Candidemia in major burn patients and its possible risk factors: A 6-year period retrospective study at a burn ICU

ObjectiveThe aims of this study were to evaluate the epidemiological and clinical characteristics of candidemia in a typical burn ICU, and to determine the risk factors associated with candidemia among major burn patients.MethodThis retrospective observational study of candidemia from 2012 to 2017 in a burn ICU was conducted in the Department of Burn, Southwest hospital, Chongqing, China.ResultsThe study included 410 major burn patients (≥40% total body surface area), 39 (9.51%) of which were diagnosed with candidemia. The annual incidences of candidemia varied from 6.06% to 17.54%, and increased gradually in the 6 years. Candida parapsilosis was the dominant pathogen (28.21% strains). The overall resistance rate of Candida spp. to fluconazole was 35.89%. Candidemia cases most frequently occurred in the 2nd (30.77%) and 3rd (23.08%) weeks after burn, and intravascular catheters were the most common sources of bloodstream Candida infections (31.58%). The crude mortality of candidemia was 23.08%, and the mortality attributable to candidemia was 14.99%. Risk factors of candidemia included inhalation injury, renal dysfunction with replacement therapy, severe gastrointestinal complications, T-cell lymphopenia and prior Candida colonization.ConclusionCandidemia has a high incidence and mortality in major burn patients. The changes in etiology and drug sensitivity may make new challenges for the management of candidemia in burn ICUs.     

Clinical factors affecting mortality in elderly burn patients admitted to a burns service

INTRODUCTION: The purpose of this retrospective study was to provide basic probabilistic predictors of mortality to assist in determining appropriate therapeutic aggression in elderly burns population. METHOD: Eighty patients over the age of 70 years were admitted to the Victorian Adult Burns Service in Melbourne, Australia, over a period of 4 years. Retrospective data was analysed, taking into account patient demographics, type, site, depth and area of burn, presence of inhalation injury, number of co-morbidities, survival time and the number of operations performed, withdrawal of care and implementation of comfort measures only. RESULTS: Comparing survivors and non-survivors, significant differences were found between age, percentage total burn surface area (TBSA%), percentage full thickness surface area (FTSA%), presence of inhalation injury, site of burn and number of operations. The number of co-morbidities and gender were not significant to outcome. FTSA%, presence of inhalation injury, site of burn, age and number of operations were all significantly related to survival time. When patients who obtained comfort care were excluded from analysis, age and the number of operations were not considered to be significantly related to mortality. CONCLUSION: This study indicates that TBSA%, FTSA%, inhalation injury and age are significant predictors of death in the elderly burns population, although only the first three remain significant when patients who receive comfort care measures only are excluded.     

Incidence and risk factors of vancomycin-resistant enterococcus colonization in burn unit patients

This study was aimed to identify the incidence of vancomycin-resistant enterococcus (VRE) colonization in burn patients, to collate risk factors for colonization and to determine the VRE resistance profile to different antimicrobial agents. This prospective study was carried out on the burn unit, during the period from September 2008 to January 2010, in 128 patients who were hospitalized at least 3 weeks or more. Periodic swabs were taken from burn wound, rectal, axillary, umblicaly and throat regions of the patients on admission and 7th, 14th, 21st days of hospitalization. Demographics and known risk factors were retrieved and assessed by statistical methods. Only 20 patients (15.6%) were colonized with enterococci on admission and these strains isolated from rectal, umblical and throat samples were sensitive to vancomycin. Initial VRE isolation was made in the first samples from the rectum of two patients on the 7th day. The rates of rectal, umblical, throat and axillary colonization increased to 21.9%, 3.1%, 3.1% and 3.1% at 28th day, respectively. VRE strains were the first isolated from burn wounds of only one patient (0.8%) on the 14th day and the colonization rate increased to 7.0% at the 28th day. Our study indicated that rectal colonization was seen more than other sites of colonization and was strictly correlate to colonizing enterococci between burn wound and other body regions. Multivariate analyses showed that glycopeptide use, burn depth and total burn surface area were independent risk factors for acquisition of VRE. All VSE strains were susceptible to teicoplanin, tigecycline and linezolid. VSE strains were more resistant to gentamicin and streptomycin, and VRE strains were more resistant to penicillin and ampicillin. The present study showed tigecycline and linezolid to be most active agents against VRE strains. The determined VRE colonization and risk factors of VRE acquisition are expected to be useful in establishing guidelines for preventing VRE infection in burn unit.     

Healthcare-associated infections in burn patients: Timeline and risk factors

BackgroundHealthcare-associated infections (HAIs) remain a major challenge in burn research and care. We aimed to describe the epidemiology and timeline of HAIs and to estimate the association of demographics and clinical characteristics with time to HAI among burn patients.MethodsA prospective cohort study was conducted in a referral burn unit in southwestern Colombia. Incidence rates were calculated for HAI types and microorganisms, using a Poisson regression model. Univariable and multivariable Cox proportional hazards regression was used to estimate the effect of risk factors on time to first HAI.ResultsOf 165 burn patients, 46 (27.9%) developed at least one HAI (incidence rate of 21.8 per 1000 patient-days). The most frequent HAIs were burn wound infections, followed by bloodstream infections. The most common microorganisms were Staphylococcus aureus, Pseudomonas spp., and Acinetobacter baumannii. Whereas gram-negative bacteria were the most common microorganisms causing HAIs, gram-positive bacteria were the first microorganisms isolated after hospital admission. The independent risk factors associated with time to first HAI were burn size (TBSA > 20%), burn mechanism (flames and scalds), central venous catheter use, and mestizo race.ConclusionThese data have implications toward generating empirical antibiotic guidelines and preventive strategies targeting the patients at highest risk for HAI.     

Determination of risk factors for burn mortality based on a regional population study in Taiwan

Background

Burns are not only major personal catastrophic events but also constitute a national health problem due to its associated morbidity, rehabilitation, mortality and high cost medical services. Advances in care and treatment have increased survival from major burn injury. However, information on the epidemiology and risk factors of burn mortality in Taiwan is limited. The study aim was to determine the nationwide epidemiological characteristics, trends, and mortality risk factors of burn inpatients in Taiwan.

Replacement of specific coagulation factors in patients with burn: A review

Major burn is often associated with inflammation and coagulation system activation, consumption of endogenous coagulation factors, which have been associated with adverse clinical outcome. Coagulation system dysfunction during early postburn period is characterized by activation of procoagulation pathways, enhanced fibrinolytic activity and impairment of natural anticoagulants activity. Treatment principles focused on the normalization of coagulation and the inhibition of systemic inflammation might have a positive impact on organ function and on the outcome in septic burn patients. Modern treatment strategies using antithrombin, protein C and recombinant factor VIIa are based on early and continuous assessment of the bleeding and coagulation status of burn patients. This allows specific goal directed treatment, thereby optimizing the patient's coagulation status early, minimizing the patient's exposure to blood products, reducing costs and improving the patient's outcome.     

Influencing factors of the quality of life in Chinese burn patients: Investigation with adapted Chinese version of the BSHS-B

Objective

The study aims to evaluate the quality of life (QOL) in burn patients in China and find out principal influencing factors, so as to provide evidence for interventions.

Methods

A total of 271 burn patients in three major burn units in China were asked to fill in the adapted Chinese version (ACV) of the Burn Specific Health Scale-Brief (ACV BSHS-B) in order to seek out the principal influencing factors in combination with a self-designed demographic and disease condition questionnaire. Multivariable linear regression was used to analyse the principal influencing factors.

Results

The findings showed that there were seven principal influencing factors for the overall ACV BSHS-B score. They were: percent total body surface area (TBSA) burned (with the standardised regression coefficient being −0.594), burn area of lower limber (0.241), itch level (−0.227), pain level (−0.220), gender (0.217), mechanical ventilation (0.216) and hand deformity (−0.141).

Conclusion

QOL decreased in burn patients to different degrees depending on the intensity of burns. With a better understanding of influencing factors of burn patients’ QOL, the medical and nursing staff can take specific countermeasures to help patients gain a higher QOL.     

Another important factor affecting fluid requirement after severe burn: a retrospective study of 166 burn patients in Shanghai

Background

The modified Evans formula is the most often used schema for calculating intravenous resuscitation fluid requirement in burn patients in China, including two parameters: body weight and burnt body surface area (BBS). The aim of this retrospective study was to analyse depth of wound influencing intravenous fluid replacement in addition to these two factors.

Methods

We reviewed the records of 166 patients admitted in Shanghai Ruijin Hospital during 2000–2008 whose BBS was larger than 25% total body surface area (TBSA). The modified Evans formula was used in all patients. The volume of fluid therapy was determined by urinary output.

Result

In the first and second 24 h the volume of intravenous fluid resuscitation per bodyweight per BBS (VIWB) showed a significant positive correlation to full-thickness burn size ratio (FBSR: full thickness BBS/total BBS) (R² = 0.138, P < 0.001; R² = 0.108, P < 0.001). The volume of fluid resuscitation was not different than the modified Evans formula in superficial burn only patients. Each 20% increase in full-thickness burn size ratio increased 0.1 in volume infused per bodyweight per BBS in the first 24 h afterburn and 0.06 in the second 24 h.

Conclusion

Full-thickness burn wounds received more volume of intravenous fluid than superficial burn wounds, especially in the second 24 h afterburn. The formula meets the fluid predictions of different depth of wound by using the modified fluid coefficients.     

Hydatid cyst of biceps brachii associated with peripheral neuropathy

IntroductionHydatidosis represents the most significant parasitic disorder in the Mediterranean countries and leads to major problems through unfavorable effects on the public health and national economy. Localization of the primary cyst hydatid infection in the extremity is rare and biceps brachii localization is also rarely reported in the literature.Presentation of caseA 43-year-old woman, who presented with the complaints of mass and pain in the left arm and numbness of the hand. Laboratory investigations, X-ray and magnetic resonance (MRI) findings revealed hydatid cyst of the biceps brachi muscle. The mass was totally excised and the diagnosis was confirmed by the macroscopic images of the mass and the pathologic results. After the surgery, the patient had an improvement in the nerve compression findings including numbness of the hand and the upper extremity and pain.DiscussionLocalization of a primary cyst hydatid infection in the upper extremity is rare and there are no reports of peripheral neuropathy secondary to mass effect. Even if the pre-surgical electromyelography performed for the nerve conduction study reveals a normal result, the potential for the hydatid cysts to cause nerve compression should be taken into consideration in such patients.ConclusionCases of concomitant neurologic findings and complaints secondary to peripheral nerve compression are very rare. The clinical findings should not be ruled out even if the EMG result is negative.     

Risk factors for primary intracerebral hemorrhage in patients in Izumo City,Japan

The annual incidence rate of primary intracerebral hemorrhage (ICH) in Izumo City, Japan, appears to be the highest rate among those reported. Despite improvement of management and surgical therapy, the overall morbidity and mortality after ICH are still high. The author investigated the risk factors for ICH in patients in Izumo. A case-control study of 242 patients (137 men and 105 women with ages ranging from 34 to 97 years) with primary ICH was conducted in Izumo between 1991 and 1998. Hypertension, diabetes mellitus, heart disease, liver disease, alcohol consumption, cigarette smoking, and serum levels of total cholesterol, aspartate aminotransferase, and alanine aminotransferase were assessed as possible risk factors for ICH by using conditional logistic regression. The prevalence of hypertension among ICH patients was 77% and the odds ratio (OR) for hypertension was 17.07 (95% CI: 8.30–35.09), which are much higher than figures reported from Western countries. The OR for hypertension was higher in individuals ≤69 years of age than in those ≥70 years of age and lower for lobar hemorrhage than for hemorrhages at other sites. High serum total cholesterol (≥220 mg/dl) was the second most important risk factor for ICH (OR: 2.52; 95% CI: 1.23–5.14), and low total cholesterol (<160 mg/dl) decreased the risk of ICH (OR: 0.47; 95% CI: 0.27–0.82). In contrast, heart disease decreased the risk of ICH, and there was no observed association between alcohol consumption, cigarette smoking, or diabetes mellitus and ICH. This study conducted in Izumo suggests that hypertension is the most important risk factor for ICH and contrary to most previous studies indicates that serum total cholesterol concentration is also positively associated with the risk of ICH. In contrast, heart disease may decrease the risk of ICH.     

Peripheral neuropathy in burn patients

Neuropathy in burn patients is frequently overlooked. This study aimed at looking for neuropathies among burn patients. It included 55 burn patients, whether symptomatic or asymptomatic, with variable depths of burn at different stages. Their ages ranged from 8 to 55 years with a mean age of 23.6 ± 11.1 years. All patients were submitted to clinical examination, electromyographic and motor conduction velocities of burned and unburned limbs. Serum electrolyte, blood urea and creatinine were measured for all patients. Sixteen patients (29 per cent) had peripheral neuropathy. Only six had symptoms and signs of peripheral neuropathy. The most frequently diagnosed neuropathy in this study was mononeuritis multiplex in nine patients (56 per cent), then generalized distal axonal neuropathy in five patients (31 per cent) and entrapment neuropathy in two patients (13 per cent). In patients with mononcuritis, 29 nerves were affected, 24 nerves related to the site of the burn and five nerves were away from the site of the burn. All the entrapment neuropathy developed after wound healing. Age above 20 years, electric burns, burns involving full thickness of the skin and a surface area of more than 20 per cent were associated with a significantly higher prevalence of neuropathy. Other parameters were not found to be significant in the development of neuropathy.     

Thromboprophylaxis in adult and paediatric burn patients: A survey of practice in the United Kingdom

IntroductionPatients with burn injuries are at an increased risk of venous thromboembolism (VTE). This predisposition is secondary to the endothelial injury, hyper-coagulable state and stasis (Virchow’s triad) associated with burn injury. Although the true incidence of VTE in burn patients has not been adequately quantified, symptomatic VTE occurs in 0.2–7% of this population.VTE prophylaxis has proven clinical effectiveness and affords a reduction in the morbidity associated with such events, but the benefits and risk of complications need to be balanced in order to provide the best quality of care.Owing to the lack of prospective data on VTE in burns, practice varies greatly, not only internationally, but also between local burns services. Our aim was to better understand current VTE practice within United Kingdom (UK) burn care services by performing a comprehensive survey.MethodsWe contacted all the inpatient burn care services in the UK and collected data on current VTE practice via a standardised questionnaire. Services were given the choice to complete the survey by telephone or email and a follow-up plan was formulated.ResultsTwenty-five burn care services were contacted and 23 agreed to participate (92% response rate). Responding services treated adults, children or both and lead burn nurses or senior medical staff familiar with current VTE practice were interviewed.Routine VTE prophylaxis was provided in 84% of burn services and the majority utilised a combination of chemoprophylaxis and thromboembolic deterrent stockings (TEDS). All used low molecular weight heparin (LMWH) as their choice of chemoprophylaxis. Of those treating adults, all used a VTE prophylaxis protocol, but none of these applied to children. Only 56% of services treating children had such a protocol. The majority discontinued prophylaxis once patients were mobile.Discussion and conclusionAlthough the true burden of VTE in burn patients is unknown, we recognise that they are a population at risk. In addition to changes in the inflammatory and clotting pathways associated with thermal injury, prolonged hospital stay, ventilatory support, multiple surgeries, numerous central venous cannulations and reduced mobility all multiply this risk.The risk associated with the administration of heparin (bleeding complications and heparin-induced thrombocytopaenia) is low and can be reduced even further to 0.1% by the use of LMWH. The risk of symptomatic VTE is far greater, therefore the benefits of VTE prophylaxis would seem to outweigh the risks of not undertaking prophylactic measures. A higher LMWH dose and routine monitoring of anti-factor Xa levels are useful for acute burn patients.Two previous surveys, performed in Canada and the United States of America (USA), found routine administration of VTE prophylaxis to be 50% and 76% respectively. Of the 71 centres in the USA participating in the survey, 30% used a combination of sequential compression devices (SCD) and heparin and 24% did not provide VTE prophylaxis at all.A lack of prospective data on VTE in burn patients appears to be associated with diverse practice, and consensus on this topic could ensure that the potential morbidity caused by VTE is reduced. A clinical tool for identifying patients at risk and guidelines for management will standardise practice, which in turn should allow us to improve and maintain high quality care for burn patients.     

Optimizing initial vancomycin dosing in burn patients

Rationale

Burned patients have altered vancomycin pharmacokinetics necessitating adjusted dosing. Published initial dosing recommendations to target troughs of 15-20 mg/L for this population are lacking.

Objective

This study was conducted to develop initial vancomycin dosing recommendations based on the pharmacokinetics of vancomycin in acute burn patients.

Methods

A retrospective chart review of 49 vancomycin treated burn patients was conducted. Mean pharmacokinetic parameters were determined and Monte Carlo Simulation was used to develop initial vancomycin dosing recommendations that target trough concentrations between 15 and 20 mg/L.

Results

Vancomycin pharmacokinetic parameters were significantly (p < 0.05) different for vancomycin levels obtained 48 h to 14 days after burn versus >14 days after burn. Monte Carlo simulation indicated that the most commonly used empiric dosing regimen (1 g iv q12 h) attained targets with a probability of <10% in all burned patients. The probability of attaining targets was optimized to 20-25% by using 1.5 g iv q8 h, 1.75 g iv q8 h, 1 g iv q6 h, 1.25 g iv q6 h or 750 mg iv q4 h in patients 48 h to 14 days after burn and 1-1.25 g iv q8 h or 500 mg iv q4 h in patients >14 days after burn.

Conclusions

This study provides initial vancomycin dosing recommendations for burned patients 48 h to 14 days after burn and patients >14 days after burn. However, because of the heterogeneity in pharmacokinetics and the observation that vancomycin pharmacokinetics change with time after burn, monitoring of vancomycin serum concentrations is required to ensure targets are met and maintained.     

Semi-open percutaneous tracheostomy in burn patients

Introduction

We describe a semi-open approach to percutaneous tracheostomy as an effective and potentially safer alternative to open tracheostomy or percutaneous techniques in burn patients.

Methods

We identified patients who underwent the modified technique from 2005 to 2007. Our method used a 2-3 cm incision and limited dissection to the pretracheal fascia. A needle was used to enter the trachea and insert a guidewire. The trachea was then dilated using a ‘Blue Rhino’ dilator. The remainder of the procedure was performed according to standard technique.

Results

39 patients were identified. 30 of these cases were performed at the bedside. The average time to tracheostomy was 19 days. The average total body surface area involved was 42%. 51% of patients had burns of the neck. Five patients had burns over the stomal site. Of these five, three required autografting prior to tracheostomy. There were no deaths related to the procedure and the only complication was intraoperative hemorrhage in one patient, which was readily controlled.

Conclusion

The semi-open modification of the percutaneous tracheostomy combines the convenience and minimally invasive advantages of the percutaneous technique with the better surgical control of the airway afforded by the traditional open technique.     

大面积深度烧伤休克期切痂植皮

目的探讨大面积深度烧伤休克期切痂植皮的必要性和可行性。方法自1991年1月至1997年6月选择伤后及时入院的12例病人,烧伤面积平均78.3％±18.3％,Ⅲ度面积平均69.2％±26.8％,其中6例合并吸入性损伤,3例气管切开。开始手术时间为伤后38.4±9.6小时,一次切痂面积39.3％±8.7％,以尿量、心率、SaO_2和 CVP 为主要监护指标。结果术中术后各监护指标都较平稳。与条件相似的19例非休克期切痂病人对比表明:休克期切痂病人愈合天数缩短14天左右,内脏并发症及菌血症发生率低,治愈率高,平均每日住院费用降低。结论休克期大面积切痂植皮是可行的。     

Serum immunoglobulin levels in pediatric burn patients

Infections remain the leading cause of death in burn patients. Immune responses play an important role in patient's defense mechanism against infection and decreasing morbidity and mortality associated with burn. Our goal was to determine serum immunoglobulin levels in pediatric burn patients in order to understand role of humoral immune defense in these patients. During this analytic cross sectional study from January 2011 to February 2012, all patients with burn and younger than 6 years old that were referred to Shahid Motahari burn and reconstruction center were enrolled. Patients had no inhalation injury or sepsis. Immunoglobulin levels were measured once on 3–5 days after burn. The burn size in 12 patients (24%) was less than 30%, in 30 patients (60%) were between 30% and 50% and in the remained 8 patients (16%) were more than 50%. In 45 patients (90%) depth and severity of burn were 2nd degree (superficial and deep) and in the remaining 5 patients (10%), it was 3rd or 4th degree. In 28 (56%), 1 (2%), 3 (6%), 35 (70%), 48 (96%), 19 (38%) and 6 (12%) patients IgG, IgM, IgA, IgG1, IgG2, IgG3 and IgG4 were lower than normal values, respectively. No significant correlation was seen between burn size (TBSA) and value of immunoglobulin (P > 0.05). Although the drop in the serum concentration of immunoglobulins is irrespective to the burn size, more severe burn is associated with more decrease in the serum levels of IgA, IgM, IgG and its subclasses. However, further studies are needed to provide complementary data on this issue.     

Epidemiology and factors associated with acute stress disorder in burned patients: a case-control study

IntroductionA burn injury is a very painful experience, with subsequent emotional problems, which have been gaining relevance to the extent that survival from burns has improved. Among the alterations of the mental sphere in this population is Acute Stress Disorder (ASD) that has been described in up to one-third of patients with major burns.MethodologyA nested case-control study was carried out in a cohort of hospitalized patients in a burn referral unit, in patients over 16 years of age. A total of 135 patients, 41 cases, and 94 controls were included. All of them underwent a psychiatric interview, a standardized form was filled out on sociodemographic and clinical information, and the PID-5-BF scale was applied to evaluate associated personality elements. The diagnosis of acute stress was made with the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria.ResultsThe incidence of acute stress was 23.4%. When the clinical and sociodemographic characteristics of both the cases and the controls were compared, the risk factors were subsidized insurance, flame burn, burn in a special area, third-degree burn, high pain, stay in the Intensive Care Unit (ICU), peritraumatic amnesia and life threat. Patients also had a higher percentage of burned body surface, higher average pulse, longer hospital length of stay, higher average in the negative affect variable and in the psychoticism variable of the PID-5-BF scale. But for the multivariate analysis using logistic regression, the model that best explains the presence of acute stress only includes the variables life threat (Odds Ratio adjusted (ORa): 117.0; Confidence Interval (CI): 10.9–1258.5), severe pain (ORa: 9.9; CI: 1.8–52.8), electrical burn (ORa: 20.8; CI: 17.2–250), burn in a special area (ORa: 8.9; CI: 1, 0–76.8), third-degree burn (ORa: 10.4; CI: 0.7–166.7).ConclusionAcute stress disorder is frequent in the hospitalised burn population, and is more frequent than in other types of trauma. Associated factors with the presentation of Acute Stress Disorder are the feeling of life threat at the time of the burn, having pain classified as strong (Visual Analog Scale (VAS) 5–10), electrical burn, and burns in special areas.