 increased by 63.9%. The overall mortality rate of hospitalized burn patients decreased by 48.1%. Median length of stay increased slightly for patients with a burn ≥20% total body surface area (TBSA) but decreased for patients with TBSA burn <20%. From 2012 to 2016, the population rate decreased by 13.4%. In 2016, an estimated 8160 children were admitted with a burn principal diagnosis, and 41.4% transferred in from other facilities. Children age 1–4 years were the most commonly admitted age group (49.7%). Patients with ≥20% TBSA burns accounted for 7.8% of admissions (95% confidence interval [CI]: 5.1–10.4%). Burn-related complications were documented in 5.9% of admissions (95% CI: 4.6–7.1%).ConclusionPediatric burn hospitalizations and burn-related mortality have decreased over time. The increases in transfers and admissions to hospitals with high pediatric burn volumes suggest increasing regionalization of care.     

Pediatric burn-trauma patients have increased length of stay compared to trauma-only patients: A propensity matched analysis

BackgroundTrauma is the leading cause of mortality in children. Burn injury involves intensive resources, especially in pediatric patients. We hypothesized that among pediatric trauma patients, combined burn-trauma (BT) patients have increased length of stay (LOS) and mortality compared to trauma-only (T) patients.MethodsThe Pediatric Trauma Quality Improvement Program (2014–2016) was queried and BT patients were 1:2 propensity-score-matched to T patients based on age, gender, hypotension on admission, injury type and severity.Results93 BT patients were matched to 186 T patients. There were no differences in matched characteristics. BT patients had a longer median LOS (4 vs 2 days, p < 0.001) with no difference in mortality (1.1% vs 1.1%, p = 1.00), intensive care unit (ICU) LOS (3 vs 3 days, p = 0.55), or complications including decubitus ulcer (0% vs 1.1%, p = 0.32), deep vein thrombosis (0% vs 0.5%, p = 0.48), extremity compartment syndrome (1.1% vs 0%, p = 0.16), and urinary tract infection (1.1% vs 1.1%, p = 1.00).ConclusionPediatric BT patients had twice the LOS compared to a matched group of pediatric T patients. There was no difference between the cohorts in ICU LOS, complications or mortality rate. When evaluating risk-stratified quality metrics such as LOS, concomitant burn injury should be incorporated.     

Feasibility and impact of the implementation of a clinical scale-based sedation-analgesia protocol in severe burn patients undergoing mechanical ventilation. A before-after bi-center study

BackgroundSevere burn patients undergo prolonged administration of sedatives and analgesics for burn care. There are currently no guidelines for the dose adaptation of sedation-analgesia in severe burn patients.MethodsWe performed a before-after 2-center study to demonstrate the feasibility and efficacy of a sedation-analgesia scale-based protocol in severely burned patients receiving ≥24 h of invasive mechanical ventilation. Before the intervention, continuous infusion of hypnotic and morphine derivatives was continued. During the Intervention phase, general anesthesia was relayed from day 1 by RASS/BPS-titrated continuous infusion of hypnotic and morphine derivatives and with short half-life drugs adminstered for daily burn dressings. The primary outcome was the duration of invasive mechanical ventilation in the ICU.ResultsEighty-seven (46.2%) patients were included in the Control phase and 101 (53.7%) in the Intervention phase. The median burned cutaneous surface was 20% [11%–38%] and median ABSI was 7 [5–9]. The durations of hypnotic and opioid infusions were not statistically different between the 2 phases (8 days [2–24] vs. 6 days [2–17] (P = 0.3) and 17 days [4–32] vs. 8 days [3–23] (P = 0.06), respectively). The duration of mechanical ventilation was 14 days [3-29] in the Control phase and 7 days [2–24] in the Intervention phase (P = 0.7). When taking into account the competition between mortality and weaning from mechanical ventilation, we found no significant difference between the 2 phases (Gray test, P = 0.4). The time-series analysis showed no difference for the duration of mechanical ventilation in the Intervention phase (P = 0.6). Eighteen (20.7%) patients died in the Control phase, and 18 (18%) in the Intervention phase (P = 0.6).ConclusionScale-based lightening of continuous sedation-analgesia with repeated short general anesthesia for dressing is feasible in severe burn patients but failed to demonstrate a decrease in the duration of invasive mechanical ventilation.     

Response of routine inflammatory biomarkers and novel Pancreatic Stone Protein to inhalation injury and its interference with sepsis detection in severely burned patients

BackgroundInhalation of thermal and chemical products of combustion evokes an immune response measurable at a systemic level. Inhalation injury related kinetics of currently available inflammatory biomarkers and novel Pancreatic Stone Protein (PSP) as well as their interference with septic events has not been addressed to literature yet.MethodsAnalysis of the influence of inhalation injury and ARDS on biomarker kinetics (PSP, procalcitonin (PCT), C-reactive Protein (CRP), white blood cells (WBC)) in 90 patients admitted to Zurich Burn Center between May 2015 and October 2018 with burns ≥15% total body surface area (TBSA) over 14 days.ResultsTwenty-five (27%) of 90 included patients presented with inhalation injury (median age 52 years [IQR 27], median TBSA 31.5% [IQR 21], mean ABSI-Score 7 ± 3). At admission, only WBC demonstrated significantly higher values in the inhalation injury group (p = 0.011). Acute respiratory distress syndrome (ARDS) was present in 32% without association to the severity of inhalation injury (p = 0.11). WBC, CRP and PCT failed to delineate inhalation injury related inflammation from septic progression at most time points. PSP was the strongest marker to identify septic patients both by its higher values and steeper increase over time (p < 0.001).ConclusionInhalation injury leads to an inflammatory response at a systemic level with alterations of biomarkers. While routine inflammatory markers demonstrated strong interferences between inhalation injury with its associated ARDS and evolving sepsis, PSP reliably identified septic patients in a setting of inflammatory turbulences secondary to inhalation injury.     

The effect of neighborhood Area Deprivation Index on residential burn injury severity

IntroductionResidential fires account for the majority of burn-related injuries and fatalities. Established risk factors for burn injury include male gender, racial minority, children and elderly individuals, poverty, and substandard housing characteristics. In North Carolina, the rate of residential fire injuries and deaths is higher than the national average. Therefore, we sought to describe residential fire hospitalizations at a large regional burn center and describe the neighborhoods in which they live. We hypothesized that patients living in areas with higher Area Deprivation Index (ADI) are more likely to have major residential burns.MethodsWe conducted a retrospective analysis of burn admissions from January 2002 to December 2015. We dichotomized patients into two cohorts: residential and non-residential burns and performed a bivariate analysis. Multivariate Poisson regression models were utilized to determine if ADI was associated with inhalation injury and ≥20% total body surface area burn.ResultsOf the 10,506 patients presented during the study period. Of these, 10,016 (95.3%) patients resided in North Carolina, and 7894 (78.8%) had a residential burn. Of the overall cohort, 6.0% (n = 458) of patients had ≥20% TBSA burns and 6.4% (n = 506) had inhalation injury. The majority of patients were in the highest (most disadvantaged) ADI quartile (n = 3050, 39.5%), and only 6.8% of patients (n = 525) were in the lowest (least disadvantaged) ADI quartile. In the Poisson multivariate regressions to determine if the ADI was associated with severe burns, patients in the highest ADI quartile had an increased relative risk of ≥20% TBSA burn (RR 1.31, 95% CI 1.02–1.68) and inhalation injury (RR 1.39, 95% CI 1.09–1.76) when compared to patients in the second-lowest ADI quartile when controlled for pertinent covariates.ConclusionResidential structure fires represent the major source of burns and fatalities. People who reside in the highest ADI quartile are more like to present with higher burn injury severity in terms of burn size and the presence of inhalation injury. The use of the ADI to target neighborhoods for burn prevention is imperative.     

Accuracy of burn size assessment prior to arrival in Dutch Burn centres and its consequences in children: a nationwide evaluation

BackgroundTotal body surface area (TBSA) burned, expressed as percentage is one of the most important aspects of the initial care of a burn victim. It determines whether transfer to a burn centre is necessary as well as the need for, and amount of, intravenous fluid resuscitation. Numerous studies, however, have highlighted inaccuracies in TBSA assessment. Therefore, the differences in burn size estimates between referrers and burn centre's in children and its consequences in terms of transfer and intravenous fluid resuscitation were investigated.MethodsThis study involved two time periods from January 2002 until March 2004 and January 2007 until August 2008. All referred children admitted to a Dutch Burn centre within 24 h post burn were eligible. Data were obtained from patient records retrospectively and in part prospectively.ResultsA total of 323 and 299 children were included in periods 1 and 2, respectively. Referring physicians overestimated burn size with a factor two (mean difference: 6% TBSA ± 5.5). About one in five children was referred to a burn centre without fulfilling the criteria for referral with regard to burn size (assessed by burn specialists) special localisation or inhalation trauma. Proportions of children receiving intravenous fluid resuscitation regardless of indication increased from 33% to 49% (p < 0.01). The received volumes tended to be higher than necessary.ConclusionsReferring physicians overestimate burn size in children admitted to Dutch burn centres. This has little negative consequences, however, in terms of unindicated transfers to a burn centre or unnecessary fluid resuscitation.     

Inhalation injury in burn patients: Establishing the link between diagnosis and prognosis

This study was to re-evaluate inhalation injury as a prognostic factor in burn patients and to determine the factors that should be considered when refining the definition of inhalation injury. A total of 192 burn patients (152 men, 40 women; mean age, 46.1 ± 13.8 years) who were suspected to have an inhalation injury and underwent bronchoscopy between January 2010 and June 2012 were included in this prospective observational study. All patients underwent bronchoscopy within 24 h of sustaining the burn. The bronchoscopic findings were classified as normal, mild, moderate, and severe. Mechanical ventilation was administered, when required. Age, percentage of TBSA burned, ABSI score, requirement of mechanical ventilation and PF ratio, but not inhalation injury, COHb level, and bronchoscopic grades, significantly differed between the survivors and non-survivors (p < 0.05). Mechanical ventilation (adjusted odds ratio [OR]: 9.787) and severe inhalation injury on bronchoscopy (adjusted OR: 45.357) were independent predictors of mortality on multivariate logistic regression analysis. Inhalation injury diagnosed through history does not predict mortality from burns. Other components such as severity of inhalation injury determined using bronchoscopy, and administration of mechanical ventilation might help predict the morbidity and mortality of burn patients with inhalation injury and all of the factors should be considered when the definition of inhalation injury is refined.     

The association between plasma gelsolin level and prognosis of burn patients

ObjectiveTo observe the change in plasma gelsolin levels among burn patients, and explore its impact on patient prognosis.MethodsThis prospective cohort study includes 98 burn patients with burns ≥30% TBSA, who were admitted to our institution between January 2010 and June 2013. Patients were grouped according to burn sizes, development and severity of sepsis, and survival from sepsis. The plasma gelsolin levels among different groups were compared by repeated measure ANOVA. The relationship between plasma gelsolin levels and the presence of sepsis and prognosis was examined by logistic regression.ResultsThe plasma gelsolin levels decreased with increasing burn sizes and increasing sepsis severity, with the lowest gelsolin level observed at 7 days after the burn. The plasma gelsolin concentrations were significantly lower among patients with sepsis than those without (P < 0.001), and were lower among those who died after sepsis than those who survived (P < 0.001). Logistic regression suggested that plasma gelsolin level was inversely associated with the occurrence of sepsis [OR 0.873 (95%CI 0.693–0.993)] and survival after sepsis [OR 0.939 (95%CI 0.859–0.992)].DiscussionPlasma gelsolin levels decrease after burn. The level is significantly lower among those with large burns and those with combined sepsis. Plasma gelsolin levels can be used to predict the prognosis of burn patients.     

The effect of the acute inflammatory response of burns and its treatment on clot characteristics and quality: A prospective case controlled study

IntroductionBurns are known to have an effect on coagulation in the early period after burn. Current coagulation tests have been criticised in acute burns due to their inherent limitations. This study aims to investigate the potential for a new quantitative functional biomarker of clot quality, fractal dimension, to identify changes in clot microstructure as a result of the burn inflammatory response and its treatment.MethodsA total of fifty-eight burn patients were included in this prospective case-controlled study. The control group (29 patients mean TBSA 1%), and case group (29 patients mean TBSA 30%) were compared at baseline and the case group investigated further over four time points (baseline, 12 h, 24 h and 5–7 days). Fractal analysis was performed, as well as current markers of coagulation, inflammatory markers and point-of-care tests, Thromboelastography and Multiplate analysis.ResultsFractal dimension did not differ between groups at admission (1.73 ± 0.06 and 1.72 ± 0.1), and fell within the healthy index normal range (1.74 ± 0.7), suggesting a normal clot microstructure in the early period after burn. Fractal dimension significantly reduced from baseline over the first 24 h following injury (1.59 ± 0.03 p < 0.005), indicating a significant reduction in mechanical clot strength and functionality consistent with a hypocoagulable state, not identified with other markers.ConclusionsThis is the first study to quantify the changes in clot microstructure following burn injury. This study confirms clot microstructure is significantly altered during the first 24 h after burn, with the production of a weaker, more porous fibrin clot, consistent with a hypocoagulable state.     

Comparison of prognostic models for burn patients: A retrospective nationwide registry study

BackgroundPrognostic burn index (PBI) is a unique model utilized to predict mortality of burn patients in Japan. In contrast, other prediction models are rarely used in Japan, and their accuracy and predictive value are unknown. The present study aimed to compare commonly used burn prediction models and determine the appropriate model for mortality prediction in Japanese burn patients.MethodsJapanese burn patients registered in the nationwide burn registry of Japanese Society for Burn Injury between April 1, 2011 and March 31, 2019 were reviewed retrospectively. The prognostic performance of PBI was compared with Baux score, revised Baux score, abbreviated burn severity index (ABSI), Ryan score and Belgian outcome in burn injury score (BOBI). The primary outcome was in-hospital mortality.ResultsThe study included 7911 acute burn patients. The overall mortality rate was 10.7%, the median age was 52 (interquartile range, 26–72) years, and the median % total body surface area was 7% (interquartile range, 3%–17%). The areas under the receiver operating characteristic curve for PBI, Baux score, ABSI, revised Baux score, Ryan score, and BOBI were 0.940 (95% confidence interval [CI]: 0.931–0.948), 0.943 (95% CI: 0.934–0.951; p = 0.002), 0.945 (95% CI: 0.937–0.953; p = 0.058), 0.946 (95% CI: 0.937–0.953; p = 0.002), 0.859 (95% CI: 0.846–0.870; p < 0.001), and 0.896 (95% CI: 0.885–0.905; p < 0.001), respectively.ConclusionAlthough the performance of PBI was good, it was not superior to the Baux score, revised Baux score, and ABSI. These three scores have a high prognostic accuracy. Hence, they are considered as alternative burn prognostic scores in Japan. The Baux score was an optimal prognostic model for patients with burns in Japan.     

Quantifying the effects of wound healing risk and potential on clinical measurements and outcomes of severely burned patients: A data-driven approach

IntroductionGiven recent advances in computational power, the goal of this study was to quantify the effects of wound healing risk and potential on clinical measurements and outcomes of severely burned patients, with the hope of providing more insight on factors that affect wound healing.MethodsThis retrospective study involved patients who had at least 10% TBSA% “burned” and three burn mappings each. To model risk to wounds, we defined the variable θ, a hypothetical threshold for TBSA% “open wound” used to demarcate “low-risk” from “high-risk” patients. Low-risk patients denoted those patients whose actual TBSA% “open wound” ≤θ, whereas high-risk patients denoted those patients whose actual TBSA% “open wound” >θ. To consider all possibilities of risk, 100 sub analyses were performed by (1) varying θ from 100% to 1% in decrements of 1%, (2) grouping all patients as either “low-risk” or “high-risk” for each θ, and (3) comparing all means and deviations of variables and outcomes between the two groups for each θ. Hence, this study employed a data-driven approach to capture trends in clinical measurements and outcomes. Plots and tables were also obtained.ResultsFor 303 patients, median age and weight were 43 [29–59] years and 85 [72–99] kg, respectively. Mean TBSA% “burned” was 25 [17–39] %, with a full-thickness burn of 4 [0–15] %. Average crystalloid volumes were 4.25 ± 2.27 mL/kg/TBSA% “burned” in the first 24 h. Importantly, for high-risk patients, decreasing θ was matched by significant increases in PaO2-FiO2 ratio, platelet count, Glasgow coma score (GCS), and MAP. On the other hand, increasing their risk θ was also matched by significant increases in creatinine, bilirubin, lactate, blood, estimated blood loss, and 24-h and total fluid volumes. As expected, for low-risk patients, clinical measurements were more stable, despite decreasing or increasing θ. At a θ of 80%, statistical tests indicated much disparity between high-risk and low-risk patients for TBSA% “burned”, full thickness burn, bilirubin (1.66 ± 1.16 mg/dL versus 0.83 ± 0.65 mg/dL, p = 0.005), GCS (7 ± 2 versus 12 ± 3, p < 0.001), MAP (42 ± 22 mm Hg versus 59 ± 22 mm Hg, p = 0.004), 24-h blood, estimated blood loss, 24-h fluid, total fluid, and ICU length of stay (81 ± 113 days versus 24 ± 27 days, p = 0.002). These differences were all statistically significant and remained significant down to θ = 10%.ConclusionWound healing risk and potential may be forecasted by many different clinical measurements and outcomes and has many implications on multi-organ function. Future work will be needed to further explain and understand these effects, in order to facilitate development of new predictive models for wound healing.