No influence of burn size on ventilator-associated pneumonia in burn patients with inhalation injury

Objective

Burn size and inhalation injury are important predictors of mortality following burn. The important factors for predicting ventilator-associated pneumonia (VAP) following burn remain unclear. The aim of our study was to investigate the effect of burn size on VAP in burn patients with inhalation injury.

Methods

We retrospectively studied 52 burn patients with inhalation injury requiring mechanical ventilation admitted to the Department of Acute Medicine, Kawasaki Medical School Hospital, Okayama, Japan, between June 2007 and October 2010.

Results

The overall mortality for all patients was 15%. Twenty-six patients (50%) developed VAP. Patients with VAP required longer ICU stay and mechanical ventilation than those without VAP. There was no difference in age, gender, mortality, and TBSA between burn patients with inhalation injury with and Without VAP. VAP rate had no difference with increasing TBSA in burn patients with inhalation injury.

Conclusions

Our data indicated that burn size had no relationship with the development of VAP in burn patients with inhalation injury.     

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.     

A model for predicting mortality among critically ill burn victims

Objective

To develop a model for predicting mortality among burn victims.

Methods

All casualties admitted to our intensive care burn unit (ICBU) with a diagnosis of thermal or inhalation injury were studied. Age, total and full-thickness body surface area (BSA) burned, presence of inhalation injury, gender, mechanism of injury, delay to ICBU admission and mechanical ventilation during the first 72 h were recorded. The 851 participants were randomly divided into derivation (671) and validation (180) sets. From univariate and multivariate logistic regression analyses a mortality predictive equation was derived.

Results

Mortality was 17.6%. In univariate analysis, all variables were significantly associated with mortality except mechanism of injury and delay to ICBU admission. In multivariate analysis, age, total and full-thickness BSA burned, female gender and early mechanical ventilation were independently associated with mortality.

Conclusions

We propose a mortality predictive equation for burned victims. In this model, MV and not inhalation injury is a mortality risk factor.     

Early single-shot intravenous steroids do not affect pulmonary complications and mortality in burned or scalded patients

Background and objectives

Inhalation injury, especially in combination with cutaneous burns, is the major cause of morbidity and mortality in patients admitted to burn care centers. Either with or without the presence of a cutaneous burn, inhalation injury contributes to high risk for developing severe pulmonary complications. Steroids may reduce a prolonged and destructive inflammatory response to toxic or allergic substances. The objective of this study was to evaluate the effect of early single-shot intravenous steroids on pulmonary complications and mortality in burned or scalded patients with or without inhalation injury.

Methods

Retrospective analysis of a prospective single center database of patients registered between 1989 and 2011 who were admitted to the intensive care unit of our burn care center after burn or scald injury. Uni-variate statistical analysis was performed comparing two groups (steroid treated vs. non steroid treated patients) with regard to clinical outcome. Main parameters were sepsis, mortality and pulmonary complications such as pneumonia, ALI and ARDS. Multi-variate analysis was used by logistic regression with mortality and pulmonary complications as the dependent variables to identify independent risk factors after burn or scald injuries.

Results

A total of 1637 patients with complete data were included in the present analysis. 199 (12.2%) received single-shot intravenous steroids during the prehospital phase of care. In 133 (66.8%) of these patients, inhalation injury was diagnosed via bronchoscopy. Steroid treated patients had sustained a significantly higher severity of burn than non-steroid treated patients (Abbreviated Burn Severity Index 7.1 ± 3 vs. 6.0 ± 2.9; p < 0.001). In a multivariate analysis using a logistic regression model early intravenous steroid treatment had no significant effect on pulmonary complications and mortality.

Conclusions

In our single center cohort of burned and scalded patients single-shot intravenous steroids during the pre-hospital phase of care was not associated with pulmonary complications or mortality.     

Sclerosis therapy of bronchial artery attenuates acute lung injury induced by burn and smoke inhalation injury in ovine model

Introduction

In burned sheep, we showed more than a 10-fold increase in bronchial blood flow following smoke inhalation. It was previously reported that sclerosis of the bronchial artery prior to smoke exposure reduces the pathophysiology of the inhalation insult. We hypothesized that sclerosis of the bronchial artery after insult attenuates smoke/burn-induced acute lung injury.

Methods

Through an incision at the 4th intercostal space, a catheter was placed via the esophageal artery into the bronchial artery such that the bronchial blood flow remained intact. Acute lung injury was induced by a 40% total body surface area, 3rd degree cutaneous burn and smoke inhalation. Adult female sheep (n = 18, 35.6 ± 1.0 kg) were divided into three groups following the injury: (1) sclerosis group: 1 h after injury, 4 mL of 70% ethanol was injected into bronchial artery via bronchial catheter, n = 6; (2) control group: 1 h after injury, an equal dose of saline was injected into bronchial artery via the bronchial catheter, n = 6; (3) sham group: no injury and no treatment, n = 6. The experiment was conducted in awake animals for 24 h.

Results

Bronchial blood flow, measured by microspheres, was significantly reduced after ethanol injection in the sclerosis group. Pulmonary function, evaluated by measurement of blood gas analysis, pulmonary mechanics, and pulmonary transvascular fluid flux, was severely impaired in the control group. However, pulmonary function was significantly improved by bronchial artery sclerosis.

Conclusion

The results of our study clearly demonstrate a crucial role of enhanced bronchial circulation in thermal injury-related morbidity. Decreasing bronchial circulation using pharmacological agents may be an effective strategy in management of burn patients with concomitant smoke inhalation injury.     

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.     

Incidence and treatment of burns: A twenty-year experience from a single center in Germany

Objective

To analyze trends in incidence and treatment of thermal injuries over the last two decades.

Methods

We retrospectively reviewed our local single center database of patients with thermal injuries admitted to the burn intensive care unit (BICU) of the Cologne-Merheim Medical Center (University Hospital of Witten/Herdecke). The cohort was divided into two groups according to the decade of admission and the epidemiology and clinical course of the patient sample admitted during the period 1991–2000 (n = 911) was compared to that of 2001–2010 (n = 695).

Results

The following variables were significantly different in the bivariate analysis: mean age (39.8 years vs. 44.0 years), burn size of total body surface area (23.2% vs. 18.0%) and size of 3rd degree burns (9.6% vs. 14.9%). The incidence of inhalation injury was significantly lower in the last decade (33.3% vs. 13.7%) and was associated with a shorter duration of mechanical ventilation (10.8 days vs. 8.5 days). The ABSI-score as an indicator of burn severity declined in the second period (6.3 vs. 6.0) contributing partially to the decline of BICU length of stay (19.1 days vs. 18.8 days) and to the mortality rate decrease (18.6% vs. 15.0%).

Conclusion

The severity of burn injuries during the last two decades declined, probably reflecting the success of prevention campaigns. Concerning mortality, the chance of dying for a given severity of injury has decreased.     

Tracheostomy in craniectomised survivors after traumatic brain injury: A cross-sectional analytical study

Background

Decompressive craniectomy (DC) is a life-saving measure for traumatic brain injury (TBI). However, survivors may remain in a vegetative or minimally conscious state and require tracheostomy to facilitate airway management. In this cross-sectional analytical study, we investigated the predictors for tracheostomy requirement and influence of tracheostomy timing on outcomes in craniectomised survivors after TBI.

Methods

We enrolled 160 patients undergoing DC and surviving >7 days after TBI in this 3-year retrospective study. The patients were subdivided into 2 groups based on whether tracheostomy was (N = 38) or was not (N = 122) performed. We identified intergroup differences in early clinical parameters. Multivariable logistic regression was used to adjust for independent predictors of the need for tracheostomy. Early tracheostomy was defined as the performance of the procedure within the first 10 days after DC. Intensive care unit (ICU) stay, hospital stay, mortality, and Glasgow outcome scale (GOS) were analysed according to the timing of the tracheostomy procedure.

Results

After TBI, 24% of craniectomised survivors required tracheostomy. In the multivariate logistic regression mode, the significant factors related to the need for tracheostomy were age (odds ratio = 1.041; p = 0.002), the Glasgow coma score (GCS) at admission (odds ratio = 0.733; p = 0.005), and normal status of basal cisterns (odds ratio = 0.000; p = 0.008). The ICU stay was shorter for patients with early tracheostomy than for those undergoing late tracheostomy (p = 0.004). The timing of tracheostomy had no influence on the hospital stay, mortality, or GOS.

Conclusion

Age and admission GCS were independent predictors of the need for tracheostomy in craniectomised survivors after TBI. If tracheostomy is necessary, an earlier procedure may assist in patient care.     

Comparison of the Berlin definition with the American European Consensus definition for acute respiratory distress syndrome in burn patients

Objective

Acute respiratory distress syndrome (ARDS) is a leading cause of mortality in burn patients. Smoke inhalation, pneumonia and inflammation process are the major causes of ARDS in burn patients. The American European Consensus Conference (AECC) definition proposed in 1994 has recently been revised by the Berlin definition. Our objective was to describe the epidemiology of ARDS comparing the Berlin definition with the AECC definition in a retrospective cohort of burn patients.

Methods

We reviewed admitted burn adult patients for a two year period, and investigated patient who received mechanical ventilation for more than 48 h and in whom pneumonia was diagnosed.

Results

40 patients were analyzed. According to the AECC definition, 11 patients met criteria for ALI (27.5%), and 29 patients for ARDS (72.5%). According to the Berlin definition, all patients met criteria for ARDS: 4 (10%) for a severe ARDS, 25 (62.5%) for a moderate ARDS, 11 (27.5%) for a mild ARDS. Inhalation injury was diagnosed in 10 patients (25%). Categorizing patients with the Berlin definition showed statistically significative difference of mortality within the three groups, but not with the AECC definition.

Conclusion

The Berlin definition seems to be more accurate than the AECC definition to assess the severity of ARDS in term of outcome in burn patients. This definition may facilitate prompt recognition of ARDS in burn patients, and promote protective ventilation strategy to a larger number of patients.     

Burns, inhalation injury and ventilator-associated pneumonia: value of routine surveillance cultures

Purpose

Burn patients with inhalation injury are at particular risk for ventilator-associated pneumonia (VAP). Routine endotracheal surveillance cultures may provide information about the causative pathogen in subsequent VAP, improving antibiotic therapy. Our objective was to assess the incidence of VAP in burn patients with inhalation injury, and the benefit of routine surveillance cultures to predict multidrug resistant (MDR) pathogens.

Procedures

Historical cohort (n = 53) including all burn patients with inhalation injury requiring mechanical ventilation, admitted to the Ghent burn unit (2002–2010).

Main findings

Median (interquartile range) age and total burned surface area were 44y (39–55y) and 35% (19–50%). Overall, 70 episodes of VAP occurred in 46 patients (86.8%). Median mechanical ventilation days (MVD) prior to VAP onset were 7d (4–9d). The incidence was 55 episodes/1000 MVD. In 23 episodes (32.9%) at least one MDR causative pathogen was involved, mostly Pseudomonas aeruginosa and Enterobacter spp. The sensitivity and specificity of surveillance cultures to predict MDR etiology in subsequent VAP was respectively 83.0% and 96.2%. The positive and negative predictive value was 87.0% and 95.0%, respectively.

Conclusions

The incidence of VAP in burn patients with inhalation injury is high. In this cohort routine surveillance cultures had excellent operating characteristics to predict MDR pathogen involvement.     

A 10-year experience with major burns from a non-burn intensive care unit

Objective

The aim of this study was to review clinical data and outcomes of patients with burns in a Mexican non-burn intensive care unit (ICU).

Methods

We did a retrospective analysis of our single-centre database of burn patients admitted to the ICU in the Hospital Civil Fray Antonio Alcalde (University Hospital). The sample was divided for analysis into two groups according to the outcome ‘death’ or ‘discharge’ from ICU.

Results

Overall mortality was 58.2%, without a decreasing trend in mortality rates through the years. We identified the presence of third-degree burns (odds ratio (OR) 1.5, p = 0.003), and >49% total burned surface area (TBSA; OR 3.3, p ≤ 0.001) was associated with mortality. Mean age was higher in deceased patients (38.2 years vs. 31.3 years, p = 0.003) as was the TBSA (62.8% vs. 36.4%, p ≤ 0.001). At multivariate analysis, inhalation injury was not associated with increased mortality, but it was with more mechanical ventilation days. Early surgical debridement/cleansing was performed in most patients; however, the mean of the procedures was 1.7 per patient in both groups.

Conclusion

We identified significant factors associated with mortality. These variables and prognosis from non-burn ICUs differ broadly compared with burn intensive care units (BICUs); thus, more structured, multidisciplinary and specialised treatment strategies are still needed.     

Prognostic factors in electrical burns: A review of 101 patients

Purpose

Electrical burn wounds are among the most devastating of burns, with wide-ranging injuries. We aimed to document the factors affecting the mortality rate of patients presenting with electrical burn wounds to our regional burn centre.

Methods

This retrospective study was conducted on 101 patients from January 2009 to June 2012. Factors were classified under 11 topics and evaluated according to their relationship with the mortality rate.

Results

The major causes of death in burn victims were multiple organ failure and infection. Twenty-six percent of the 101 patients died, all of whom were male. One (1.4%) of the patients who survived was female; 73 (98.6%) survivors were male. The mean age in the deceased group was statistically higher than that of the other patients (32.7 vs. 35.6 years; P < 0.05). All-cause mortality was 2.79 times higher for larger burns (>25% total body surface area). The values for creatine kinase, creatine kinase-MB, total body surface area of burn, hospitalised period in the intensive care unit and intubation rate were significantly higher in the exitus group. Renal injury requiring haemofiltration was associated with an almost 12-fold increased risk for mortality. There was no statistically significant difference between patients regarding surgical interventions.

Conclusion

Electrical injury remains a major cause of mortality and long-term disability among young people. Our data demonstrated several risk factors associated with increased mortality rate in patients with electrical burn wounds.     

Evaluation of the spontaneous breathing trial in burn intensive care patients

Background

The extubation failure rate in our burn patients is 30%.

Objective

To evaluate the influence of the 30 min spontaneous breathing trial on extubation outcome in burn patients.

Methods

A prospective, observational study in a burn intensive care unit. All adult patients requiring mechanical ventilation for >24 h and meeting the inclusion criteria underwent a 30 min spontaneous breathing trial (SBT). Extubation was undertaken after a successful SBT.

Results

Of 49 planned extubations, 9 failed (18%), much lower than the 30% extubation failure rate identified prior to the implementation of the SBT. The duration of ventilation was significantly shorter (p = 0.04) in the patients who passed a SBT and those who failed extubation were significantly older (p = 0.003). The logistic regression analysis identified that age independently predicted extubation outcome. Patients who failed extubation, after a successful SBT, had a significantly longer duration of ventilation (p = 0.0001) and ITU length of stay (p = 0.001).

Conclusions

The incidence of extubation failure was much lower and the duration of ventilation significantly shorter in patients who were extubated after a successful SBT. These findings support the use of the SBT in burn patients. Age independently predicts extubation outcome in burn patients who have passed a SBT.     

Hypoalbuminemia in the first 24 h of admission is associated with organ dysfunction in burned patients

Objective

Hypoalbuminemia is a common finding in burned patients, but its association with increased morbidity and mortality has not been well established. We assessed whether hypoalbuminemia in the first 24 h of admission is associated with organ dysfunction in patients with severe burns.

Methods

For a two year period (2008–2009), we reviewed the records of burn adult patients with a total body surface area 20% admitted in our unit within the first 24 h of injury. A multiple linear regression analysis was conducted to assess hypoalbuminemia as an independent predictor of organ dysfunction.

Results

56 subjects were analyzed. Multiple linear regression analysis showed that hypoalbuminemia in the first 24 h of admission was an independent predictor of organ dysfunction. Serum albumin concentration ≤30 g/L was associated with a two-fold increase in organ dysfunction [SOFA scores at day 0 (p = 0.005), day 1 (p = 0.005) and first week mean values (p = 0.004)], but not with mortality (p = 0.061).

Conclusion

Hypoalbuminemia is associated with organ dysfunction in burned patients. Unlike unmodifiable predictors such as age, burn surface and inhalation burn, correction of hypoalbuminemia might represent a goal for a future trial in burn patients.     

A study of energy-related injuries from hospital admissions among children and adults in South Africa

Introduction

Burn and ingestion injuries are common in developing countries because of poor access to safe energy sources, crowded living conditions, and insufficient knowledge of potential risks. The purpose of this study is to understand the scope of burn and ingestion injuries due to various energy source usages in South Africa.

Methods

Patients at 16 regional hospitals throughout South Africa presenting with an energy-related injury between 2006 and 2012 were interviewed to obtain demographics and injury characteristics.

Results

A total of 12,443 patients were included in this study. Children aged 1–2 years predominantly experienced burn and ingestion injuries (21%). Liquid burns (30%) were more common than flame burns (14%). Chi-squared tests show that age was significantly related to degree of burn, type of burn, and severity of burn (p < 0.001). Non-intentional injuries (45%) were more frequent than self-inflicted or assault injuries. Temporal and seasonal injury trends reflect usage patterns. Burn injuries result in longer hospital length of stay than ingestion injuries.

Conclusion

Non-intentional liquid burns and ingestions to infants and babies were most common in this study, with many injuries also occurring among young adults. It is advised that interventions targeting low-income communities be conducted to increase awareness of burn and ingestion injuries.     

Early tracheostomy improves outcomes in severely injured children and adolescents

Background

Early tracheostomy has been advocated for adult trauma patients to improve outcomes and resource utilization. We hypothesized that timing of tracheostomy for severely injured children would similarly impact outcomes.

Methods

Injured children undergoing tracheostomy over a 10-year period (2002–2012) were reviewed. Early tracheostomy was defined as post-injury day ≤ 7. Data were compared using Student's t test, Pearson chi-squared test and Fisher exact test. Statistical significance was set at p < 0.05 with 95% confidence intervals.

Results

During the 10-year study period, 91 patients underwent tracheostomy following injury. Twenty-nine (32%) patients were < 12 years old; of these, 38% received early tracheostomy. Sixty-two (68%) patients were age 13 to 18; of these, 52% underwent early tracheostomy. Patients undergoing early tracheostomy had fewer ventilator days (p = 0.003), ICU days (p = 0.003), hospital days (p = 0.046), and tracheal complications (p = 0.03) compared to late tracheostomy. There was no difference in pneumonia (p = 0.48) between early and late tracheostomy.

Conclusion

Children undergoing early tracheostomy had improved outcomes compared to those who underwent late tracheostomy. Early tracheostomy should be considered for the severely injured child.

Summary

Early tracheostomy is advocated for adult trauma patients to improve patient comfort and resource utilization. In a review of 91 pediatric trauma patients undergoing tracheostomy, those undergoing tracheostomy on post-injury day ≤ 7 had fewer ventilator days, ICU days, hospital days, and tracheal complications compared to those undergoing tracheostomy after post-injury day 7.     

Evaluation of mortality following severe burns injury in Hungary: External validation of a prediction model developed on Belgian burn data

Purpose

To evaluate mortality in a group of Hungarian burn patients and, as such, to perform an external validation of a prediction model developed on Belgian burn data by which the mortality appraisal was executed.

Basic procedures

In a historical cohort we analysed all burn patients admitted between 1998 and 2006 to the Debrecen University Hospital (n = 2326). The prediction model, based on three criteria (age, burned surface area (BSA) and inhalation injury) was also used to evaluate several subpopulations based on gender and age.

Main findings

Mean age was 35.3 years, mean BSA was 10.7%, 54% of the population was male, inhalation injury was rare (n = 7; 0.3%) and overall mortality was 1.4% (1.6% male, 1.1% female). The men were younger and more severely burned, which was significant in every age group above 2 years. The model gave an accurate prediction of mortality, with a small overestimation in the lower risk categories. The receiver operating characteristic analysis demonstrated an area under the curve of 0.94 (95% confidence interval: 0.89–0.98).

Conclusion

Overall burn mortality in Hungary was low. The mortality prediction model demonstrated a high discriminative value. As such, this model is a helpful tool for outcome prediction and risk stratification for research purposes in burn patients.     

Epidemiology of hospitalized burn patients in a tertiary care hospital in South India

Background

The epidemiological pattern of burns varies widely in different parts of the world. To suggest effective preventive measures, an insight into the pattern of injury is desirable. However, data on burn victims and outcome is limited from this part of the world.

Methods

This study was conducted in the Department of Surgery, from April 2006 to April 2007. All consecutive patients with major burns admitted for in-hospital treatment during the study period were included in the study. The data collected included age, gender, cause and mode of burns, presence or absence of inhalational injury, facial burns, time delay from burn injury to admission in the hospital, burns depth, total body surface area distribution of burns, associated injuries and co-morbid illness, microbiological profile and outcome. Inhalational injury was assessed by clinical examination as bronchoscopy was not available.

Results

A total of 222 consecutive patients admitted for in-hospital treatment of burn injury were included in the study. 177 patients were adults and 45 were <13 years of age. The female:male ratio was 1.7:1. In adults, 52.5% of burns were due to non-intentional injury and 43.9% were due to self-immolation. In patients <13 years of age, 95.6% of cases were due to non-intentional injury. The mean TBSA was 48.75% and 30.18% of patients had predominantly deep burns. The overall mortality was 60.8%. The predominant organisms colonizing the burn wound were Pseudomonas aeruginosa (81.1%) followed by Acinetobacter species and MRSA. Multivariate logistic regression analysis of factors predicting survival in patients with burn injury showed that TBSA > 30%, age > 20 years, female gender and presence of facial injury were statistically significant as predictors of risk of death.

Conclusions

In patients with burns, total body surface area involvement more than 30%, age more than 20 years, female gender and presence of facial injury are statistically significant, as predictors of poor outcome and risk of death. The strongest association was seen with facial injury, which increased the risk of death by fourfold.