Fluid volumes infused during burn resuscitation 1980–2015: A quantitative review

Introduction‘Fluid creep’ or excessive fluid delivered to burn patients during early resuscitation has been suggested by several studies from individual burn centers.MethodsWe performed a Medline search from 1980 to 2015 in order to identify studies of burn patients predominantly resuscitated with lactated Ringers with infusion adjusted per urinary output. Data was abstracted for 48 publications (3196 patients) that met entry criteria.ResultsHigher resuscitation volumes compared to Parkland estimates were reported, but the trend of increasing resuscitation volumes over the last 30 years is not supported by regression of total fluid infused versus year of study. Mean 24 h fluid infused for all studies was 5.2 ± 1.1 mL/kg per %TBSA. The mean 24 h urinary output reported in 30 studies was 1.2 ± 0.5 mL/kg per hr. Burns with inhalation injuries (5 studies) received significantly more fluid than non-inhalation injured burn patients (5.0 ± 1.3 versus 3.9 ± 0.9 mL/kg per %TBSA). Fluid infused and urinary outputs were similar for adults and pediatric patients. The most striking finding of our analyses was the great ranges of the means and high standard deviations of volumes infused compared to the original Baxter publication that introduced the Parkland formulaConclusionsThese analyses suggest that burn units currently administer volumes larger than Parkland formula with great patient variability. Individual patient hourly data is needed to better understand the record of burn resuscitation and Fluid Creep.     

Prevalence and Risk Factors for Hypertrophic Scarring of Split Thickness Autograft Donor Sites in a Pediatric Burn Population

TitlePrevalence and Risk Factors for Hypertrophic Scarring of Split Thickness Autograft Donor Sites in a Pediatric Burn Population.ObjectiveThe split-thickness autograft remains a fundamental treatment for burn injuries; however, donor sites may remain hypersensitive, hyperemic, less pliable, and develop hypertrophic scarring. This study sought to assess the long-term scarring of donor sites after pediatric burns.MethodsA retrospective review of pediatric burn patients treated at a single institution (2010–2016) was performed. Primary outcomes were prevalence of donor site hypertrophic scarring, scarring time course, and risk factor assessment.Results237 pediatric burn patients were identified. Mean age at burn was 7 yrs., mean %TBSA was 26% with 17% being Full Thickness. Mean follow-up was 2.4 yrs. Hypertrophic scarring was observed in 152 (64%) patients with 81 (34%) patients having persistent hypertrophic scarring through long-term follow-up. Patient-specific risk factors for hypertrophic scarring were Hispanic ethnicity (P = 0.03), increased %TBSA (P = 0.03), %Full Thickness burn (P = 0.02) and total autograft amount (P = 0.03). Donor site factors for hypertrophic scarring were longer time to epithelialization (P < 0.0001), increased donor site harvest depth (P < 0.0001), autografts harvested in the acute burn setting (P = 0.008), and thigh donor site location (vs. all other sites; P < 0.0001). The scalp, arm, foot, and lower leg donor sites (vs. all other sites) were less likely to develop HTS (P < 0.0001, 0.02, 0.005, 0.002, respectively), along with a history of previous donor site harvest (P = 0.04).ConclusionsHypertrophic scarring is a prominent burden in donor site wounds of pediatric burn patients. Knowledge of pertinent risk factors can assist with guiding management and expectations.     

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.     

Acute Kidney Injury: It's not just the ‘big’ burns

BackgroundAcute Kidney Injury (AKI) complicates the management of at least 25% of patients with severe burns and is associated with long term complications. Most research focuses on the patients with more severe burns, and whether the same factors are associated with the development of AKI in patients with burns between 10 and 19% total body surface area (TBSA) is unknown. The aims of this study were to examine the incidence of, and factors associated with, the development of AKI in patients with %TBSA ≥ 10, as well as the relationship with hospital metrics such as length of stay (LOS).MethodsRetrospective medical record review of consecutive burns patients admitted to The Alfred Hospital, the major adult burns centre in Victoria, Australia. Demographic and injury details were recorded. Factors associated with AKI were determined using multiple logistic regression.ResultsBetween 2010 and June 2014, 300 patients were admitted with burn injury and data on 267 patients was available for analysis. Median age was 54.5 years with 78% being male. Median %TBSA was 15 (IQR 12, 20). The AKI incidence, as measured by the RIFLE criteria, was 22.5%, including 15% (27/184) in patients with %TBSA 10–19. Factors associated with AKI included increasing age and %TBSA (OR 1.05 p < 0.001) as well as increased surgeries (p < 0.041) and a cardiac comorbidity (p < 0.01). All patients with renal comorbidity developed AKI. In the %TBSA 10–19 cohort, only increasing age (OR 1.05 p < 0.001) was associated with AKI. After accounting for confounding factors, the probability of discharge from hospital in Non-AKI group was greater than for the AKI patients at all time points (P < 0.001).ConclusionThis is the first study to show an association between patients with %TBSA 10–19 and AKI. Given the association between AKI and complications, prospective research is needed to further understand AKI in burns with the aim of risk reduction.     

Response-based therapy for ruptured appendicitis reduces resource utilization

PurposeWe examined the effectiveness of a postoperative ruptured appendicitis protocol that eliminated Pseudomonas coverage and based the duration of IV antibiotic treatment and length of hospital stay on the patient’s clinical response.MethodsIn our new protocol, IV antibiotics were administered until the patient met discharge criteria: adequate oral intake, pain control with oral medications, and afebrile for 24 h. We collected data on all patients with ruptured appendicitis at our institution following protocol implementation (May 1, 2012, to April 30, 2013) and compared them to a control group.Results306 patients were treated (154 prior protocol, 152 new protocol). The new clinical response-based protocol led to a decrease in hospital stay from 134 h (SD 66.1) to 94.5 h (SD 61.7) (p < 0.001) and total cost of care per patient also decreased from $13,610 (SD $6859) to $9870 (SD $5670) (p < 0.001).ConclusionOur clinical response-based protocol for pediatric patients with ruptured appendicitis decreased LOS, cost, and IV antibiotics use without significant changes in adverse events.     

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.     

Sources of regional and center-level variability in survival and cost of care for congenital diaphragmatic hernia (CDH)

PurposeEnormous variability in management and cost occurs in CDH care. The purpose of this study was to identify regional mortality and cost patterns underlying this variability.MethodsThis is a retrospective study of neonatal CDH patients at U.S. hospitals using data from the Pediatric Health Information System (PHIS) database (2015–2018). Patients were risk-stratified using CDH Study Group predicted survival (CDHSG-PS), and mortality and costs were assessed by region (East, West, Mid-West, and South) and center.ResultsHigher mortality and extracorporeal life support (ECLS) rates were found in the Mid-West and South (p < 0.0001). Higher mortality was seen with ECLS among low-volume centers in the South (p = 0.007). When broken down by CHDSG-PS, higher severity patients had higher mortality in the Mid-West and South (p = 0.038). Cost was significantly lower for high severity nonsurvivors than survivors ($244,005 vs $565,487, p = 0.0008). The East spent more on high-severity patients with lower mortality compared to other regions, but also spent 3.5 times more on low severity nonsurvivors than survivors. Costs were higher at high-volume centers for low- and medium-severity patients, but all centers spent the same on high-severity patients.ConclusionCenter volume, region, and patient severity all contribute to the complex survival and cost disparities that exist in CDH care. Standardization of care may improve survival and reduce cost variability.Type of studyRetrospective database study.Level of evidenceLevel II     

How self-inflicted injury and gender impacted the outcome following a severe burn

BackgroundA high prevalence of self-inflicted burn injury is noted in severe burn injury. It remains unclear as to whether gender and past psychiatric history impact upon whether injury is self-inflicted and the outcomes.AimsReview the psychiatric history of patients treated in a statewide burn service following severe burn injury and determine whether psychiatric history, extent of burn and mortality are impacted by gender and whether the injury was self-inflicted.MethodA data linkage study was performed with psychiatric history and mental health service contact data matched to patients’ data collected via a previous retrospective file audit. Unadjusted and adjusted logistic regression modelling measured interactions between gender and self-inflicted burn status, and other study outcomes.ResultsIn total, 298 patients (47 with a self-inflicted burn) were admitted following a severe burn. Patients with self-inflicted burns were significantly more likely to have total body surface area burn of at least 50% (OR = 9.3; 95%CI: 4.7–18.5) and die within 24 h of admission (OR = 10.5; 95%CI:4.7–23.2). They were significantly more likely to have a past psychiatric diagnosis and public mental health service contact in the month pre-injury (OR = 18.9; 95%CI: 7.5–47.2). Male patients had significantly lower rates of a psychiatric diagnosis and recent mental health service contact. Males with self-inflicted injury are far more likely to die than males with a non-self-inflicted injury.ConclusionsPsychiatric clinicians should assertively screen the psychiatric history of patients with severe burn injury, and participate in the acute and longer-term management of persons admitted with a self-inflicted burn.     

Healthcare resource utilization,treatment patterns,and cost of care among patients with thermal burns and inpatient autografting in two large privately insured populations in the United States

The current standard of care for severe burns includes autografting; however, there is scarce knowledge regarding the long-term economic burden associated with thermal burns and inpatient autografting. The objective of this study was to characterize healthcare resource utilization, treatment patterns, and cost of care for thermal burn patients in two large privately insured populations in the United States who underwent inpatient autografting between 01/01/2011 and 06/30/2016. Patient demographics, clinical characteristics, healthcare resource utilization, and total cost were examined during baseline (one year before the initial hospitalization with autografting) and two-year evaluation period. There was a substantial economic burden on thermal burn patients who received inpatient autografts (HIRD® database [HIRD]: N = 371, mean age = 39.6 years, male = 67.1%; MarketScan® database [MarketScan]: N = 698, mean age = 38.2 years, male = 63.3%) in the year 1 evaluation period (HIRD: mean = $184,805; MarketScan: mean = $155,272), which was mainly driven by the initial hospitalization with autografting (HIRD: mean = $157,384 and MarketScan: mean = $131,470). The percentage of patients with burn-related healthcare resource utilization and average burn-related costs were considerably reduced in the year 2 evaluation period (HIRD: mean = $3020; MarketScan: mean = $1990). Consistent with previous studies, mean length of hospital stay (days) and mean total medical costs generally increased as the percentage of total body surface area burned increased.     

Assessment and determinants of global outcomes among 445 mass-casualty burn survivors: A 2-year retrospective cohort study in Taiwan

PurposeTo study outcomes among survivors of the mass-casualty powder explosion on 27 June 2015, at Formosa Fun Coast Waterpark, New Taipei City, Taiwan.MethodsUsing retrospective data on Taiwanese survivors, we analyzed prehospital management, burns assessment and prognosis, functional recovery, and medical costs, followed-up through 30 June 2017. We related outcomes to burn extent, categorized according to the percentages of total body surface area with second/third-degree burns (%TBSA) or autologous split-thickness skin grafts (%STSG), and an investigational scale: f{SASG} = (%TBSA + %STSG)/2, stratified by %STSG. Analyses included casualty dispersal, comparisons between %TBSA, %STSG and f{SASG}, and their relationships with length of hospitalization, times to rehabilitation and social/school re-entry, physical/mental disability, and medical costs. We also investigated how burn scars restricting joint mobility affected rehabilitation duration.Results445 hospitalized casualties (excluding 16 foreigners, 23 with 0% TBSA and 15 fatalities) aged 12–38 years, had mean TBSA of 41.1%. Hospitalization and functional recovery durations correlated with %TBSA, %STSG and f{SASG} – mean length of stay per %TBSA was 1.5 days; more numerous burn scar contractures prolonged rehabilitation. Females had worse burns than males, longer hospitalization and rehabilitation, and later school/social re-entry; at follow-up, 62.3% versus 37.7% had disabilities and 57.7% versus 42.3% suffered mental trauma (all p ≤ 0.001). Disabilities affecting 225/227 people were skin-related; 34 were severely disabled but 193 had mild/moderate impairments. The prevalence of stress-related and mood disorders increased with burn extent. Treatment costs (mean USD-equivalents ∼$48,977/patient, ∼$1192/%TBSA) increased with burn severity; however, the highest %TBSA, %STSG and f{SASG} categories accounted for <10% of total costs, whereas TBSA 41–80% accounted for 73.2%.ConclusionsBesides %TBSA, skin-graft requirements and burn scar contractures are complementary determinants of medium/long-term outcomes. We recommend further elucidation of factors that influence burn survivors’ recovery, long-term physical and mental well-being, and quality of life.     

Direct healthcare costs of hip,vertebral, and non-hip,non-vertebral fractures

Limited data exist regarding the cost of non-hip, non-vertebral (NHNV) fractures. Although NHNV fractures may be less expensive than hip and vertebral fractures, they have a higher incidence rate. The objective of this study was to quantify first-year healthcare costs of hip, vertebral, and NHNV fractures. This was a claims-based retrospective analysis using a case-control design among patients with commercial insurance and Medicare employer-based supplemental coverage. Patients were ≥ 50 years old with a closed hip, vertebral, or NHNV fracture between 7/1/2001 and 12/31/2004, and continuous enrollment 6 months prior to and 12 months after the index fracture. Adjusted mean first-year healthcare costs associated with these fractures were determined. Six cohorts were identified. Patients 50–64 years: NHNV (n = 27,424), vertebral (n = 3386) and hip (n = 2423); patients ≥ 65 years: NHNV (n = 40,960), vertebral (n = 11,751) and hip (n = 21,504). The ratio of NHNV to hip fractures was 11:1 in the 50–64 cohort and 2:1 in the ≥ 65 cohort. Adjusted mean first-year costs associated with hip, vertebral, and NHNV fractures were $26,545, $14,977, and $9183 for the 50–64 age cohort, and $15,196, $6701, and $6106 for patients ≥ 65 years. After taking prevalence rate into account, the proportion of the total fracture costs accounted for by NHNV, hip, and vertebral fractures were 66%, 21% and 13% for the 50–64 age cohort, and 36%, 52% and 12% for the ≥ 65 age cohort. Limitations included the exclusion of the uninsured and those covered by Medicaid or military-based insurance programs. The results of this study demonstrate that osteoporotic fractures are associated with significant costs. Although NHNV fractures have a lower per-patient cost than hip or vertebral fractures, their total first-year cost is greater for those 50–64 because of their higher prevalence.     

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.     

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.     

Management of combined massive burn and blast injury: A 20-year experience

IntroductionBlast injuries are complex types of physical trauma resulting from direct or indirect exposure to an explosion, which can be divided into four classes: primary, secondary, tertiary, and quaternary. Primary blast injury results in damage, principally, in gas-containing organs such as the lungs (blast lung injury, BLI). BLI is defined as radiological and clinical evidence of acute lung injury occurring within 12 h of exposure to an explosion and not due to secondary or tertiary injury. BLI often combines with cutaneous thermal injury, a type of quaternary blast injury, either in terrorist bomb attacks or in civilian accidental explosions. This report summarizes our experience in the management of combined massive burn and BLI at a Shanghai Burn Center in China.MethodsA retrospective observational analysis of clinical data was performed for massive burn patients with or without BLI during a 20-year interval. Patient characteristics, causes of injury, clinical parameters, management, and outcomes were recorded and evaluated.ResultsA total of 151 patients (120 males and 31 females) with severe burn injury (≥50% TBSA) treated at the Burn Center of Changhai Hospital in Shanghai between July 1997 and June 2017 were enrolled in this study. Their mean age was 38.6 ± 17.8 (3–75) years. Among them, 28 patients had combined BLI and burn injury and 39 patients had no BLI or smoke inhalation injury (non-BLI-SII). No significant difference was observed in the burn area or full-thickness burn area between the two groups. The lowest PaO₂/fraction of inspired oxygen (FiO₂) ratio during the first 24 h in BLI patients was significantly lower than that in non-BLI-SII patients. Exudative changes were observed by X-ray radiography in all BLI patients but not in non-BLI-SII patients within 6 h after injury. A significantly higher proportion of colloids were used for fluid resuscitation in BLI patients than that in non-BLI-SII patients. A higher proportion and longer time of mechanical ventilation were needed for BLI patients than those for non-BLI-SII patients, and a higher proportion of patients received sedative agents in the BLI group than those in the non-BLI-SII group. The first escharectomy was performed relatively later in BLI patients than in non-BLI-SII patients because of more time taken by BLI patients to recover from lung injury. The length of ICU and hospital stay in BLI patients was significantly longer than that in non-BLI-SII patients. No significant difference in the overall mortality was detected between these two groups.ConclusionIt is a formidable challenge for clinicians to diagnose and manage massive burn patients combined with BLI. A comprehensive treatment approach is strongly recommended, including fluid resuscitation, airway management, mechanical ventilation, and surgical treatment. Given the high mortality of massive burn patients combined with BLI even in a recognized burn center, more prospective studies are encouraged to assess more effective strategies for the treatment of such patients.     

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.     

Long term sensory function after minor partial thickness burn: A pilot study to determine if recovery is complete or incomplete

BackgroundAcute burn damages skin architecture, including nerve endings, altering sensation and influencing recovery of quality of life and participation. It is established that sensation is reduced in scars after deep burn. However, it is unclear if sensory deficits exist in mild scars. The aim of this trial was to determine if sensory deficits persist in mature scars after minor partial thickness burn.MethodsThis observational pilot involved 30 patients with ‘good quality’ scars (defined as VSS ≤5 at ≥6 months post-burn). Sensory function was compared in scars and site matched uninjured skin using von Frey filaments and two-point discrimination (2-PD). Multivariable regression was used to predict the influence of burn and confounders on sensory outcomes.ResultsBoth pressure and 2-PD distance were significantly greater in scar compared to uninjured sites, indicating reduced sensory function. For von Frey filaments, the median was 3.84 (IQR = 1) in scars and 3.22 (IQR = 1) for uninjured (p = 0.001). For 2-PD, the median was 3.9 cm (IQR = 1.8) for scars and 2.6 cm (IQR = 1.6) for control sites (p = 0.001).ConclusionMeasureable sensory deficits persist in mature, good quality burn scars. These deficits may influence long-term recovery after minor partial thickness burn.     

The frailty tipping point: Determining which patients are targets for intervention in a burn population

ObjectiveElderly burn patients vary in physiologic age and frailty. While previous evidence suggests that frailty on admission is associated with poor outcomes, changes in frailty during hospitalization for a burn injury have not been reported.MethodsWe performed a two-year retrospective review of all elderly (≥65 years) burn-patients admitted to our burn center. Patients who died during admission were excluded. Data collected include: demographics, injury characteristics, outcomes, and discharge disposition. Canadian Study on Health and Aging Clinical Frailty Scores (CFS) were calculated on admission and at discharge. Change in frailty was calculated for each patient. Mean values are represented as mean ± standard deviation, median values are represented as median (IQR).ResultsSeventy-nine patients, mean age of 75 ± 8 years, with a mean admission CFS was 4.3 ± 1.2 and discharge CFS was 5.1 ± 1.2 were included in the study. The mean change in CFS was −0.55 ± 0.93. Forty-six patients (59%) had no change or an improvement in frailty during hospitalization while 32 (41%) had worsened CFS at discharge. Patients whose CFS was worse at discharge had larger burns (12.8 ± 10.7% vs. 6.28 ± 5.7%), lower admission CFS (3.88 ± 1.5 vs. 4.93 ± 1.0), and longer ICU stays (15.6 ± 18.9 vs. 7.64 ±  10.6 days) than patients without change in CFS. On multivariate regression analysis TBSA (OR 1.2 (1.07–1.3)) and admission CFS of 1–4 (OR 7.9 (2.2–28)) were significant predictors of worsened CFS at discharge.ConclusionsIn our study population, patients with low admission frailty scores are at greatest risk for worsened frailty at discharge and should be targeted for the development of future frailty prevention programs.     

A remarkable point for evaluating the severity of burns: Thiol–disulfide profile

AimThe objective of this study was to examine the thiol–disulfide profile tests in patients suffering from burn injuries.MethodsThis case–control study comprised 48 patients with thermal burn injuries and 61 healthy individuals. Thiol–disulfide tests were conducted in both groups, and also, the changes of thiol–disulfide parameters were analyzed at zero time and on days 3, 7, 15, and 30 of the admission in patients with burn injuries.ResultsThe patients had significantly decreased native and total thiol levels and native thiol/total thiol ratios, and significantly increased disulfide/native thiol and disulfide/total thiol ratios compared to control individuals (p < 0.001 for all). The variations of native thiol levels, total thiol levels, and disulfide/native thiol ratios were significantly different over time in patients with burn injuries (p < 0.001, p < 0.001, p < 0.05, respectively). There were strong associations with the clinical parameters and thiol–disulfide profile tests (p < 0.05 for all).ConclusionThere was a metabolic disturbance of the thiol–disulfide system among patients with burn injuries. The courses of thiol–disulfide variables in time overlapped with the burn mechanism. Strong associations provide that thiol–disulfide homeostasis might be a notable key for evaluating the severity of burns and predicting the survival.     

Characterization of critically ill adult burn patients admitted to a Brazilian intensive care unit

IntroductionTo characterize the evolution of clinical and physiological variables in severe adult burn patients admitted to a Brazilian burn ICU, we hypothesized that characteristics of survivors are different from non-survivors after ICU admission.MethodsA five-year observational study was carried out. The clinical characteristics, physiological variables, and outcomes were collected during this period.ResultsA total of 163 patients required ICU support and were analyzed. Median age was 34 [25,47] years. Total burn surface area (TBSA) was 29 [18,43]%, and hospital mortality rate was 42%. Lethal burn area at which fifty percent of patients died (LA50%) was 36.5%. Median SAPS3 was 41 [34,54]. Factors associated with hospital mortality were analyzed in three steps, the first incorporated ICU admission data, the second incorporated first day ICU data, and the third incorporated data from the first week of an ICU stay. We found a significant association between hospital mortality and SAPS3 [OR(95%CI) = 1.114(1.062–1.168)], TBSA [OR(95%CI) = 1.043(1.010–1.076)], suicide attempts [OR(95%CI) = 8.126(2.284–28.907)], and cumulative fluid balance per liter within the first week [OR(95%CI) = 1.090(1.030–1.154)]. Inhalation injury was present in 45% of patients, and it was not significantly associated with hospital mortality.ConclusionsIn this study of an ICU in a developing country, the mortality rate of critically ill burn patients was high and the TBSA was an independent risk factor for death. SAPS3 at admission and cumulative fluid balance in the first seven days, were also associated with unfavorable outcomes. The implementation of judicious fluid management after an acute resuscitation phase may help to improve outcomes in this scenario.