Influence of burn severity on endothelial glycocalyx shedding following thermal trauma: A prospective observational study

ObjectiveSevere burns cause hypermetabolic and inflammatory responses are treated with significant volume resuscitation. This study aimed to evaluate correlations between glycocalyx metabolites and the burn size as well as certain clinical parameters such as administered fluid volumes.Study designSeverely burned patients with a total body surface area (TBSA) burned smaller and larger than 20% were included. Clinical parameters including length of stay, mortality, fluid administration and Sequential Organ Failure Assessment (SOFA) score as well as syndecan and heparansulfate, as laboratory parameters for endothelial damage, were obtained.ResultsA total of 39 patients (32 males, 7 females) with a mean age at burn of 45 ± 21 years were included. Syndecan levels decreased and heparansulfate levels increased over time. In both heparansulfate and syndecan, there was no significant difference between burns smaller and larger than 20% TBSA at any time point. Syndecan levels at 24 h after burn correlated significantly with IL-10 levels at admission (R = 0.58 and p < 0.05). There were significant linear correlations of %TBSA and cumulative administration of fluids after 24 h on syndecan levels after 48 h. Correlations between clinical parameters and syndecan or heparansulfate levels over time were not found.ConclusionsThis study shows that even though there are moderate correlations with burn size and administered fluid volume, levels of syndecan and heparansulfate are not predictive for clinical outcomes of burned patients in our cohort. Further studies with higher numbers evaluating the effect of large burns on glycocalyx shedding over a longer period of time are needed. Showing significant glycocalyx shedding in large burn including potentially correlations with clinical outcomes may yield new therapeutic targets.     

Safety and potential anticoagulant effects of nebulised heparin in burns patients with inhalational injury at Singapore General Hospital Burns Centre

Background

Nebulised heparin, N-acetylcysteine (NAC) and salbutamol were shown to decrease reintubation rates, incidence of atelectasis and mortality in paediatric patients and reduce lung injury scores in adult burns patients with inhalational lung injury (ILI). Nebulised heparin, NAC and salbutamol treatment protocol was introduced in Singapore General Hospital (SGH) Burns Centre in 2006. However, safety data on the use of nebulised heparin and NAC for burns patients with ILI is not well established. In this study, we investigated the safety and potential anticoagulant effects of nebulised heparin in burns patients with ILI.

Methods

A retrospective study with historical control was conducted. The treatment group consisted of 52 mechanically ventilated adult patients, with a diagnosis of ILI as confirmed by bronchoscopy, admitted to burn intensive care unit (BICU) from the year 2006 to 2009. The group was treated with nebulised heparin, NAC and salbutamol. The control group consists of 11 mechanically ventilated BICU ILI patients treated from year 2001 to 2005 before protocol initiation. Blood coagulation indices (prothrombin time (PT), activated partial thromboplastin time (APTT) and platelet count) were monitored and bleeding incidences were assessed.

Findings

Blood coagulation indices did not suggest an increase risk of bleeding with nebulised heparin. The APTT, PT and platelet count followed a similar trend for both groups over 7 days. No clinically significant increase in bleeding risk was found to be associated with nebulised heparin.

Conclusion

Nebulised heparin was not found to potentiate the risk of bleeding in burns patients with ILI.     

严重烧伤或伴吸入性损伤患者休克期输液问题及死亡原因探讨

的　探讨严重烧伤或伴吸入性损伤患者休克期输液问题以及死亡原因。　方法在 1991～ 2 0 0 0年间收治的严重烧伤或伴吸入性损伤患者 112例 ,对这些患者休克期的诊断、输液情况、死亡情况进行了总结。　结果　休克期的输液情况可归纳为 :第 1个 2 4h总入量 2 2ml/ (%TBSA·kg) ,其中胶体 0 5ml/ (%TBSA·kg) ,晶体 1ml/ (%TBSA·kg) ,其余为水分。第 2个 2 4h总入量 1 8ml/(%TBSA·kg) ,其中胶体 0 4ml/ (%TBSA·kg) ,其余为晶体、水分各半。单纯烧伤与烧伤伴吸入性损伤的输液情况 ,两者并无差异。休克期 7例患者死亡 ,原因均为呼吸衰竭 ,其中 3例休克未能纠正。　结论　各种输液公式均可为休克期补液提供参考 ,最重要的是应根据病人具体情况进行输液 ,以保证病人平稳渡过休克为最终目的。单纯烧伤和烧伤伴吸入性损伤患者休克期输液量并无不同。     

Critical care management of inhalational injury and severe burns

Inhalational injury and severe burns are common. Most will present to district general hospitals and thus an understanding of how to assess and manage these patients is vital for all practising anaesthetists with on-call commitments. In this article we emphasize the requirement for a highly functioning multidisciplinary approach with excellent communication both within and between treating teams. We will challenge the dogmatic approach to airway management and discuss the increasing problem of fluid creep. The key areas of burns assessment, sedation/analgesia and nutrition management in these patients is also discussed.     

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.     

Tracheostomy in burns patients revisited

Objective

The use of tracheostomy in burns patients has been controversial. A retrospective study was conducted to assess the use, complications and outcome of tracheostomy in ventilated adult burns patients.

Methods

Data was collected retrospectively regarding the extent of injury in each patient, the indication for tracheostomy, and outcome in terms of length of stay, days of mechanical ventilation, airway and pulmonary complications and survival. Patients were followed until discharge from the unit or death.

Results

Comparing patients who received tracheostomy to those who had translaryngeal intubation showed similar age distribution and no significant difference in the total burn surface area (TBSA). The use of tracheostomy was significantly higher in patients with TBSA >60%. Inhalation injury was significantly higher and mean probability of survival (ABSI), significantly lower in patients receiving tracheostomy. Duration of mechanical ventilation, length of stay in HDU/ITU and the incidence of pulmonary sepsis were significantly higher in tracheostomy group patients. However, there was no significant difference in mortality between the two groups.

Conclusion

Burn survivors with TBSA >60% are more likely to undergo repeated surgery and have burns to the head and neck region, therefore increasing the requirement for tracheostomy. Tracheostomy is a safe procedure with minimal perioperative complications. Late complications in this patient group may be related to duration of intubation and mechanical ventilation and the presence of an airway burn.Tracheostomy was associated with a higher prevalence of chest infection. We suspect that the cause of this is multifactorial, possibly due to a higher incidence of inhalation injury, greater burn size and prolonged mechanical ventilation in this group.     

Factors associated with duration of hospitalization and outcome in burns patients: A cross sectional study from Government Tertiary Care Hospital in Karachi,Pakistan

Objective

Burns are important contributors toward mortality in trauma related injuries in Karachi, Pakistan. The aim of the present study was to delineate the factors contributing to the duration of hospitalization and mortality in such patients.

Methods

We performed a single center retrospective study of patients admitted during a 2 year period (January 2009 till December 2010) in Burns Center, Karachi. Patients with incomplete record were excluded. Variables included were age and gender of the patient, the percent total body surface area (%TBSA) burn, the cause of the burn and the body parts affected along with the micro-organisms isolated from the burn wounds. The relationship of these variables with the duration of hospitalization and the outcome of patients was assessed by means of Pearson Chi Square test in SPSS version 14.

Results

Mean age of patients was 26.64 years (±13.430). More males (56.6%) were admitted than females (43.4%), giving a male to female ratio of 1.3:1. Mean percent total body surface area (%TBSA) burnt and mortality were 24.69% and 26.38% respectively with both having higher values in females (p < 0.001). Males had a mean longer duration of hospitalization compared to females (35.94 days vs. 27.63 days). The most common micro-organism colonizing the wounds was found to be Staphylococcus aureus. Factors significantly (p < 0.05) associated with increased duration of hospitalization and mortality include the age and gender of the patient, the cause of burn, inhalation injury, the region affected and %TBSA burnt.

Conclusion

The relationship of age and gender of the patient, the cause of burn, inhalation injury, the region affected and %TBSA burnt are important factors in determining the duration of hospitalization of the patients and whether the patients will survive or succumb to injuries.     

Management of patients with musculoskeletal disease and burns

Musculoskeletal disorders include a wide range of disorders which affect the locomotor system, i.e. muscles, bones, joints, and associated connective tissues like tendons and ligaments, which are listed in Chapter XIII of the International Classification of Diseases (ICD-10). While the primary pathology affects locomotor system, a number of these disorders are associated with systemic complications, resulting in increased morbidity and mortality in the perioperative period.Burns are an acute emergency and require anaesthetic or critical care input for assessment of injuries, early surgical intervention or organ support. Major burns are a multisystem disorder and although they account for less than 5% of all new burns cases, their management is complex and requires multidisciplinary approach in a specialized centre. This chapter highlights the important considerations for perioperative management of these conditions.     

Defining the criteria for intubation of the patient with thermal burns

Objectives

Recent studies demonstrate that burn patients are undergoing unnecessary intubations. We sought to determine the clinical criteria that predict intubations with benefit.

Modern trends in fluid therapy for burns

The majority of burn centres use the crystalloid-based Parkland formula to guide fluid therapy, but patients actually receive far more fluid than the formula predicts. Resuscitation with large volumes of crystalloid has numerous adverse consequences, including worsening of burn oedema, conversion of superficial into deep burns, and compartment syndromes. Resuscitation fluids influence the inflammatory response to burns in different ways and it may be possible, therefore to affect this response using the appropriate fluid, at the appropriate time. Starches are effective volume expanders and early use of newer formulations may limit resuscitation requirements and burn oedema by reducing inflammation and capillary leak. Advanced endpoint monitoring may guide clinicians in when to ‘turn off’ aggressive fluid therapy and therefore avoid the problems of over-resuscitation.     

Controversies in fluid resuscitation for burn management: literature review and our experience

The purpose of this review is to summarise the commonly used formulae for fluid resuscitation in major burns and to discuss the controversy surrounding the use of protein-based colloids as a component of these types of formulae. Fluid resuscitation in major burns is one of the most critical steps in managing this type of injury. In practice, a wide variety of formulae for fluid resuscitation has been suggested. Some propose only the use of crystalloids, while others combine the colloids together with crystalloids. A review was performed of the literature addressing fluid resuscitation formulae and our experience using our formula is presented. At the authors' burn centre a unique formula is in use, which combines plasma and crystalloids. Our experience using this specific formula extends over a period of 15 years and 356 patients with major burns have been resuscitated using this protocol. At our centre, 27 deaths were recorded, 19 of which had third degree burns of more than 80% total body surface area (TBSA). The protein-based colloids are included in most of the formulae and the beneficial effect is considered to be higher than the potential side effects. We are in favour of administering colloids during the resuscitation period for major burns, starting in the early period after injury.     

Plasma protein C levels are directly associated with better outcomes in patients with severe burns

Protein C circulates in human plasma to regulate inflammation and coagulation. It has shown a crucial role in wound healing in animals, and low plasma levels predict the presence of a wound in diabetic patients. However, no detailed study has measured protein C levels in patients with severe burns over the course of a hospital admission. A severe burn is associated with dysfunction of inflammation and coagulation as well as a significant risk of morbidity and mortality. The current methods of burn assessment have shortcomings in reliability and have limited prognostic value. The discovery of a biomarker that estimates burn severity and predicts clinical events with greater accuracy than current methods may improve management, resource allocation and patient counseling. This is the first study to assess the potential role of protein C as a biomarker of burn severity.We measured the plasma protein C levels of 86 patients immediately following a severe burn, then every three days over the first three weeks of a hospital admission. We also analysed the relationships between burn characteristics, blood test results including plasma protein C levels and clinical events. We used a primary composite outcome of increased support utilisation defined as: a mean intravenous fluid administration volume of five litres or more per day over the first 72 h of admission, a length of stay in the intensive care unit of more than four days, or greater than four surgical procedures during admission. The hypothesis was that low protein C levels would be negatively associated with increased support utilisation.At presentation to hospital after a severe burn, the mean plasma protein C level was 76 ± 20% with a range of 34–130% compared to the normal range of 70–180%. The initial low can be plausibly explained by impaired synthesis, increased degradation and excessive consumption of protein C following a burn. Levels increased gradually over six days then remained at a steady-state until the end of the inpatient study period, day 21. A multivariable regression model (Nagelkerke’s R² = 0.83) showed that the plasma protein C level on admission contributed the most to the ability of the model to predict increased support utilisation (OR = 0.825 (95% CI = 0.698-0.977), P = 0.025), followed by burn size (OR = 1.252 (95% CI = 1.025–1.530), P = 0.027), burn depth (partial thickness was used as the reference, full thickness OR = 80.499 (1.569–4129.248), P = 0.029), and neutrophil count on admission (OR = 1.532 (95% CI = 0.950–2.473), P = 0.08). Together, these four variables predicted increased support utilisation with 93.2% accuracy, 83.3% sensitivity and 97.6% specificity. However if protein C values were disregarded, only 49.5% of the variance was explained, with 82% accuracy, 63% sensitivity and 91.5% specificity. Thus, protein C may be a useful biomarker of burn severity and study replication will enable validation of these novel findings.     

Critical care management of patients with severe burns and inhalational injury

Anaesthetists and critical care physicians involved in emergency care provision must be equipped with the adequate knowledge and skills to accurately assess and manage patients with severe burns. This summary aims to review the key principles in managing patients with severe burns including airway management, fluid resuscitation, sedation, burn care, analgesia and nutrition.     

Critical care management of patients with severe burns and inhalational injury

Anaesthetists and critical care physicians involved in emergency care provision must be equipped with the adequate knowledge and skills to accurately assess and manage patients with severe burns. This summary aims to review the key principles in managing patients with severe burns including airway management, fluid resuscitation, sedation, burn care, analgesia and nutrition.     

Impact of inhalation injury on outcomes in critically ill burns patients: 12-year experience at a regional burns centre

IntroductionBurns inhalation injury increases the attributable mortality of burns related trauma. However, diagnostic uncertainties around bronchoscopically graded severity, and its effect on outcomes, remain. This study evaluated the impact of different bronchoscopic burns inhalation injury grades on outcomes.MethodsA single-centre cohort study of all patients admitted to the London Burns centre intensive care unit (BICU) over 12 years. Demographic data, burn and burns inhalation injury characteristics, and ICU-related parameters were collected retrospectively. The primary outcome was mortality. Secondary outcomes were hospital and ICU lengths of stay. The impact of pneumonia was determined. Univariate and multivariable Cox’s proportional hazards regression analyses informed factors predicting mortality.ResultsBurns inhalation injury was diagnosed in 84 of 231 (36%) critically ill burns patients; 20 mild (grade 1), 41 severe (grades 2/3) and 23 unclassified bronchoscopically. Median (IQR) total body surface area burned (TBSA) was 20% (10?40). Mortality was significantly higher in patients with burns inhalation injury vs those without burns inhalation injury (38/84 [45%] vs 35/147 [24%], p < 0.001). Patients with pneumonia had a higher mortality than those without (34/125 [27%] vs 8/71 [11%], p = 0.009). In multivariable analysis, severe burns inhalation injury significantly increased mortality (adjusted HR=2.14, 95%CI: 1.12–4.09, p = 0.022), compared with mild injury (adjusted HR=0.58, 95% CI: 0.18–1.86, p = 0.363). Facial burns (adjusted HR=3.13, 95%CI: 1.69–5.79, p < 0.001), higher TBSA (adjusted HR=1.05, 95%CI: 1.04–1.06, p < 0.001) and older age (adjusted HR=1.04, 95%CI: 1.02–1.07, p < 0.001) also independently predicted mortality, though pneumonia did not.ConclusionsSevere burns inhalation injury is a significant risk factor for mortality in critically ill burns patients. However, pneumonia did not increase mortality from burns inhalation injury. This work confirms prior implications of bronchoscopically graded burns inhalation injury. Further study is suggested, through registries, into the diagnostic accuracy and reliability of bronchoscopy in burns related lung injury.     

Management of patients with musculoskeletal disease and burns

Musculoskeletal disorders include a wide range of disorders which affect the locomotor system (i.e. muscles, bones, joints and associated connective tissues like tendons and ligaments, which are listed in chapter XIII of the International Classification of Diseases – 10). While the primary pathology affects the locomotor system, a number of these disorders are associated with systemic complications, resulting in increased morbidity and mortality in the perioperative period. Burns are an acute emergency and require anaesthetic or critical care input for assessment of injuries, early surgical intervention or organ support. Major burns are a multisystem disorder and although they account for less than 5% of all new burns cases, their management is complex and requires multidisciplinary approach in a specialized centre. This article highlights the important considerations for perioperative management of these conditions.     

Factors affecting survival in adult patients with massive burns

Objective: To identify treatment-related factors associated with mortality in massively burned adult patients. Methods: This retrospective cohort study examined survival outcomes at a burn unit of 54 beds and 10 burn ICU beds, totaling 900 admissions per year. The cases of 102 adult patients, admitted consecutively from January 1993 to October 2007, with massive burns (burn area > 70% of the total body surface area, TBSA) were studied. Relevant variables were recorded from the initial injury and throughout the hospital course. Survival analysis, based on univariate and stepwise multivariate Cox proportional hazards regression, was performed to determine which variables predicted mortality. Results: The overall mortality rate was 30.4%. Burn size, severe inhalation injury, full-thickness burns, serum creatinine levels, inotropic support, platelet counts < 20,000 per mm³, sepsis and ventilator dependency were significantly associated with mortality as determined by univariate analysis. Only sepsis, ventilator dependency and platelet counts were significant independent predictors of mortality as determined by multivariate analysis. Conclusions: Sepsis, ventilator dependence (indicating severe respiratory complications), and low platelet counts (indicating thrombocytopenia) are associated with increased mortality risk in adult patients with massive burns. Methods should be sought to ameliorate these complications during treatment in burn-care units.     

Cardiac dysfunction after burns

OBJECTIVES: Using transoesophageal echocardiography (TEE) we investigated the occurrence, and the association of possible abnormalities of motion of the regional wall of the heart (WMA) or diastolic dysfunction with raised troponin concentrations, or both during fluid resuscitation in patients with severe burns. PATIENTS AND METHODS: Ten consecutive adults (aged 36-89 years, two women) with burns exceeding 20% total burned body surface area who needed mechanical ventilation were studied. Their mean Baux index was 92.7, and they were resuscitated according to the Parkland formula. Thirty series of TEE examinations and simultaneous laboratory tests for myocyte damage were done 12, 24, and 36h after the burn. RESULTS: Half (n=5) the patients had varying grades of leakage of the marker that correlated with changeable WMA at 12, 24 and 36h after the burn (p< or =0.001, 0.044 and 0.02, respectively). No patient had WMA and normal concentrations of biomarkers or vice versa. The mitral deceleration time was short, but left ventricular filling velocity increased together with stroke volume. CONCLUSION: Acute myocardial damage recorded by both echocardiography and leakage of troponin was common, and there was a close correlation between them. This is true also when global systolic function is not deteriorated. The mitral flow Doppler pattern suggested restrictive left ventricular diastolic function.     

Clinical outcomes after burns in elderly patients over 70 years: A 17-year retrospective analysis

Introduction

In the United Stated population >70 years is likely to double by the year 2050. Elderly population (>70 years) are most vulnerable to burns and outcomes following such injuries in this special group is poorly studied. This study aimed to look at outcomes following burns in patients >70 years over a period of 17 years.

Fluid resuscitation for major burn patients with the TMMU protocol

Background

Fluid resuscitation is one of the critical treatments for the major burn patient in the early phases after injury. We evaluated the practice of fluid resuscitation for severely burned patients with the Third Military Medical University (TMMU) protocol, which is most widely used in many regions of China.

Methods

Patients with major burns (>30% total body surface area (TBSA)) presenting to Southwest Hospital, Third Military Medical University, between January 2005 and October 2007, were included in this study. Fluid resuscitation was initiated by the TMMU protocol.

Results

A total of 71 patients were (46 adults and 25 children) included in this study. All patients survived the first 48 h after injury smoothly and none developed abdominal compartment syndrome or other recognised complications associated with fluid resuscitation. The average quantity of fluid infused was 3.3–61.33% more than that calculated based on the TMMU protocol in both adult and paediatric groups. The average urine output during the first 24 h after injury was about 1.2 ml per kg body weight per hour in the two groups, but reached 1.2 ml and 1.7 ml during the second 24 h in adult and pediatric groups, respectively.

Conclusion

This study indicates that the TMMU protocol for fluid resuscitation is a feasible option for burn patients. Individualised resuscitation – guided by the physiological response to fluid administration – is still important as in other protocols.