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Kruse M, Liesenborghs KE, Josuttis D, Plettig P, Guembel D, Lenz IK, Guethoff C, Gebhardt V, Schmittner MD. Early Autocalibrated Arterial Waveform Analysis for the Management of Burn Shock-A Cohort Study. J Intensive Care Med 2024; 39:655-664. [PMID: 38173245 DOI: 10.1177/08850666231224388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Adequate fluid therapy is crucial for resuscitation after major burns. To adapt this to individual patient demands, standard is adjustment of volume to laboratory parameters and values of enhanced hemodynamic monitoring. To implement calibrated parameters, patients must have reached the intensive care unit (ICU). The aim of this study was, to evaluate the use of an auto-calibrated enhanced hemodynamic monitoring device to improve fluid management before admission to ICU. We used PulsioflexProAqt® (Getinge) during initial treatment and burn shock resuscitation. Analysis was performed regarding time of measurement, volume management, organ dysfunction, and mortality. We conducted a monocentre, prospective cohort study of 20 severely burned patients, >20% total body surface area (TBSA), receiving monitoring immediately after admission. We compared to 57 patients, matched in terms of TBSA, age, sex, and existence of inhalation injury out of a retrospective control group, who received standard care. Hemodynamic measurement with autocalibrated monitoring started significantly earlier: 3.75(2.67-6.0) hours (h) after trauma in the study group versus 13.6(8.1-17.5) h in the control group (P < .001). Study group received less fluid after 6 h: 1.7(1.2-2.2) versus 2.3(1.6-2.8) ml/TBSA%/kg, P = .043 and 12 h: 3.0(2.5-4.0) versus 4.2(3.1-5.0) ml/TBSA%/kg, P = .047. Dosage of norepinephrine was higher after 18 h in the study group: 0.20(0.12-0.3) versus 0.08(0.02-0.18) µg/kg/min, P = .014. The study group showed no adult respiratory distress syndrome versus 21% in the control group, P = .031. There was no difference in other organ failures, organ replacement therapy, and mortality. The use of auto-calibrated enhanced hemodynamic monitoring is a fast and feasible way to guide early fluid therapy after burn trauma. It reduces the time to reach information about patient's volume capacity. Management of fluid application changed to a more restrictive fluid use in the early period of burn shock and led to a reduction of pulmonary complications.
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Affiliation(s)
- Marianne Kruse
- Department of Anesthesiology, Intensive Care and Pain Medicine, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
| | - Konrad Ernst Liesenborghs
- Department of Anesthesiology, Intensive Care and Pain Medicine, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
| | - David Josuttis
- Department of Anesthesiology, Intensive Care and Pain Medicine, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
| | - Philip Plettig
- Department of Anesthesiology, Intensive Care and Pain Medicine, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
| | - Denis Guembel
- Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
- Department of Trauma, Reconstructive Surgery and Rehabilitation Medicine, University Medicine Greifswald, Greifswald, DE, Germany
| | - Ida Katinka Lenz
- Department of Anesthesiology, Intensive Care and Pain Medicine, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
| | - Claas Guethoff
- Centre for Clinical Research, Biostatistics, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
| | - Volker Gebhardt
- Department of Anesthesiology, Intensive Care and Pain Medicine, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
| | - Marc Dominik Schmittner
- Department of Anesthesiology, Intensive Care and Pain Medicine, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
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Huang D, Zhang Z, Jian J, Jiang X, Gao J, Yang M, Ding X. Parecoxib sodium attenuates acute lung injury following burns by regulating M1/M2 macrophage polarization through the TLR4/NF-κB pathway. Eur J Pharmacol 2024; 968:176407. [PMID: 38365106 DOI: 10.1016/j.ejphar.2024.176407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 01/04/2024] [Accepted: 02/07/2024] [Indexed: 02/18/2024]
Abstract
High temperature-induced burn injury often leads to an excessive inflammatory cascade resulting in multiple organ dysfunction syndrome, such as acute lung injury (ALI), in addition to skin tissue damage. As a specific COX2 inhibitor, parecoxib sodium suppresses the inflammatory response during burn injury. The effect of parecoxib sodium on ALI induced by burn injury and the associated molecular mechanism still need to be investigated. The role of parecoxib sodium in burn injury-induced ALI through the TLR4/NF-κB pathway was explored in the present study. A burn-induced ALI mouse model was constructed, and M1/M2 macrophages in lung tissue and markers involved in the TLR4/NF-κB signalling pathway were evaluated in bronchoalveolar lavage fluid (BALF) and MH-S mouse alveolar macrophages in vitro. The results indicated that parecoxib sodium attenuated lung injury after burn injury, decreased iNOS and TNF-α expression, increased IL-10 expression in BALF, and regulated the CD86-and CD206-mediated polarization of M1/M2 macrophages in lung tissue along with MH-S mouse alveolar macrophages. The effect of parecoxib sodium might be reversed by a TLR4 agonist. Overall, the results suggested that parecoxib sodium can regulate the polarization of M1/M2 macrophages through the TLR4/NF-κB pathway to attenuate ALI induced by skin burns.
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Affiliation(s)
- Dongxiao Huang
- Department of Anaesthesiology, Jiangnan University Medical Center, Wuxi No.2 People's Hospital, Wuxi, 214002, China
| | - Zhongjun Zhang
- Department of Anaesthesiology, The Affiliated Hospital of Jiangnan University, No.1000 Hefeng Road, Wuxi, 214122, China
| | - Jinjin Jian
- Department of Anaesthesiology, The Affiliated Hospital of Jiangnan University, No.1000 Hefeng Road, Wuxi, 214122, China
| | - Xuliang Jiang
- Department of Anesthesiology. Fudan University Shanghai Cancer Center, Shanghai, 200030, China
| | - Jie Gao
- Department of Anaesthesiology, The Affiliated Hospital of Jiangnan University, No.1000 Hefeng Road, Wuxi, 214122, China
| | - Minlie Yang
- Burn and Palstic Surgery, The Affiliated Hospital of Jiangnan University, No.1000 Hefeng Road, Wuxi, 214122, China.
| | - Xian Ding
- Department of Anaesthesiology, The Affiliated Hospital of Jiangnan University, No.1000 Hefeng Road, Wuxi, 214122, China.
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Ji Q, Tang J, Li S, Chen J. Survival and analysis of prognostic factors for severe burn patients with inhalation injury: based on the respiratory SOFA score. BMC Emerg Med 2023; 23:1. [PMID: 36604623 PMCID: PMC9813898 DOI: 10.1186/s12873-022-00767-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 12/20/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND It is important to determine the severity of inhalation injury in severely burned patients. The oxygenation index PaO2/FiO2(PF) ratio is a key clinical indicator of inhalation injury. Sequential organ failure assessment (SOFA) is developed to assess the acute incidence of critical illness in the population. We hope to provide an assessment of survival or prognostic factor for severely burned patients with inhalation injury based on the respiratory SOFA score. METHODS This is a retrospective cohort study of all admissions to Department of Burn and Plastic Surgery at West China Hospital of Sichuan University from July 2010 to March 2021. Data was analyzed using Cox regression models to determine significant predictors of mortality. Survival analysis with time to death event was performed using the Kaplan-Meier survival curve with the log-rank test. All potential risk factors were considered independent variables, while survival was considered the risk dependent variable. RESULTS One hundred eighteen severe burn patients with inhalation injury who met the inclusion and exclusion criteria were admitted, including men accounted for 76.3%. The mean age and length of stay were 45.9 (14.8) years and 44.3 (38.4) days. Flame burns are the main etiology of burn (74.6%). Patients with the respiratory SOFA score greater than 2 have undergone mechanical ventilation. Univariate Kaplan-Meier analysis identified age, total body surface area burned (TBSA), ICU admission and the respiratory SOFA score as significant factors on survival. Cox regression analysis showed that TBSA and the respiratory SOFA score were associated with patient survival (p < 0.001). In some patients with severe burns and inhalation damage, the survival probability drops to less than 10% (TBSA greater than 80%: 8.9% and respiratory SOFA score greater than 2: 5.6%). This study statistically found that the TBSA with the respiratory SOFA score model (AUROC: 0.955) and the rBaux score (AUROC: 0.927) had similar predictive value (p = 0.175). CONCLUSION The study indicates that a high respiratory system SOFA score was identified as a strong and independent predictor of severely burned patients with inhalation injury during hospitalization. When combined with TBSA, the respiratory SOFA scores can dynamically assess the severity of the patient's lung injury and improve the predictive level.
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Affiliation(s)
- Qiang Ji
- grid.412901.f0000 0004 1770 1022Department of Burn and Plastic Surgery, West China Hospital, Sichuan University, Guoxue Alley, Wuhou District, 610041 Chengdu, China
| | - Jun Tang
- grid.412901.f0000 0004 1770 1022Department of Burn and Plastic Surgery, West China Hospital, Sichuan University, Guoxue Alley, Wuhou District, 610041 Chengdu, China
| | - Shulian Li
- grid.412901.f0000 0004 1770 1022Department of Burn and Plastic Surgery, West China Hospital, Sichuan University, Guoxue Alley, Wuhou District, 610041 Chengdu, China ,grid.412901.f0000 0004 1770 1022 Department of Thyroid Surgery, West China Hospital, Sichuan University, Guoxue Alley, Wuhou District, 610041 Chengdu, China
| | - Junjie Chen
- grid.412901.f0000 0004 1770 1022Department of Burn and Plastic Surgery, West China Hospital, Sichuan University, Guoxue Alley, Wuhou District, 610041 Chengdu, China
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Extracorporeal Life Support for Severely Burned Patients with Concurrent Inhalation Injury and Acute Respiratory Distress Syndrome: Experience from a Military Medical Burn Center. Injury 2023; 54:124-130. [PMID: 36163205 PMCID: PMC9448699 DOI: 10.1016/j.injury.2022.08.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 08/18/2022] [Accepted: 08/26/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Both inhalation injury and acute respiratory distress syndrome (ARDS) are risk factors that predict mortality in severely burned patients. Extracorporeal life support (ECLS) is widely used to rescue these patients; however, its efficacy and safety in this critical population have not been well defined. We report our experience of using ECLS for the treatment of severely burned patients with concurrent inhalation injury and ARDS. METHODS This was a retrospective analysis of 14 patients collected from a single medical burn center from 2012 to 2019. All patients suffered from major burns with inhalation injury and ARDS, and were treated with ECLS. RESULTS The median total body surface area of deep dermal or full thickness burns was 94.5%, ranging 47.7-99.0 %. The median revised Baux score was 122.0, ranging 90.0-155.0. All patients developed ARDS with a median partial pressure of arterial oxygen to a fraction of inspired oxygen ratio of 61.5, ranging 49.0-99.0. Indications for ECLS included sustained hypoxemia and unstable hemodynamics. The median interval for initiating ECLS was 2.5 days, ranging 1.0-156.0 days. The median duration of ECLS was 2.9 days, ranging 0.3-16.7 days. The overall survival to discharge was 42.8%. Causes of death included sepsis and multiple organ failure. ECLS-related complications included cannulation bleeding, catheter-related infection, and hemolysis. The incidence of risk factors reported in literature were higher in non-survivors, including Baux>120, albumin < 3.0 g/dL, and lactate > 8 mmol/L. CONCLUSIONS For severely burned patients with concurrent inhalation injury and ARDS, ECLS could be a salvage treatment to improve sustained hypoxemia. However, the efficacy of hemodynamic support was limited. Identifying definite ECLS indications and rigorous patient selection would contribute to better clinical outcomes.
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Huang RY, Chen SJ, Hsiao YC, Kuo LW, Liao CH, Hsieh CH, Bajani F, Fu CY. Positive signs on physical examination are not always indications for endotracheal tube intubation in patients with facial burn. BMC Emerg Med 2022; 22:36. [PMID: 35260094 PMCID: PMC8903723 DOI: 10.1186/s12873-022-00594-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 02/24/2022] [Indexed: 11/10/2022] Open
Abstract
Background After clinical evaluation in the emergency department (ED), facial burn patients are usually intubated to protect their airways. However, the possibility of unnecessary intubation or delayed intubation after admission exists. Objective criteria for the evaluation of inhalation injury and the need for airway protection in facial burn patients are needed. Methods Facial burn patients between January 2013 and May 2016 were reviewed. Patients who were and were not intubated in the ED were compared. All the intubated patients received routine bronchoscopy and laboratory tests to evaluate whether they had inhalation injuries. The patients with and without confirmed inhalation injuries were compared. Multivariate logistic regression analysis was used to identify the independent risk factors for inhalation injuries in the facial burn patients. The reasons for intubation in the patients without inhalation injuries were also investigated. Results During the study period, 121 patients were intubated in the ED among a total of 335 facial burn patients. Only 73 (60.3%) patients were later confirmed to have inhalation injuries on bronchoscopy. The comparison between the patients with and without inhalation injuries showed that shortness of breath (odds ratio = 3.376, p = 0.027) and high total body surface area (TBSA) (odds ratio = 1.038, p = 0.001) were independent risk factors for inhalation injury. Other physical signs (e.g., hoarseness, burned nostril hair, etc.), laboratory examinations and chest X-ray findings were not predictive of inhalation injury in facial burn patients. All the patients with a TBSA over 60% were intubated in the ED even if they did not have inhalation injuries. Conclusions In the management of facial burn patients, positive signs on conventional physical examinations may not always be predictive of inhalation injury and the need for endotracheal tube intubation in the ED. More attention should be given to facial burn patients with shortness of breath and a high TBSA. Airway protection is needed in facial burn patients without inhalation injuries because of their associated injuries and treatments. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-022-00594-9.
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Affiliation(s)
- Ruo-Yi Huang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Szu-Jen Chen
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Yen-Chang Hsiao
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Ling-Wei Kuo
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Chien-Hung Liao
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Hsun Hsieh
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Francesco Bajani
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan.
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Sasaki J, Matsushima A, Ikeda H, Inoue Y, Katahira J, Kishibe M, Kimura C, Sato Y, Takuma K, Tanaka K, Hayashi M, Matsumura H, Yasuda H, Yoshimura Y, Aoki H, Ishizaki Y, Isono N, Ueda T, Umezawa K, Osuka A, Ogura T, Kaita Y, Kawai K, Kawamoto K, Kimura M, Kubo T, Kurihara T, Kurokawa M, Kobayashi S, Saitoh D, Shichinohe R, Shibusawa T, Suzuki Y, Soejima K, Hashimoto I, Fujiwara O, Matsuura H, Miida K, Miyazaki M, Murao N, Morikawa W, Yamada S. Japanese Society for Burn Injuries (JSBI) Clinical Practice Guidelines for Management of Burn Care (3rd Edition). Acute Med Surg 2022; 9:e739. [PMID: 35493773 PMCID: PMC9045063 DOI: 10.1002/ams2.739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/29/2022] [Accepted: 02/03/2022] [Indexed: 01/28/2023] Open
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Kirkwood KI, Christopher MW, Burgess JL, Littau SR, Foster K, Richey K, Pratt BS, Shulman N, Tamura K, MacCoss MJ, MacLean BX, Baker ES. Development and Application of Multidimensional Lipid Libraries to Investigate Lipidomic Dysregulation Related to Smoke Inhalation Injury Severity. J Proteome Res 2021; 21:232-242. [PMID: 34874736 DOI: 10.1021/acs.jproteome.1c00820] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The implication of lipid dysregulation in diseases, toxic exposure outcomes, and inflammation has brought great interest to lipidomic studies. However, lipids have proven to be analytically challenging due to their highly isomeric nature and vast concentration ranges in biological matrices. Therefore, multidimensional techniques such as those integrating liquid chromatography, ion mobility spectrometry, collision-induced dissociation, and mass spectrometry (LC-IMS-CID-MS) have been implemented to separate lipid isomers as well as provide structural information and increased identification confidence. These data sets are however extremely large and complex, resulting in challenges for data processing and annotation. Here, we have overcome these challenges by developing sample-specific multidimensional lipid libraries using the freely available software Skyline. Specifically, the human plasma library developed for this work contains over 500 unique lipids and is combined with adapted Skyline functions such as indexed retention time (iRT) for retention time prediction and IMS drift time filtering for enhanced selectivity. For comparison with other studies, this database was used to annotate LC-IMS-CID-MS data from a NIST SRM 1950 extract. The same workflow was then utilized to assess plasma and bronchoalveolar lavage fluid (BALF) samples from patients with varying degrees of smoke inhalation injury to identify lipid-based patient prognostic and diagnostic markers.
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Affiliation(s)
- Kaylie I Kirkwood
- Department of Chemistry, North Carolina State University, Raleigh, North Carolina 27695, United States
| | - Michael W Christopher
- Department of Chemistry, North Carolina State University, Raleigh, North Carolina 27695, United States
| | - Jefferey L Burgess
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona 85721, United States
| | - Sally R Littau
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona 85721, United States
| | - Kevin Foster
- Department of Genome Sciences, University of Washington, Seattle, Washington 98195, United States
| | - Karen Richey
- Department of Genome Sciences, University of Washington, Seattle, Washington 98195, United States
| | - Brian S Pratt
- Arizona Burn Center, Valleywise Health, Phoenix, Arizona 85008, United States
| | - Nicholas Shulman
- Arizona Burn Center, Valleywise Health, Phoenix, Arizona 85008, United States
| | - Kaipo Tamura
- Arizona Burn Center, Valleywise Health, Phoenix, Arizona 85008, United States
| | - Michael J MacCoss
- Arizona Burn Center, Valleywise Health, Phoenix, Arizona 85008, United States
| | - Brendan X MacLean
- Arizona Burn Center, Valleywise Health, Phoenix, Arizona 85008, United States
| | - Erin S Baker
- Department of Chemistry, North Carolina State University, Raleigh, North Carolina 27695, United States.,Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina 27695, United States
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Charles WN, Collins D, Mandalia S, Matwala K, Dutt A, Tatlock J, Singh S. Impact of inhalation injury on outcomes in critically ill burns patients: 12-year experience at a regional burns centre. Burns 2021; 48:1386-1395. [PMID: 34924231 DOI: 10.1016/j.burns.2021.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 11/15/2021] [Accepted: 11/22/2021] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Burns 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. METHODS A 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. RESULTS Burns 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. CONCLUSIONS Severe 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.
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Affiliation(s)
- Walton N Charles
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Declan Collins
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom; Department of Burns, Plastic and Reconstructive Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Sundhiya Mandalia
- Intensive Care Unit, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom; Department of Research and Development, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Kabir Matwala
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Atul Dutt
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Jason Tatlock
- Intensive Care Unit, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Suveer Singh
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom; Intensive Care Unit, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom; Department of Research and Development, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom; Academic Department of Anaesthesia, Pain Management and Intensive Care (APMIC), Imperial College London, Chelsea and Westminster Hospital NHS Foundation Trust and Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom.
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Wang B, Chenru W, Jiang Y, Hu L, Fang H, Zhu F, Yu Q, Zhu B, Wu G, Sun Y, Xia Z. Incidence and Mortality of Acute Respiratory Distress Syndrome in Patients With Burns: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2021; 8:709642. [PMID: 34869410 PMCID: PMC8634659 DOI: 10.3389/fmed.2021.709642] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 09/17/2021] [Indexed: 11/18/2022] Open
Abstract
Objective: We conducted a systematic review and meta-analysis to comprehensively estimate the incidence and mortality of acute respiratory distress syndrome (ARDS) in overall and subgroups of patients with burns. Data sources: Pubmed, Embase, the Cochrane Library, CINAHL databases, and China National Knowledge Infrastructure database were searched until September 1, 2021. Study selection: Articles that report study data on incidence or mortality of ARDS in patients with burns were selected. Data extraction: Two researchers independently screened the literature, extracted data, and assessed the quality. We performed a meta-analysis of the incidence and mortality of ARDS in patients with burns using a random effects model, which made subgroup analysis according to the study type, inclusion (mechanical ventilation, minimal burn surface), definitions of ARDS, geographic location, mean age, burn severity, and inhalation injury. Primary outcomes were the incidence and mortality of burns patients with ARDS, and secondary outcomes were incidence for different subgroups. Data synthesis: Pooled weighted estimate of the incidence and mortality of ARDS in patients with burns was 0.24 [95% confidence interval (CI)0.2-0.28] and 0.31 [95% CI 0.18-0.44]. Incidences of ARDS were obviously higher in patients on mechanical ventilation (incidence = 0.37), diagnosed by Berlin definition (incidence = 0.35), and with over 50% inhalation injury proportion (incidence = 0.41) than in overall patients with burns. Patients with burns who came from western countries and with inhalation injury have a significantly higher incidence of ARDS compared with those who came from Asian/African countries (0.28 vs. 0.25) and without inhalation injury (0.41 vs. 0.24). Conclusion: This systematic review and meta-analysis revealed that the incidence of ARDS in patients with burns is 24% and that mortality is as high as 31%. The incidence rates are related to mechanical ventilation, location, and inhalation injury. The patients with burns from western countries and with inhalation injury have a significantly higher incidence than patients from Asian/African countries and without inhalation injury. Systematic Review Registration: identifier: CRD42021144888.
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Affiliation(s)
- Baoli Wang
- Department of Burn Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
- Department of Burns and Plastic Surgery, General Hospital of Central Theater Command of Chinese People's Liberation Army, Shanghai, China
- Research Unit of Key Techniques for Treatment of Burns and Combined Burns and Trauma Injury, Chinese Academy of Medical Sciences, Shanghai, China
| | - Wei Chenru
- Department of Burn Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Yong Jiang
- Department of Burn Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Lunyang Hu
- Department of Burn Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - He Fang
- Department of Burn Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Feng Zhu
- Department of Burn Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Qing Yu
- Department of Burn Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Banghui Zhu
- Department of Burn Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Guosheng Wu
- Department of Burn Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Yu Sun
- Department of Burn Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Zhaofan Xia
- Department of Burn Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
- Research Unit of Key Techniques for Treatment of Burns and Combined Burns and Trauma Injury, Chinese Academy of Medical Sciences, Shanghai, China
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Modified abbreviated burn severity index as a predictor of in-hospital mortality in patients with inhalation injury: development and validation using independent cohorts. Surg Today 2020; 51:242-249. [PMID: 32691141 DOI: 10.1007/s00595-020-02085-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 07/05/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The ability to accurately evaluate the severity of inhalation injury can help to optimize patient care. However, there is no accepted severity grading system, especially for inhalation injury. METHODS We screened a multicenter burn registry and included adult patients who required oxygen treatment or mechanical ventilation. After the patient data were divided into development and validation cohorts, missing values were replaced with multiple imputation. Twelve potential predictors were analyzed using multivariate logistic regression to identify prognostic variables for in-hospital mortality and scores were assigned to each predictor based on odds ratios to develop the Modified Abbreviated Burn Severity Index, mABSI. The mABSI was validated using c-statistics and calibration curves. RESULTS We randomly assigned 1377 and 919 patients to the development and validation cohorts, respectively. Age, self-inflicted injury, cutaneous burn area, and mechanical ventilation requirement were identified as independent predictors, and the mABSI (1-17 scale) was, thus, developed. The mABSI has a high discriminatory power (c-statistic = 0.94; 95% CI 0.92-0.97), and both estimated and observed in-hospital mortalities increased from 1% at score ≤ 5 to almost 100% at score ≥ 14 with linear calibration plots. CONCLUSIONS We developed and validated the mABSI which accurately predicts in-hospital mortality.
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Klein HJ, Rittirsch D, Buehler PK, Schweizer R, Giovanoli P, Cinelli P, Plock JA, Reding T, Graf R. Response of routine inflammatory biomarkers and novel Pancreatic Stone Protein to inhalation injury and its interference with sepsis detection in severely burned patients. Burns 2020; 47:338-348. [PMID: 33272743 DOI: 10.1016/j.burns.2020.04.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/28/2020] [Accepted: 04/28/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Inhalation of thermal and chemical products of combustion evokes an immune response measurable at a systemic level. Inhalation injury related kinetics of currently available inflammatory biomarkers and novel Pancreatic Stone Protein (PSP) as well as their interference with septic events has not been addressed to literature yet. METHODS Analysis of the influence of inhalation injury and ARDS on biomarker kinetics (PSP, procalcitonin (PCT), C-reactive Protein (CRP), white blood cells (WBC)) in 90 patients admitted to Zurich Burn Center between May 2015 and October 2018 with burns ≥15% total body surface area (TBSA) over 14 days. RESULTS Twenty-five (27%) of 90 included patients presented with inhalation injury (median age 52 years [IQR 27], median TBSA 31.5% [IQR 21], mean ABSI-Score 7±3). At admission, only WBC demonstrated significantly higher values in the inhalation injury group (p=0.011). Acute respiratory distress syndrome (ARDS) was present in 32% without association to the severity of inhalation injury (p=0.11). WBC, CRP and PCT failed to delineate inhalation injury related inflammation from septic progression at most time points. PSP was the strongest marker to identify septic patients both by its higher values and steeper increase over time (p<0.001). CONCLUSION Inhalation injury leads to an inflammatory response at a systemic level with alterations of biomarkers. While routine inflammatory markers demonstrated strong interferences between inhalation injury with its associated ARDS and evolving sepsis, PSP reliably identified septic patients in a setting of inflammatory turbulences secondary to inhalation injury.
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Affiliation(s)
- Holger J Klein
- Department of Plastic Surgery and Hand Surgery, Burn Center, University Hospital Zurich, Zurich, Switzerland; Regenerative and Reconstructive Plastic Surgery Research Laboratory, University of Zurich, Zurich, Switzerland.
| | - Daniel Rittirsch
- Department of Plastic Surgery and Hand Surgery, Burn Center, University Hospital Zurich, Zurich, Switzerland
| | - Philipp K Buehler
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Riccardo Schweizer
- Department of Plastic Surgery and Hand Surgery, Burn Center, University Hospital Zurich, Zurich, Switzerland; Regenerative and Reconstructive Plastic Surgery Research Laboratory, University of Zurich, Zurich, Switzerland
| | - Pietro Giovanoli
- Department of Plastic Surgery and Hand Surgery, Burn Center, University Hospital Zurich, Zurich, Switzerland
| | - Paolo Cinelli
- Center for Surgical Research, University and University Hospital Zurich, Zurich, Switzerland
| | - Jan A Plock
- Department of Plastic Surgery and Hand Surgery, Burn Center, University Hospital Zurich, Zurich, Switzerland; Regenerative and Reconstructive Plastic Surgery Research Laboratory, University of Zurich, Zurich, Switzerland
| | - Theresia Reding
- Pancreas Research Laboratory, Department of Visceral Surgery & Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Rolf Graf
- Pancreas Research Laboratory, Department of Visceral Surgery & Transplantation, University Hospital Zurich, Zurich, Switzerland
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12
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Suresh M, Pruskowski KA, Rizzo JA, Gurney JM, Cancio LC. Characteristics and outcomes of patients with inhalation injury treated at a military burn center during U.S. combat operations. Burns 2020; 46:454-458. [DOI: 10.1016/j.burns.2019.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 08/12/2019] [Accepted: 08/13/2019] [Indexed: 11/26/2022]
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13
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Lidocaine infusion has a 25% opioid-sparing effect on background pain after burns: A prospective, randomised, double-blind, controlled trial. Burns 2020; 46:465-471. [DOI: 10.1016/j.burns.2019.08.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 08/06/2019] [Accepted: 08/14/2019] [Indexed: 11/15/2022]
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Abdelrahman I, Steinvall I, Fredrikson M, Sjoberg F, Elmasry M. Use of the burn intervention score to calculate the charges of the care of burns. Burns 2019; 45:303-309. [PMID: 30612888 DOI: 10.1016/j.burns.2018.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 11/16/2018] [Accepted: 12/10/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND To our knowledge this is the first published estimate of the charges of the care of burns in Sweden. The Linköping Burn Interventional Score has been used to calculate the charges for each burned patient since 1993. The treatment of burns is versatile, and depends on the depth and extension of the burn. This requires a flexible system to detect the actual differences in the care provided. We aimed to describe the model of burn care that we used to calculate the charges incurred during the acute phase until discharge, so it could be reproduced and applied in other burn centres, which would facilitate a future objective comparison of the expenses in burn care. METHODS All patients admitted with burns during the period 2010-15 were included. We analysed clinical and economic data from the daily burn scores during the acute phase of the burn until discharge from the burn centre. RESULTS Total median charge/patient was US$ 28 199 (10th-90th centiles 4668-197 781) for 696 patients admitted. Burns caused by hot objects and electricity resulted in the highest charges/TBSA%, while charges/day were similar for the different causes of injury. Flame burns resulted in the highest mean charges/admission, probably because they had the longest duration of stay. Mean charges/patient increased in a linear fashion among the different age groups. CONCLUSION Our intervention-based estimate of charges has proved to be a valid tool that is sensitive to the procedures that drive the costs of the care of burns such as large TBSA%, intensive care, and operations. The burn score system could be reproduced easily in other burn centres worldwide and facilitate the comparison regardless of the differences in the currency and the economic circumstances.
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Affiliation(s)
- Islam Abdelrahman
- The Plastic Surgery Unit, Surgery Department, Suez Canal University, Ismailia, Egypt; Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
| | - Ingrid Steinvall
- Department of Hand Surgery, Plastic Surgery and Burns, Department of Clinical and Experimental Medicine, 8 Linköping University, Linköping, Sweden.
| | - Mats Fredrikson
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
| | - Folke Sjoberg
- Department of Hand Surgery, Plastic Surgery and Burns, Department of Clinical and Experimental Medicine, 8 Linköping University, Linköping, Sweden; Department of Anaesthesiology and Intensive Care, Linköping University, Linköping, Sweden.
| | - Moustafa Elmasry
- The Plastic Surgery Unit, Surgery Department, Suez Canal University, Ismailia, Egypt; Department of Hand Surgery, Plastic Surgery and Burns, Department of Clinical and Experimental Medicine, 8 Linköping University, Linköping, Sweden.
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15
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Wang W, Yu X, Zuo F, Yu S, Luo Z, Liu J, Wang Y, Zhu G, Lin H, Xu N, Ren H, Zhang J. Risk factors and the associated limit values for abnormal elevation of extravascular lung water in severely burned adults. Burns 2018; 45:849-859. [PMID: 30527647 DOI: 10.1016/j.burns.2018.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 10/18/2018] [Accepted: 11/14/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Increased extravascular lung water (EVLW) correlates with pulmonary morbidity and mortality in critical illness. The extravascular lung water index (EVLWI), which reflects the degree of EVLW in an individual, increases in the fluid reabsorption stage rather than the initial resuscitation stage in severe burn cases. While many factors contribute to EVLWI variation, the risk factors contributing to its abnormal elevation in severe burns remain unclear. The aim of this study was to identify the risk factors and associated limit values for abnormal elevation of EVLWI during the fluid reabsorption stage in a cohort of severely burned adults. METHOD This prospective, single-center study included only adults with burn sizes≥50% of the total body surface area (TBSA) who were admitted within 24h after burn. Demographic data were collected, and transpulmonary thermodilution (TPTD) measurements and blood biochemistry tests were performed upon admission and up to day (PBD) 9. Risk factors for abnormal EVLWI were analyzed by logistic regression. Receiver operating characteristic (ROC) curves were constructed to determine the optimal cut-offs for each risk factor. RESULTS Seventy-two patients were ultimately enrolled, with a mean age of 40.3 years and mean burn size of 69.4% TBSA. EVLWI began to abnormally increase (>7ml/kg) on day 3 and up to PBD 9, indicating that a supranormal EVLWI developed in the fluid reabsorption stage. Several relevant factors were considered, including patient age, burn size, intrathoracic blood volume index (ITBVI), pulmonary vascular permeability index (PVPI), cardiac index (CI), systemic vascular resistance index (SVRI), serum albumin, time of first excision and grafting, and number of operations and daily fluid administration. Among these factors, we found that only burn size and ITBVI were significantly correlated with EVLWI variation and were further identified as the independent risk factors for EVLWI abnormality. ROC analysis showed that the limits for predicting a supranormal EVLWI during the fluid reabsorption stage were 65.5% TBSA for burn size and 845ml/m2 for ITBVI. Patients with burn sizes or ITBVIs higher than the limit showed significantly longer mechanical ventilation time and substantially higher occurrences of acute respiratory distress syndrome (ARDS) and pneumonia within two weeks after burn. CONCLUSIONS Burn size and ITBVI are the independent risk factors for EVLWI abnormality during the fluid reabsorption stage in severely burned adults. The limit values for predicting a supranormal EVLWI in those patients are 65.5% TBSA for burn size and 845ml/m2 for ITBVI.
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Affiliation(s)
- Weiyi Wang
- School of Nursing, Third Military Medical University (Army Medical University), Chongqing, 400038, China; Institute of Burn Research, State Key Laboratory of Trauma, Burns and Combined Injury, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China.
| | - Xiaofeng Yu
- School of Nursing, Third Military Medical University (Army Medical University), Chongqing, 400038, China; Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Jinan, China.
| | - Fengli Zuo
- School of Nursing, Third Military Medical University (Army Medical University), Chongqing, 400038, China.
| | - Shuixiu Yu
- School of Nursing, Third Military Medical University (Army Medical University), Chongqing, 400038, China.
| | - Zhenghui Luo
- Institute of Burn Research, State Key Laboratory of Trauma, Burns and Combined Injury, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China.
| | - Jie Liu
- Institute of Burn Research, State Key Laboratory of Trauma, Burns and Combined Injury, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China.
| | - Yuan Wang
- Institute of Burn Research, State Key Laboratory of Trauma, Burns and Combined Injury, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China.
| | - Guoqin Zhu
- Institute of Burn Research, State Key Laboratory of Trauma, Burns and Combined Injury, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China.
| | - Hui Lin
- Department of Gastroenterology, Xinqiao Hospital, Third Military Medical University (Army Medical University), Chongqing, China.
| | - Ning Xu
- Department of Pathology, No. 261 Hospital of PLA, Beijing, China.
| | - Hui Ren
- School of Nursing, Third Military Medical University (Army Medical University), Chongqing, 400038, China.
| | - Jiaping Zhang
- Institute of Burn Research, State Key Laboratory of Trauma, Burns and Combined Injury, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China.
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16
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Pompermaier L, Elmasry M, Abdelrahman I, Fredrikson M, Sjöberg F, Steinvall I. Are there any differences in the provided burn care between men and women? A retrospective study. BURNS & TRAUMA 2018; 6:22. [PMID: 30123802 PMCID: PMC6088398 DOI: 10.1186/s41038-018-0125-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 07/13/2018] [Indexed: 12/22/2022]
Abstract
Background Disparity between medical treatment for men and women has been recorded worldwide. However, it is difficult to find out if the disparities in both the use of resources and outcome depend entirely on sex-related discrimination. Our aim was to investigate if there are differences in burn treatments between the sexes. Methods All patients admitted with burns to Linköping University Hospital during the 16-year period 2000–2015 were included. Interventions were prospectively recorded using the validated Burn SCoring system (BSC). Data were analysed using a multivariable panel regression model adjusted for age, percentage total body surface area (%TBSA), and in-hospital mortality. Results A total of 1363 patients were included, who generated a total of 22,301 daily recordings while they were inpatients. Males were 70% (930/1363). Sex was not an independent factor for daily scores after adjustment for age, %TBSA, and mortality in hospital (model R2=0.60, p < 0.001). Conclusion We found no evidence of inequity between the sexes in treatments given in our burn centre when we had adjusted for size of burn, age, and mortality. BSC seems to be an appropriate model in which to evaluate sex-related differences in the delivery of treatments.
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Affiliation(s)
- Laura Pompermaier
- 1Department of Plastic Surgery, Hand Surgery, and Burns, Linköping University, Linköping, Sweden.,2Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.,5the Burn Centre, Linköping University Hospital, 58185 Linköping, Sweden
| | - Moustafa Elmasry
- 1Department of Plastic Surgery, Hand Surgery, and Burns, Linköping University, Linköping, Sweden.,2Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Islam Abdelrahman
- 2Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.,3Department of Surgery, Plastic Surgery Unit, Suez Canal University, Ismailia, Egypt
| | - Mats Fredrikson
- 2Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Folke Sjöberg
- 1Department of Plastic Surgery, Hand Surgery, and Burns, Linköping University, Linköping, Sweden.,2Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.,4Department of Anaesthesia and Intensive Care, Linköping University, Linköping, Sweden
| | - Ingrid Steinvall
- 1Department of Plastic Surgery, Hand Surgery, and Burns, Linköping University, Linköping, Sweden.,2Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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Dolp R, Rehou S, McCann MR, Jeschke MG. Contributors to the length-of-stay trajectory in burn-injured patients. Burns 2018; 44:2011-2017. [PMID: 30104050 DOI: 10.1016/j.burns.2018.07.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 07/16/2018] [Accepted: 07/20/2018] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Burn patients have a highly variable length-of-stay (LOS) due to the complexity of the injury itself. The LOS for burn patients is estimated as one day per percent total body surface area (TBSA) burn. To focus care expectation and prognosis we aimed to identify key factors that contribute to prolonged LOS. METHODS This was a retrospective cohort-study (2006-2016) in an adult burn-centre that included patients with ≥10% TBSA burn. Patients were stratified into expected-LOS (<2 days LOS/%TBSA) and longer-than-expected-LOS (≥2 days LOS/%TBSA). We assessed demographics, comorbidities, and in-hospital complications. Logistic regression and propensity matching was utilized. RESULTS Of the 583 total patients, 477 had an expected-LOS whereas 106 a longer-than-expected-LOS. Non-modifiable factors such as age, 3rd degree TBSA%, inhalation injuries and comorbidities were greater in the exceeded LOS patients. Subsequent matched analysis revealed factors like number of procedures performed, days ventilated and in-hospital complications (bacteremia, pneumonia, sepsis, graft loss, and respiratory failure) were significantly increased in the longer-than-expected-LOS group. CONCLUSIONS Progress has been made to update the conventional one day/%TBSA to better aid health care providers in giving appropriate outcomes for patients and their families and to supply intensive care units with valuable data to assess quality of care and to improve patient prognosis.
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Affiliation(s)
- Reinhard Dolp
- Sunnybrook Research Institute, Toronto, Ontario, Canada; Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sarah Rehou
- Sunnybrook Research Institute, Toronto, Ontario, Canada; Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Marc G Jeschke
- Sunnybrook Research Institute, Toronto, Ontario, Canada; Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Division of Plastic and Reconstructive Surgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Immunology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
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18
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Deutsch C, Tan A, Smailes S, Dziewulski P. The diagnosis and management of inhalation injury: An evidence based approach. Burns 2018; 44:1040-1051. [DOI: 10.1016/j.burns.2017.11.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 10/03/2017] [Accepted: 11/20/2017] [Indexed: 10/28/2022]
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Ray JJ, Straker RJ, Hart VJ, Meizoso JP, Schulman CI, Loebe M, Ghodsizad A. The Use of Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome in Severe Burns Without Inhalation Injury. J Burn Care Res 2018; 39:640-644. [PMID: 29901798 DOI: 10.1093/jbcr/irx021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Burn injury results in a severe systemic inflammatory response which is associated with the development of acute respiratory distress syndrome (ARDS), even without associated inhalation injury. Venous-venous extracorporeal membrane oxygenation (VV-ECMO) has been implemented in various cases of ARDS to provide support and allow for protective lung ventilation strategies. We report the case of a 27-year-old man presenting with a 60% total body surface area partial thickness burn who developed refractory ARDS with Murray Score of 3.75. ECMO was initiated on hospital day 9 for a total of 10 days with concurrent lung-protective ventilation. He subsequently recovered and was discharged on hospital day 48. ECMO should be considered as an adjunctive strategy in burn patients without inhalation injury to minimize ventilator-induced lung injury when high levels of support are needed to achieve adequate ventilation in patients with ARDS.
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Affiliation(s)
- Juliet J Ray
- DeWitt Daughtry Family Department of Surgery, Miami, Florida
| | | | - Valerie J Hart
- DeWitt Daughtry Family Department of Surgery, Miami, Florida
| | | | - Carl I Schulman
- DeWitt Daughtry Family Department of Surgery, Miami, Florida
| | - Matthias Loebe
- Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, Florida
| | - Ali Ghodsizad
- Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, Florida
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The abbreviated burn severity index as a predictor of acute respiratory distress syndrome in young individuals with severe flammable starch-based powder burn. Burns 2018; 44:1573-1578. [PMID: 29886117 DOI: 10.1016/j.burns.2018.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 12/27/2017] [Accepted: 01/04/2018] [Indexed: 11/23/2022]
Abstract
Here, we investigated whether the abbreviated burn severity index (ABSI) scoring system predicts acute respiratory distress syndrome (ARDS) in a retrospective analysis of a severe flammable starch-based powder burn population. Demographics, total body surface area (TBSA) burn, the presence of mouth and nose burn, ABSI, inhalation injury, and clinical outcomes for each patient were analysed for association with inpatient ARDS based on the Berlin definition. We treated 53 patients (64% male, 36% female) and observed no fatalities. The median age, TBSA burn, and the ABSI were 22.2±3.6, 42.2±21, and 7.8±2.8, respectively. Inhalation injury was present in 56.6% of the cases, and mouth and nose burn was present in 30.2%. ARDS was prevalent at 30%. The mean abbreviated burn severity index (ABSI) was 10.6±1.5 in the ARDS group and 6.6±2.3 in the non-ARDS (P<0.001) group. The mean TBSA burn percentage for ARDS and the non-ARDS groups were 61.4±13.9% and 34±18%, respectively (P<0.001). The area under the curve of the receiver operating characteristic curves for an ABSI≥9 was 0.905. Our results show that the ABSI is effective for predicting ARDS in young individuals with severe starch-based powder burn.
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21
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Aung MT, Garner D, Pacquola M, Rosenblum S, McClure J, Cleland H, Pilcher DV. The use of a simple three-level bronchoscopic assessment of inhalation injury to predict in-hospital mortality and duration of mechanical ventilation in patients with burns. Anaesth Intensive Care 2018; 46:67-73. [PMID: 29361258 DOI: 10.1177/0310057x1804600110] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Major burn centres in Australia use bronchoscopy to assess severity of inhalation injuries despite limited evidence as to how best to classify severity of inhalational injury or its relationship to patient outcomes. All patients with burns who were admitted to the intensive care unit (ICU) at The Alfred Hospital between February 2010 and July 2014 and underwent bronchoscopy to assess inhalational injury, were reviewed. Age, total body surface area burnt, severity of illness indices and mechanisms of injury were extracted from medical histories and local ICU and burns registries. Inhalational injury was classified based on the Abbreviated Injury Score and then grouped into three categories (none/mild, moderate, or severe injury). Univariable and multivariable analyses were undertaken to examine the relationship between inhalational injury and outcomes (in-hospital mortality and duration of mechanical ventilation). One hundred and twenty-eight patients were classified as having none/mild inhalational injury, 81 moderate, and 13 severe inhalation injury. Mortality in each group was 2.3% (3/128), 7.4% (6/81) and 30.7% (4/13) respectively. Median (interquartile range) duration of mechanical ventilation in each group was 26 (11-82) hours, 84 (32-232) hours and 94 (21-146) hours respectively. After adjusting for age, total body surface area burnt and severity of illness, only the severe inhalation injury group was independently associated with increased mortality (odds ratio 20.4 [95% confidence intervals {CI} 1.74 to 239.4], <i>P</i>=0.016). Moderate inhalation injury was independently associated with increased duration of ventilation (odds ratio 2.25 [95% CI 1.53 to 3.31], <i>P</i> <0.001), but not increased mortality. This study suggests that stratification of bronchoscopically-assessed inhalational injury into three categories can provide useful prognostic information about duration of ventilation and mortality. Larger multicentre prospective studies are required to validate these findings.
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Affiliation(s)
| | | | | | | | | | - H Cleland
- Department of Surgery, Central and Eastern Clinical School, Monash University, Melbourne, Victoria
| | - D V Pilcher
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria
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Acute Respiratory Distress Syndrome in Burn Patients: A Comparison of the Berlin and American-European Definitions. J Burn Care Res 2018; 37:e461-9. [PMID: 27070223 DOI: 10.1097/bcr.0000000000000348] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The purpose of this study was to compare the Berlin definition to the American-European Consensus Conference (AECC) definition in determining the prevalence of acute respiratory distress syndrome (ARDS) and associated mortality in the critically ill burn population. Consecutive patients admitted to our institution with burn injury that required mechanical ventilation for more than 24 hours were included for analysis. Included patients (N = 891) were classified by both definitions. The median age, % TBSA burn, and injury severity score (interquartile ranges) were 35 (24-51), 25 (11-45), and 18 (9-26), respectively. Inhalation injury was present in 35.5%. The prevalence of ARDS was 34% using the Berlin definition and 30.5% using the AECC definition (combined acute lung injury and ARDS), with associated mortality rates of 40.9 and 42.9%, respectively. Under the Berlin definition, mortality rose with increased ARDS severity (14.6% no ARDS; 16.7% mild; 44% moderate; and 59.7% severe, P < 0.001). By contrast, under the AECC definition increased mortality was seen only for ARDS category (14.7% no ARDS; 15.1% acute lung injury; and 46.0% ARDS, P < 0.001). The mortality of the 22 subjects meeting the AECC, but not the Berlin definition was not different from patients without ARDS (P = .91). The Berlin definition better stratifies ARDS in terms of severity and correctly excludes those with minimal disease previously captured by the AECC.
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Reducing the Indication for Ventilatory Support in the Severely Burned Patient: Results of a New Protocol Approach at a Regional Burn Center. J Burn Care Res 2018; 37:e205-12. [PMID: 25882516 DOI: 10.1097/bcr.0000000000000238] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Initial management of the severely injured routinely includes sedation and mechanical ventilatory support. However, nonjudiciously applied mechanical ventilatory support can itself lead to poorer patient outcomes. In an attempt to reduce this iatrogenic risk, a standardized, in-house, five-point protocol providing clinical guidance on the use and duration of ventilation was introduced and analyzed, and the impact on patient outcomes was assessed. In 2007, a protocol for early spontaneous breathing was introduced and established in clinical practice. This protocol included: 1) early extubation (≤6 hours after admission) in the absence of absolute ventilatory indication; 2) avoidance of "routine intubation" in spontaneously breathing patients; 3) early postoperative extubation, including patients requiring multiple surgical interventions; 4) intensive chest and respiratory physiotherapy with routine application of expectorants; and 5) early active mobilization. A retrospective clinical study compared patients (group A) over a 2-year period admitted under the new protocol with a historical patient group (group B). Patients in group A (n = 38) had fewer ventilator days over the time-course of treatment (3 [1; 5.8] vs 18.5 days [0.5; 20.5]; P = .0001) with a lower rate of tracheostomies (15.8 vs 54%; P = .0003). Patients on ventilation at admission in group A had shorter ventilation periods after admission (4.75 [4; 22.25] vs 378 hours [8.5; 681.5]; P = .0003), and 66.7% of these patients were extubated within 6 hours of admission (vs 9.1% in group B). No patients fulfilling the inclusion criteria required re- or emergency intubation. In the first 5 days of treatment, significantly lower Sequential Organ Failure Assessment scores were recorded in group A. There was also a trend for lower mortality rates (0 [0%] vs 6 [14%]), sepsis rates (24 [63.2%] vs 37 [88.1%]), and cumulative fluid balance on days 3 and 7 in group A. In contrast, group A demonstrated an elevated rate of pneumonia (15 [39.5%] vs 8 [19%]). These trends, however, lacked statistical significance. Our five-point protocol was safe and easily translated into clinical practice. In the authors experience, this protocol significantly reduced the ventilatory period in severely injured. Furthermore, this study suggests that many injured may be over-treated with routine ventilation, which carries accompanying risks.
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Foncerrada G, Culnan DM, Capek KD, González-Trejo S, Cambiaso-Daniel J, Woodson LC, Herndon DN, Finnerty CC, Lee JO. Inhalation Injury in the Burned Patient. Ann Plast Surg 2018; 80:S98-S105. [PMID: 29461292 PMCID: PMC5825291 DOI: 10.1097/sap.0000000000001377] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Inhalation injury causes a heterogeneous cascade of insults that increase morbidity and mortality among the burn population. Despite major advancements in burn care for the past several decades, there remains a significant burden of disease attributable to inhalation injury. For this reason, effort has been devoted to finding new therapeutic approaches to improve outcomes for patients who sustain inhalation injuries.The three major injury classes are the following: supraglottic, subglottic, and systemic. Treatment options for these three subtypes differ based on the pathophysiologic changes that each one elicits.Currently, no consensus exists for diagnosis or grading of the injury, and there are large variations in treatment worldwide, ranging from observation and conservative management to advanced therapies with nebulization of different pharmacologic agents.The main pathophysiologic change after a subglottic inhalation injury is an increase in the bronchial blood flow. An induced mucosal hyperemia leads to edema, increases mucus secretion and plasma transudation into the airways, disables the mucociliary escalator, and inactivates hypoxic vasocontriction. Collectively, these insults potentiate airway obstruction with casts formed from epithelial debris, fibrin clots, and inspissated mucus, resulting in impaired ventilation. Prompt bronchoscopic diagnosis and multimodal treatment improve outcomes. Despite the lack of globally accepted standard treatments, data exist to support the use of bronchoscopy and suctioning to remove debris, nebulized heparin for fibrin casts, nebulized N-acetylcysteine for mucus casts, and bronchodilators.Systemic effects of inhalation injury occur both indirectly from hypoxia or hypercapnia resulting from loss of pulmonary function and systemic effects of proinflammatory cytokines, as well as directly from metabolic poisons such as carbon monoxide and cyanide. Both present with nonspecific clinical symptoms including cardiovascular collapse. Carbon monoxide intoxication should be treated with oxygen and cyanide with hydroxocobalamin.Inhalation injury remains a great challenge for clinicians and an area of opportunity for scientists. Management of this concomitant injury lags behind other aspects of burn care. More clinical research is required to improve the outcome of inhalation injury.The goal of this review is to comprehensively summarize the diagnoses, treatment options, and current research.
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Affiliation(s)
- Guillermo Foncerrada
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, USA
- Shriners Hospitals for Children - Galveston, Galveston, Texas, USA
| | - Derek M. Culnan
- JMS Burn and Reconstructive Center at Merit Health Central, Jackson, MS, USA
| | - Karel D. Capek
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, USA
- Shriners Hospitals for Children - Galveston, Galveston, Texas, USA
| | - Sagrario González-Trejo
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, USA
- Shriners Hospitals for Children - Galveston, Galveston, Texas, USA
| | - Janos Cambiaso-Daniel
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, USA
- Shriners Hospitals for Children - Galveston, Galveston, Texas, USA
| | - Lee C. Woodson
- Shriners Hospitals for Children - Galveston, Galveston, Texas, USA
- Department of Anesthesiology, University of Texas Medical Branch Galveston, Texas, USA
| | - David N. Herndon
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, USA
- Shriners Hospitals for Children - Galveston, Galveston, Texas, USA
| | - Celeste C. Finnerty
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, USA
- Shriners Hospitals for Children - Galveston, Galveston, Texas, USA
| | - Jong O. Lee
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, USA
- Shriners Hospitals for Children - Galveston, Galveston, Texas, USA
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Validation of the burn intervention score in a National Burn Centre. Burns 2018; 44:1159-1166. [PMID: 29475745 DOI: 10.1016/j.burns.2018.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Revised: 01/11/2018] [Accepted: 02/02/2018] [Indexed: 11/20/2022]
Abstract
The Linköping burn score has been used for two decades to calculate the cost to the hospital of each burned patient. Our aim was to validate the Burn Score in a dedicated Burn Centre by analysing the associations with burn-specific factors: percentage of total body surface area burned (TBSA%), cause of injury, patients referred from other (non-specialist) centres, and survival, to find out which of these factors resulted in higher scores. Our second aim was to analyse the variation in scores of each category of care (surveillance, respiration, circulation, wound care, mobilisation, laboratory tests, infusions, and operation). We made a retrospective analysis of all burned patients admitted during the period 2000-15. Multivariable regression models were used to analyse predictive factors for an increased daily burn score, the cumulative burn score (the sum of the daily burn scores for each patient) and the total burn score (total sum of burn scores for the whole group throughout the study period) in addition to sub-analysis of the different categories of care that make up the burn score. We retrieved 22301 daily recordings for inpatients. Mobilisation and care of the wound accounted for more than half of the total burn score during the study. Increased TBSA% and age over 45 years were associated with increased cumulative (model R2 0.43, p<0.001) and daily (model R2 0.61, p<0.001) burn scores. Patients who died had higher daily burn scores, while the cumulative burn score decreased with shorter duration of hospital stay (p<0.001). To our knowledge this is the first long term analysis and validation of a system for scoring burn interventions in patients with burns that explores its association with the factors important for outcome. Calculations of costs are based on the score, and it provides an indicator of the nurses' workload. It also gives important information about the different dimensions of the care provided from thorough investigation of the scores for each category.
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Abdelrahman I, Elmasry M, Steinvall I, Fredrikson M, Sjoberg F. Improvement in mortality at a National Burn Centre since 2000: Was it the result of increased resources? Medicine (Baltimore) 2017; 96:e6727. [PMID: 28640072 PMCID: PMC5484180 DOI: 10.1097/md.0000000000006727] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The aim of this study was to find out whether the charging costs (calculated using interventional burn score) increased as mortality decreased.During the last 2 decades, mortality has declined significantly in the Linköping Burn Centre. The burn score that we use has been validated as a measure of workload and is used to calculate the charging costs of each burned patient.We compared the charging costs and mortality in 2 time periods (2000-2007 and 2008-2015). A total of 1363 admissions were included. We investigated the change in the burn score, as a surrogate for total costs per patient. Multivariable regression was used to analyze risk-adjusted mortality and burn score.The median total body surface area % (TBSA%) was 6.5% (10-90 centile 1.0-31.0), age 33 years (1.3-72.2), duration of stay/ TBSA% was 1.4 days (0.3-5.3), and 960 (70%) were males. Crude mortality declined from 7.5% in 2000-2007 to 3.4% in 2008-2015, whereas the cumulative burn score was not increased (P = .08). Regression analysis showed that risk-adjusted mortality decreased (odds ratio 0.42, P = .02), whereas the adjusted burn score did not change (P = .14, model R 0.86).Mortality decreased but there was no increase in the daily use of resources as measured by the interventional burn score. The data suggest that the improvements in quality obtained have been achieved within present routines for care of patients (multidisciplinary/orientated to patients' safety).
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Affiliation(s)
- Islam Abdelrahman
- Plastic Surgery Unit, Surgery Department, Suez Canal University, Ismailia, Egypt
- The Burn Centre, Department of Plastic Surgery, Hand Surgery, and Burns
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Moustafa Elmasry
- Plastic Surgery Unit, Surgery Department, Suez Canal University, Ismailia, Egypt
- The Burn Centre, Department of Plastic Surgery, Hand Surgery, and Burns
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Ingrid Steinvall
- The Burn Centre, Department of Plastic Surgery, Hand Surgery, and Burns
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Mats Fredrikson
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Folke Sjoberg
- The Burn Centre, Department of Plastic Surgery, Hand Surgery, and Burns
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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Kupffer Cell p38 Mitogen-Activated Protein Kinase Signaling Drives Postburn Hepatic Damage and Pulmonary Inflammation When Alcohol Intoxication Precedes Burn Injury. Crit Care Med 2017; 44:e973-9. [PMID: 27322363 DOI: 10.1097/ccm.0000000000001817] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Clinical and animal studies demonstrate that alcohol intoxication at the time of injury worsens postburn outcome. The purpose of this study was to determine the role and mechanism of Kupffer cell derangement in exacerbating postburn end organ damage in alcohol-exposed mice. DESIGN Interventional study. SETTING Research Institute. SUBJECTS Male C57BL/6 mice. INTERVENTIONS Alcohol administered 30 minutes before a 15% scald burn injury. Antecedent Kupffer cell depletion with clodronate liposomes (0.5 mg/kg). p38 mitogen-activated protein kinase inhibition via SB203580 (10 mg/kg). MEASUREMENTS AND MAIN RESULTS Kupffer cells were isolated 24 hours after injury and analyzed for p38 activity and interleukin-6 production. Intoxicated burned mice demonstrated a two-fold (p < 0.05) elevation of Kupffer cell p38 activation relative to either insult alone, and this corresponded to a 43% (p < 0.05) increase in interleukin-6 production. Depletion of Kupffer cells attenuated hepatic damage as seen by decreases of 53% (p < 0.05) in serum alanine aminotransferase and 74% (p < 0.05) in hepatic triglycerides, as well as a 77% reduction (p < 0.05) in serum interleukin-6 levels compared to matched controls. This mitigation of hepatic damage was associated with a 54% decrease (p < 0.05) in pulmonary neutrophil infiltration and reduced alveolar wall thickening by 45% (p < 0.05). In vivo p38 inhibition conferred nearly identical hepatic and pulmonary protection after the combined injury as mice depleted of Kupffer cells. CONCLUSIONS Intoxication exacerbates postburn hepatic damage through p38-dependent interleukin-6 production in Kupffer cells.
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Abdelrahman I, Elmasry M, Olofsson P, Steinvall I, Fredrikson M, Sjoberg F. Division of overall duration of stay into operative stay and postoperative stay improves the overall estimate as a measure of quality of outcome in burn care. PLoS One 2017; 12:e0174579. [PMID: 28362844 PMCID: PMC5376076 DOI: 10.1371/journal.pone.0174579] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 03/06/2017] [Indexed: 11/19/2022] Open
Abstract
Total duration of stay adjusted for percentage of the total body surface area burned (TBSA%) is a commonly used outcome measure in burn care. However, it has been criticised as it is affected by many factors, some of which are not strictly part of burn care. A division into operative stay and postoperative stay may improve this measure. The aim was to evaluate if operative stay can serve as a more standardised measure by: comparing the variation in operative stay/TBSA% with the variation in total stay/TBSA%, and to study different factors associated with operative stay and postoperative stay.
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Affiliation(s)
- Islam Abdelrahman
- Plastic Surgery Unit, Surgery Department, Suez Canal University, Ismailia, Egypt
- Department of Plastic Surgery, Hand Surgery, and Burns, Linköping University, Linköping, Sweden
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Moustafa Elmasry
- Plastic Surgery Unit, Surgery Department, Suez Canal University, Ismailia, Egypt
- Department of Plastic Surgery, Hand Surgery, and Burns, Linköping University, Linköping, Sweden
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Pia Olofsson
- Department of Plastic Surgery, Hand Surgery, and Burns, Linköping University, Linköping, Sweden
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Ingrid Steinvall
- Department of Plastic Surgery, Hand Surgery, and Burns, Linköping University, Linköping, Sweden
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
- * E-mail:
| | - Mats Fredrikson
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Folke Sjoberg
- Department of Plastic Surgery, Hand Surgery, and Burns, Linköping University, Linköping, Sweden
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
- Department of Anaesthesiology and Intensive Care, Linköping University, Linköping, Sweden
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Onishi S, Osuka A, Kuroki Y, Ueyama M. Indications of early intubation for patients with inhalation injury. Acute Med Surg 2017; 4:278-285. [PMID: 29123875 PMCID: PMC5674455 DOI: 10.1002/ams2.269] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 01/13/2017] [Indexed: 12/05/2022] Open
Abstract
Aim For patients with inhalation injury, the indications for early intubation are diverse. The purpose of this study was to identify the most reliable symptoms, physical findings, and medical examinations with which to determine the indications for early intubation in patients with inhalation injury. Methods We retrospectively collected patient data from medical records. Collected data included age, sex, burn size, symptoms, physical findings, carboxyhemoglobin levels (COHb), and bronchial wall thickness (BWT) determined from chest computed tomography images. We analyzed the relationships between these findings and the early intubation. We performed fiberoptic bronchoscopy in all patients, and analyzed the relationships between bronchoscopic severity and other findings. Results Of the 205 patients, 80 patients were diagnosed as having inhalation injury, and 34 patients were intubated. Burn size, facial burns, neck burns, use of accessory respiratory muscles, and COHb seemed to be related with intubation, whereas singed nasal hair was not. If the patients suffered ≥27% total body surface area burn and BWT ≥3.5 mm, the positive predictive value for early intubation was 1.00. If the patients suffered smaller cutaneous burn without neck burn, and their COHb <4.0%, the negative predictive value for early intubation was 0.97. Fiberoptic bronchoscopy findings from above the glottis were mainly related with patients’ symptoms. Findings from below the glottis were mainly related with BWT and COHb. Conclusions Patients’ symptoms, especially use of accessory respiratory muscles, are reliable, and BWT and COHb are also useful tools, for determining the indication for early intubation.
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Affiliation(s)
- Shinya Onishi
- Department of Trauma, Critical Care Medicine and Burn Center Japan Community Health Care Organization Chukyo Hospital Nagoya AICHI Japan
| | - Akinori Osuka
- Department of Trauma, Critical Care Medicine and Burn Center Japan Community Health Care Organization Chukyo Hospital Nagoya AICHI Japan
| | - Yuichi Kuroki
- Department of Trauma, Critical Care Medicine and Burn Center Japan Community Health Care Organization Chukyo Hospital Nagoya AICHI Japan
| | - Masashi Ueyama
- Department of Trauma, Critical Care Medicine and Burn Center Japan Community Health Care Organization Chukyo Hospital Nagoya AICHI Japan
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Goh CT, Jacobe S. Ventilation strategies in paediatric inhalation injury. Paediatr Respir Rev 2016; 20:3-9. [PMID: 26628193 DOI: 10.1016/j.prrv.2015.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 10/19/2015] [Indexed: 10/22/2022]
Abstract
Inhalation injury increases morbidity and mortality in burns victims. While the diagnosis remains largely clinical, bronchoscopy is also helpful to diagnose and grade the severity of any injury. Inhalation injury results from direct thermal injury or chemical irritation of the respiratory tract, systemic toxicity from inhaled substances, or a combination of these factors. While endotracheal intubation is essential in cases where upper airway obstruction may occur, it has its own risks and should not be performed prophylactically in all cases of inhalation injury. The evidence-base informing the selection of optimal ventilation strategy in inhalation injury is sparse, and most recommendations are based on extrapolation from (largely adult) studies in acute respiratory distress syndrome (ARDS). Conventional ventilation using a lung-protective approach (i.e. low tidal volume, limited plateau pressure, and permissive hypercarbia) is recommended as the initial approach if invasive ventilation is required; various rescue strategies may become necessary if there is a poor response. The efficacy of many widely used pharmacologic adjuncts in inhalation injury remains uncertain. Further research is urgently required to address these gaps in our knowledge.
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Affiliation(s)
- Chong Tien Goh
- Advanced Trainee in Intensive Care Medicine, Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Sydney.
| | - Stephen Jacobe
- Senior Staff Specialist, Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Sydney, and Clinical Associate Professor, Sydney Medical School, University of Sydney, NSW, Australia
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Yeligar SM, Chen MM, Kovacs EJ, Sisson JH, Burnham EL, Brown LAS. Alcohol and lung injury and immunity. Alcohol 2016; 55:51-59. [PMID: 27788778 DOI: 10.1016/j.alcohol.2016.08.005] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 07/07/2016] [Accepted: 08/24/2016] [Indexed: 02/06/2023]
Abstract
Annually, excessive alcohol use accounts for more than $220 billion in economic costs and 80,000 deaths, making excessive alcohol use the third leading lifestyle-related cause of death in the US. Patients with an alcohol-use disorder (AUD) also have an increased susceptibility to respiratory pathogens and lung injury, including a 2-4-fold increased risk of acute respiratory distress syndrome (ARDS). This review investigates some of the potential mechanisms by which alcohol causes lung injury and impairs lung immunity. In intoxicated individuals with burn injuries, activation of the gut-liver axis drives pulmonary inflammation, thereby negatively impacting morbidity and mortality. In the lung, the upper airway is the first checkpoint to fail in microbe clearance during alcohol-induced lung immune dysfunction. Brief and prolonged alcohol exposure drive different post-translational modifications of novel proteins that control cilia function. Proteomic approaches are needed to identify novel alcohol targets and post-translational modifications in airway cilia that are involved in alcohol-dependent signal transduction pathways. When the upper airway fails to clear inhaled pathogens, they enter the alveolar space where they are primarily cleared by alveolar macrophages (AM). With chronic alcohol ingestion, oxidative stress pathways in the AMs are stimulated, thereby impairing AM immune capacity and pathogen clearance. The epidemiology of pneumococcal pneumonia and AUDs is well established, as both increased predisposition and illness severity have been reported. AUD subjects have increased susceptibility to pneumococcal pneumonia infections, which may be due to the pro-inflammatory response of AMs, leading to increased oxidative stress.
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Affiliation(s)
- Samantha M Yeligar
- Department of Medicine, Emory University and Atlanta Veterans Affairs Medical Center, Decatur, GA 30033, USA
| | - Michael M Chen
- Burn and Shock Trauma Research Institute, Alcohol Research Program, Integrative Cell Biology Program, Loyola University Chicago Stritch School of Medicine, Maywood, IL 60153, USA
| | - Elizabeth J Kovacs
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Joseph H Sisson
- Pulmonary, Critical Care, Sleep and Allergy Division, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Ellen L Burnham
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Lou Ann S Brown
- Department of Pediatrics, Emory University, Atlanta, GA 30322, USA.
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Shults JA, Curtis BJ, Boe DM, Ramirez L, Kovacs EJ. Ethanol intoxication prolongs post-burn pulmonary inflammation: role of alveolar macrophages. J Leukoc Biol 2016; 100:1037-1045. [PMID: 27531926 DOI: 10.1189/jlb.3ma0316-111r] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 07/26/2016] [Indexed: 02/06/2023] Open
Abstract
In this study, the role and fate of AMs were examined in pulmonary inflammation after intoxication and injury. Clinical evidence has revealed that half of all burn patients brought to the emergency department are intoxicated at the time of injury. This combined insult results in amplified neutrophil accumulation and pulmonary edema, with an increased risk of lung failure and mortality, relative to either insult alone. We believe that this excessive pulmonary inflammation, which also parallels decreased lung function, is mediated in part by AMs. Restoration of lung tissue homeostasis is dependent on the eradication of neutrophils and removal of apoptotic cells, both major functions of AMs. Thirty minutes after binge ethanol intoxication, mice were anesthetized and given a 15% total body surface area dorsal scald injury. At 24 h, we found a 50% decrease in the total number of AMs (P < 0.05) and observed a proinflammatory phenotype on the remaining lung AMs. Loss of AMs paralleled a 6-fold increase in the number of TUNEL+ lung apoptotic cells (P < 0.05) and a 3.5-fold increase in the percentage of annexin V+ apoptotic cells in BAL (P < 0.05), after intoxication and injury, relative to controls. In contrast to the reduction in the number of cells, AMs from intoxicated and injured mice had a 4-fold increase in efferocytosis (P < 0.05). In summary, these data suggest that loss of AMs may delay resolution of inflammation, resulting in the pulmonary complications and elevated mortality rates observed in intoxicated and burn-injured patients.
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Affiliation(s)
- Jill A Shults
- Alcohol Research Program, Loyola University Chicago, Health Sciences Campus, Stritch School of Medicine, Maywood, Illinois, USA.,Burn and Shock Trauma Research Institute, Loyola University Chicago, Health Sciences Campus, Stritch School of Medicine, Maywood, Illinois, USA.,Department of Surgery, Loyola University Chicago, Health Sciences Campus, Stritch School of Medicine, Maywood, Illinois, USA.,Integrative Cell Biology Program, Loyola University Chicago, Health Sciences Campus, Stritch School of Medicine, Maywood, Illinois, USA
| | - Brenda J Curtis
- Alcohol Research Program, Loyola University Chicago, Health Sciences Campus, Stritch School of Medicine, Maywood, Illinois, USA.,Burn and Shock Trauma Research Institute, Loyola University Chicago, Health Sciences Campus, Stritch School of Medicine, Maywood, Illinois, USA.,Department of Surgery, Loyola University Chicago, Health Sciences Campus, Stritch School of Medicine, Maywood, Illinois, USA
| | - Devin M Boe
- Alcohol Research Program, Loyola University Chicago, Health Sciences Campus, Stritch School of Medicine, Maywood, Illinois, USA.,Burn and Shock Trauma Research Institute, Loyola University Chicago, Health Sciences Campus, Stritch School of Medicine, Maywood, Illinois, USA.,Department of Surgery, Loyola University Chicago, Health Sciences Campus, Stritch School of Medicine, Maywood, Illinois, USA.,Integrative Cell Biology Program, Loyola University Chicago, Health Sciences Campus, Stritch School of Medicine, Maywood, Illinois, USA
| | - Luis Ramirez
- Alcohol Research Program, Loyola University Chicago, Health Sciences Campus, Stritch School of Medicine, Maywood, Illinois, USA.,Burn and Shock Trauma Research Institute, Loyola University Chicago, Health Sciences Campus, Stritch School of Medicine, Maywood, Illinois, USA.,Department of Surgery, Loyola University Chicago, Health Sciences Campus, Stritch School of Medicine, Maywood, Illinois, USA
| | - Elizabeth J Kovacs
- Alcohol Research Program, Loyola University Chicago, Health Sciences Campus, Stritch School of Medicine, Maywood, Illinois, USA; .,Burn and Shock Trauma Research Institute, Loyola University Chicago, Health Sciences Campus, Stritch School of Medicine, Maywood, Illinois, USA.,Department of Surgery, Loyola University Chicago, Health Sciences Campus, Stritch School of Medicine, Maywood, Illinois, USA.,Integrative Cell Biology Program, Loyola University Chicago, Health Sciences Campus, Stritch School of Medicine, Maywood, Illinois, USA
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The Acute Respiratory Distress Syndrome (ARDS) in mechanically ventilated burn patients: An analysis of risk factors, clinical features, and outcomes using the Berlin ARDS definition. Burns 2016; 42:1423-1432. [PMID: 27520712 DOI: 10.1016/j.burns.2016.01.031] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 01/22/2016] [Accepted: 01/26/2016] [Indexed: 01/28/2023]
Abstract
BACKGROUND The Berlin definition of Acute Respiratory Distress Syndrome (ARDS) has been applied to military burns resulting from combat-related trauma, but has not been widely studied among civilian burns. This study's purpose was to use the Berlin definition to determine the incidence of ARDS, and its associated respiratory morbidity, and mortality among civilian burn patients. METHODS Retrospective study of burn patients mechanically ventilated for ≥48h at an American Burn Association-verified burn center. The Berlin criteria identified patients with mild, moderate, and severe ARDS. Logistic regression was used to identify variables predictive of moderate to severe ARDS, and mortality. The outcome measures of interest were duration of mechanical ventilation and in-hospital mortality. Values are shown as the median (Q1-Q3). RESULTS We included 162 subjects [24% female, age 48 (35-60), % total body surface area (TBSA) burn 28 (19-40), % body surface area (BSA) full thickness (FT) burn 13 (0-30), and 62% with inhalation injury]. The incidence of ARDS was 43%. Patients with ARDS had larger %TBSA burns [30.5 (23.1-47.0) vs. 24.8 (17.1-35), p=0.007], larger FT burns [20.5(5.4-35.5) vs. 7 (0-22.1), p=0.001], but had no significant difference in the incidence of inhalation injury (p=0.216), compared to those without ARDS. The % FT burn predicted the development of moderate to severe ARDS [OR 1.034, 95%CI (1.013-1.055), p=0.001]. ARDS developed in the 1st week after burn in 86% of cases. Worsening severity of ARDS was associated with increased days of mechanical ventilation in survivors (p=0.001), a reduction in ventilator-free days/1st 30 days in all subjects (p=0.004), and a strong indication of increased mortality (0% in mild ARDS vs. 50% in severe ARDS, unadjusted p=0.02). Neither moderate ARDS nor severe ARDS were significant predictors of death. CONCLUSIONS ARDS is common among mechanically ventilated civilian burn patients, and develops early after burn. The extent of full thickness burn predicted development of moderate to severe ARDS. Increasing severity of ARDS based upon the Berlin definition was associated with a significantly greater duration of mechanical ventilation and a trend toward higher mortality.
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Shults JA, Curtis BJ, Chen MM, O'Halloran EB, Ramirez L, Kovacs EJ. Impaired respiratory function and heightened pulmonary inflammation in episodic binge ethanol intoxication and burn injury. Alcohol 2015; 49:713-20. [PMID: 26364264 DOI: 10.1016/j.alcohol.2015.06.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 06/18/2015] [Accepted: 06/19/2015] [Indexed: 01/25/2023]
Abstract
Clinical data indicate that cutaneous burn injuries covering greater than 10% of the total body surface area are associated with significant morbidity and mortality, in which pulmonary complications, including acute respiratory distress syndrome (ARDS), contribute to nearly half of all patient deaths. Approximately 50% of burn patients are intoxicated at the time of hospital admission, which increases days on ventilators by 3-fold, and doubles the length of hospitalization, compared to non-intoxicated burn patients. The most common drinking pattern in the United States is binge drinking, where an individual rapidly consumes alcoholic beverages (4 for women, 5 for men) in 2 h. An estimated 38 million Americans binge drink, often several times per month. Experimental data demonstrate that a single binge-ethanol exposure, prior to scald injury, impairs innate and adaptive immune responses, thereby enhancing infection susceptibility and amplifying pulmonary inflammation, neutrophil infiltration, and edema, and is associated with increased mortality. Since these characteristics are similar to those observed in ARDS burn patients, our study objective was to determine whether ethanol intoxication and burn injury and the subsequent pulmonary congestion affect physiological parameters of lung function, using non-invasive and unrestrained plethysmography in a murine model system. Furthermore, to mirror young adult binge-drinking patterns, and to determine the effect of multiple ethanol exposures on pulmonary inflammation, we utilized an episodic binge-ethanol exposure regimen, where mice were exposed to ethanol for a total of 6 days (3 days ethanol, 4 days rest, 3 days ethanol) prior to burn injury. Our analyses demonstrate mice exposed to episodic binge ethanol and burn injury have higher mortality, increased pulmonary congestion and neutrophil infiltration, elevated neutrophil chemoattractants, and respiratory dysfunction, compared to burn or ethanol intoxication alone. Overall, our study identifies plethysmography as a useful tool for characterizing respiratory function in a murine burn model and for future identification of therapeutic compounds capable of restoring pulmonary functionality.
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Aliannejad R. Comment on "Comparison of virtual bronchoscopy to fiber-optic bronchoscopy for assessment of inhalation injury severity". Burns 2015; 41:1613-5. [PMID: 26387428 DOI: 10.1016/j.burns.2015.05.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Accepted: 05/14/2015] [Indexed: 11/26/2022]
Affiliation(s)
- Rasoul Aliannejad
- Department of Pulmonary, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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Lundy JB, Chung KK, Pamplin JC, Ainsworth CR, Jeng JC, Friedman BC. Update on Severe Burn Management for the Intensivist. J Intensive Care Med 2015; 31:499-510. [PMID: 26112758 DOI: 10.1177/0885066615592346] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Accepted: 06/01/2015] [Indexed: 11/15/2022]
Abstract
Thermal injury of humans causes arguably the most severe perturbations in physiology that can be experienced. These physiologic derangements start immediately and can persist in some form until months or even years after the burn wounds are healed. Burn shock, marked activation of the systemic inflammatory response, multiple-organ failure, infection, and wound failure are just a few of the insults that may require management by the intensivist. The purpose of this article is to review recent advances in the critical care management of thermally injured patients.
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Affiliation(s)
- Jonathan B Lundy
- Burn Center, United States Army Institute of Surgical Research, Fort Sam Houston, TX, USA Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Kevin K Chung
- Burn Center, United States Army Institute of Surgical Research, Fort Sam Houston, TX, USA Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Jeremy C Pamplin
- Burn Center, United States Army Institute of Surgical Research, Fort Sam Houston, TX, USA Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Craig R Ainsworth
- Department of Medicine, William Beaumont Army Medical Center, Fort Bliss, TX, USA
| | - James C Jeng
- Department of Surgery, Mount Sinai Beth Israel Medical Center, New York, NY, USA
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Kwon HP, Zanders TB, Regn DD, Burkett SE, Ward JA, Nguyen R, Necsoiu C, Jordan BS, York GE, Jimenez S, Chung KK, Cancio LC, Morris MJ, Batchinsky AI. Comparison of virtual bronchoscopy to fiber-optic bronchoscopy for assessment of inhalation injury severity. Burns 2014; 40:1308-15. [PMID: 25112807 DOI: 10.1016/j.burns.2014.06.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 06/16/2014] [Accepted: 06/17/2014] [Indexed: 11/20/2022]
Abstract
PURPOSE Compare virtual bronchoscopy (VB) to fiberoptic bronchoscopy (FOB) for scoring smoke inhalation injury (SII). METHODS Swine underwent computerized tomography (CT) with VB and FOB before (0) and 24 and 48 h after SII. VB and FOB images were scored by 5 providers off line. RESULTS FOB and VB scores increased over time (p<0.001) with FOB scoring higher than VB at 0 (0.30±0.79 vs. 0.03±0.17), 24 h (4.21±1.68 vs. 2.47±1.50), and 48h (4.55±1.83 vs. 1.94±1.29). FOB and VB showed association with PaO2-to-FiO2 ratios (PFR) with areas under receiver operating characteristic curves (ROC): for PFR≤300, VB 0.830, FOB 0.863; for PFR≤200, VB 0.794, FOB 0.825; for PFR≤100, VB 0.747, FOB 0.777 (all p<0.001). FOB showed 80.3% specificity, 77% sensitivity, 88.8% negative-predictive value (NPV), and 62.3% positive-predictive value (PPV) for PFR≤300 and VB showed 67.2% specificity, 85.5% sensitivity, 91.3% NPV, and 53.4% PPV. CONCLUSIONS VB provided similar injury severity scores to FOB, correlated with PFR, and reliably detected airway narrowing. VB performed during admission CT may be a useful screening tool specifically to demonstrate airway narrowing induced by SII.
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Affiliation(s)
- Herbert P Kwon
- Pulmonary/Critical Care Service, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234, United States
| | - Thomas B Zanders
- Pulmonary/Critical Care Service, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234, United States
| | - Dara D Regn
- Pulmonary/Critical Care Service, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234, United States
| | - Samuel E Burkett
- Pulmonary/Critical Care Service, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234, United States
| | - John A Ward
- Department of Clinical Investigation, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, United States
| | - Ruth Nguyen
- Pulmonary/Critical Care Service, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234, United States
| | - Corina Necsoiu
- Pulmonary/Critical Care Service, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234, United States
| | - Bryan S Jordan
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234-6315, United States
| | - Gerald E York
- Department of Radiology, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, United States
| | - Santiago Jimenez
- Department of Radiology, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, United States
| | - Kevin K Chung
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234-6315, United States
| | - Leopoldo C Cancio
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234-6315, United States
| | - Michael J Morris
- Pulmonary/Critical Care Service, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234, United States
| | - Andriy I Batchinsky
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234-6315, United States.
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Lowry DM, Morishita K, Eliceiri BP, Bansal V, Coimbra R, Costantini TW. The vagus nerve alters the pulmonary dendritic cell response to injury. J Surg Res 2014; 192:12-8. [PMID: 25005822 DOI: 10.1016/j.jss.2014.06.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 05/29/2014] [Accepted: 06/04/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND We have shown previously that vagal nerve stimulation (VNS) protects against burn-induced acute lung injury (ALI). Although the mobilization and activation of immune cells is central to tissue injury caused by the systemic inflammatory response, the specific inflammatory cell populations that are modulated by VNS have yet to be fully defined. The purpose of this study was to assess whether VNS alters inflammatory cell recruitment to the lung after severe burn injury. MATERIALS AND METHODS Male C57BL/6 mice were subjected to 30% total body surface area steam burn with and without electrical stimulation of the right cervical vagus nerve. The relative levels of pulmonary dendritic cells (DC) and macrophages were compared at 4 h versus 24 h after burn injury. Lung tissue injury was characterized by histology to assess changes in lung architecture, and measure the protein levels of interleukin 6 and transforming growth factor-β1. RESULTS Severe burn caused an increase in pulmonary DC recruitment at 4 h after injury that persisted at 24 h after severe burn, whereas there was no change in the number of pulmonary macrophages. In contrast, VNS limited the burn-induced recruitment of pulmonary DC. VNS prevented histologic lung injury and attenuated the release of interleukin 6 and transforming growth factor-β1 in the lung after burn injury. CONCLUSIONS VNS is an effective method to limit pulmonary DC recruitment to the lung and prevent ALI after burn injury. Identifying strategies to limit inflammatory cell recruitment to the lung may have clinical utility in preventing ALI in severely burned patients.
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Affiliation(s)
- Debra M Lowry
- Division of Trauma, Surgical Critical Care, and Burns, Department of Surgery, University of California, San Diego Health Sciences, San Diego, California
| | - Koji Morishita
- Division of Trauma, Surgical Critical Care, and Burns, Department of Surgery, University of California, San Diego Health Sciences, San Diego, California
| | - Brian P Eliceiri
- Division of Trauma, Surgical Critical Care, and Burns, Department of Surgery, University of California, San Diego Health Sciences, San Diego, California
| | - Vishal Bansal
- Division of Trauma, Surgical Critical Care, and Burns, Department of Surgery, University of California, San Diego Health Sciences, San Diego, California
| | - Raul Coimbra
- Division of Trauma, Surgical Critical Care, and Burns, Department of Surgery, University of California, San Diego Health Sciences, San Diego, California
| | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, and Burns, Department of Surgery, University of California, San Diego Health Sciences, San Diego, California.
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Acute respiratory distress syndrome in wartime military burns: application of the Berlin criteria. J Trauma Acute Care Surg 2014; 76:821-7. [PMID: 24553555 DOI: 10.1097/ta.0b013e3182aa2d21] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) prevalence and related outcomes in burned military casualties from Iraq and Afghanistan have not been described previously. The objective of this article was to report ARDS prevalence and its associated in-hospital mortality in military burn patients. METHODS Demographic and physiologic data were collected retrospectively on mechanically ventilated military casualties admitted to our burn intensive care unit from January 2003 to December 2011. Patients with ARDS were identified in accordance with the new Berlin definition of ARDS. Subjects were categorized as having mild, moderate, or severe ARDS. Multivariate logistic regression identified independent risk factors for developing moderate-to-severe ARDS. The main outcome measure was the prevalence of ARDS in a cohort of patients burned as a result of recent combat operations. RESULTS A total of 876 burned military casualties presented during the study period, of whom 291 (33.2%) required mechanical ventilation. Prevalence of ARDS in this cohort was 32.6%, with a crude overall mortality of 16.5%. Mortality increased significantly with ARDS severity: mild (11.1%), moderate (36.1%), and severe (43.8%) compared with no ARDS (8.7%) (p < 0.001). Predictors for the development of moderate or severe ARDS were inhalation injury (odds ratio [OR], 1.90; 95% confidence interval [CI], 1.01-3.54; p = 0.046), Injury Severity Score (ISS) (OR, 1.04; 95% CI, 1.01-1.07; p = 0.0021), pneumonia (OR, 198; 95% CI, 1.07-3.66; p = 0.03), and transfusion of fresh frozen plasma (OR, 1.32; 95% CI, 1.01-1.72; p = 0.04). Size of burn was associated with moderate or severe ARDS by univariate analysis but was not an independent predictor of ARDS by multivariate logistic regression (p > 0.05). Age, size of burn, and moderate or severe ARDS were independent predictors of mortality. CONCLUSION In this cohort of military casualties with thermal injuries, nearly a third required mechanical ventilation; of those, nearly one third developed ARDS, and nearly one third of patients with ARDS did not survive. Moderate and severe ARDS increased the odds of death by more than fourfold and ninefold, respectively. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level III.
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Hussain A, Choukairi F, Dunn K. Predicting survival in thermal injury: A systematic review of methodology of composite prediction models. Burns 2013; 39:835-50. [DOI: 10.1016/j.burns.2012.12.010] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 11/13/2012] [Accepted: 12/06/2012] [Indexed: 12/26/2022]
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Dries DJ, Endorf FW. Inhalation injury: epidemiology, pathology, treatment strategies. Scand J Trauma Resusc Emerg Med 2013; 21:31. [PMID: 23597126 PMCID: PMC3653783 DOI: 10.1186/1757-7241-21-31] [Citation(s) in RCA: 141] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Accepted: 04/11/2013] [Indexed: 01/19/2023] Open
Abstract
Lung injury resulting from inhalation of smoke or chemical products of combustion continues to be associated with significant morbidity and mortality. Combined with cutaneous burns, inhalation injury increases fluid resuscitation requirements, incidence of pulmonary complications and overall mortality of thermal injury. While many products and techniques have been developed to manage cutaneous thermal trauma, relatively few diagnosis-specific therapeutic options have been identified for patients with inhalation injury. Several factors explain slower progress for improvement in management of patients with inhalation injury. Inhalation injury is a more complex clinical problem. Burned cutaneous tissue may be excised and replaced with skin grafts. Injured pulmonary tissue must be protected from secondary injury due to resuscitation, mechanical ventilation and infection while host repair mechanisms receive appropriate support. Many of the consequences of smoke inhalation result from an inflammatory response involving mediators whose number and role remain incompletely understood despite improved tools for processing of clinical material. Improvements in mortality from inhalation injury are mostly due to widespread improvements in critical care rather than focused interventions for smoke inhalation. Morbidity associated with inhalation injury is produced by heat exposure and inhaled toxins. Management of toxin exposure in smoke inhalation remains controversial, particularly as related to carbon monoxide and cyanide. Hyperbaric oxygen treatment has been evaluated in multiple trials to manage neurologic sequelae of carbon monoxide exposure. Unfortunately, data to date do not support application of hyperbaric oxygen in this population outside the context of clinical trials. Cyanide is another toxin produced by combustion of natural or synthetic materials. A number of antidote strategies have been evaluated to address tissue hypoxia associated with cyanide exposure. Data from European centers supports application of specific antidotes for cyanide toxicity. Consistent international support for this therapy is lacking. Even diagnostic criteria are not consistently applied though bronchoscopy is one diagnostic and therapeutic tool. Medical strategies under investigation for specific treatment of smoke inhalation include beta-agonists, pulmonary blood flow modifiers, anticoagulants and antiinflammatory strategies. Until the value of these and other approaches is confirmed, however, the clinical approach to inhalation injury is supportive.
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Affiliation(s)
- David J Dries
- Department of Surgery, Regions Hospital, St. Paul, MN 55101, USA.
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Preemptive Use of High-Frequency Oscillatory Ventilation in Pediatric Burn Patients. J Burn Care Res 2013; 34:237-42. [DOI: 10.1097/bcr.0b013e31826fc5fa] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Admission chest CT complements fiberoptic bronchoscopy in prediction of adverse outcomes in thermally injured patients. J Burn Care Res 2012; 33:532-8. [PMID: 22210063 DOI: 10.1097/bcr.0b013e318237455f] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In burned patients, inhalation injury can result in progressive pulmonary dysfunction, infection, and death. Although bronchoscopy is the standard for diagnosis, it only assesses the proximal airway and does not provide a comprehensive analysis of pulmonary insult. Chest radiographs have not been proven helpful in diagnosis of inhalation injury. Our hypothesis is that a CT scan alone or in conjunction with bronchoscopy can be used as a prognostic tool for critically ill burn patients, especially those with inhalation injury. The authors performed a retrospective study of all patients admitted to the U.S. Army Institute of Surgical Research Burn Center between 2002 and 2008 with chest CT within 24 hours of admission. They divided subjects into two groups, those with evidence of inhalation injury on bronchoscopy and those without. They used a radiologist's score to assess the degree of damage to the pulmonary parenchyma. The primary endpoint was a composite of pneumonia, acute lung injury/acute respiratory distress syndrome, and death. The inhalation injury group consisted of 25 patients and the noninhalation injury group of 19 patients. Groups were not different in age, TBSA burned, and percentage full-thickness burn. By multiple logistic regression, detection of inhalation injury on bronchoscopy was associated with an 8.3-fold increase in the composite endpoint. The combination of inhalation injury on bronchoscopy and a high radiologist's score was associated with a 12.7-fold increase in the incidence of the composite endpoint. Admission CT assists in predicting future lung dysfunction in burn patients.
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Tokarik M, Sjöberg F, Vajtr D, Broz L, Balik M, Vranova J. Natriuretic peptide proANP (1-98), a biomarker of ALI/ARDS in burns. Burns 2012; 39:243-8. [PMID: 23006832 DOI: 10.1016/j.burns.2012.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Revised: 05/31/2012] [Accepted: 06/19/2012] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Plasma atrial natriuretic peptide levels (proANP (1-98)), a parameter of myocardial dysfunction, have been reported to be increased in critically ill patients with acute lung injury/acute respiratory distress syndrome (ALI/ARDS). The aim of the study was to examine if proANP is a biomarker of ALI/ARDS as assessed by the Sequential Organ Failure Assessment score (SOFA Lung ≥2) in burn patients, and how it compares to the corresponding values for age, total body surface area percent (TBSA%) and inhalation injury for mortality prediction. METHODS A group of 22 burn patients with a mean TBSA of 30% (10-75%) and a mean age of 52 years (25-84 years) was investigated during 2010. Organ dysfunction/failure was classified according to the SOFA score. The criteria for ALI/ARDS were based on SOFA Lung ≥2. ProANP (1-98) concentrations (nmoll(-1)) were measured by commercially available enzyme linked immunosorbent assay (ELISA) immunoassays (Biomedica Austria) on post-burn days 2 and 7. RESULTS ProANP levels on day 7 post-burn positively correlated with a SOFA score day 7 post-burn, c=0.91. The receiver operating curve (ROC) analysis proved a sensitivity of 75% and a specificity of 75% for ALI/ARDS at cut-off values >3.35 nmoll(-1). The ROC value of proANP for ALI/ARDS (SOFA Lung ≥2) was significantly larger than that of age, TBSA% and inhalation injury: 0.90, 0.71, 0.74, and 0.69 (p<0.001). CONCLUSIONS ProANP levels, as a biomarker of ALI/ARDS, in critically burn patients correlated with SOFA scoring. The inhalation injury did not lead to increase in proANP values.
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Affiliation(s)
- Monika Tokarik
- Prague Burn Center, Third Faculty of Medicine, Charles University, Prague, Czech Republic.
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Prone positioning improves oxygenation in adult burn patients with severe acute respiratory distress syndrome. J Trauma Acute Care Surg 2012; 72:1634-9. [PMID: 22695433 DOI: 10.1097/ta.0b013e318247cd4f] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Prone positioning (PP) improves oxygenation and may provide a benefit in patients with acute respiratory distress syndrome (ARDS). This approach adds significant challenges to patients in intensive care by limiting access to the endotracheal or tracheostomy tube and vascular access. PP also significantly complicates burn care by making skin protection and wound care more difficult. We hypothesize that PP improves oxygenation and can be performed safely in burn patients with ARDS. METHODS PP was implemented in a burn intensive care unit for 18 patients with severe refractory ARDS. The characteristics of these patients were retrospectively reviewed to evaluate the impact of PP on Pao2:FiO2 ratio (PFR) during the first 48 hours of therapy. Each patient was considered his or her own control before initiation of PP, and trends in PFR were evaluated with one-way analysis of variance. Secondary measures of complications and mortality were also evaluated. RESULTS Mean PFR before PP was 87 (± 38) with a mean sequential organ failure assessment score of 11 (± 4). PFR improved during 48 hours in 12 of 14 survivors (p < 0.05). Mean PFR was 133 (± 77) immediately after PP, 165 (± 118) at 6 hours, 170 (± 115) at 12 hours, 214 (± 126) at 24 hours, 236 (± 137) at 36 hours, and 210 (± 97) at 48 hours. At each measured time interval except the last, PFR significantly improved. There were no unintended extubations. Facial pressure ulcers developed in four patients (22%). Overall, 14 survived 48 hours (78%), 12 survived 28 days (67%), and six survived to hospital discharge (33%). CONCLUSIONS PP improves oxygenation in burn patients with severe ARDS and was safely implemented in a burn intensive care unit. Mortality in this population remains high, warranting investigation into additional complementary rescue therapies. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Incidence of early burn-induced effects on liver function as reflected by the plasma disappearance rate of indocyanine green: A prospective descriptive cohort study. Burns 2012; 38:214-24. [DOI: 10.1016/j.burns.2011.08.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Revised: 08/24/2011] [Accepted: 08/25/2011] [Indexed: 12/23/2022]
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Pulmonary activation of coagulation and inhibition of fibrinolysis after burn injuries and inhalation trauma. ACTA ACUST UNITED AC 2011; 70:1389-97. [PMID: 21460745 DOI: 10.1097/ta.0b013e31820f85a7] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pulmonary coagulopathy is intrinsic to pneumonia and other forms of acute lung injury. We hypothesized patients with burn injuries and inhalation trauma to have similar alterations in pulmonary coagulation and fibrinolysis. METHODS We performed a prospective study on changes in pulmonary and systemic thrombin generation and fibrinolytic activity in patients with burn injuries and inhalation trauma requiring mechanical ventilation. Nondirected bronchial lavage was performed on alternate days. Patients requiring mechanical ventilation for nonpulmonary reasons who did not meet the North American European Consensus Conference criteria for acute lung injury functioned as control patients. RESULTS We studied 13 patients with burn injuries and inhalation trauma and 15 control patients. On admission, patients with burn injuries and inhalation trauma showed a significant increase in thrombin generation in the airways compared with control patients, as reflected by increased lavage fluid levels of thrombin-antithrombin complexes and fibrin degradation products, and decreased lavage fluid levels of activated protein C and antithrombin. Simultaneously, burn patients showed a significant decrease in fibrinolytic activity, as reflected by decreased lavage fluid levels of plasminogen activator activity. Pulmonary coagulopathy persisted throughout the period of mechanical ventilation and was accompanied by similar changes in systemic coagulation and fibrinolysis. There was no significant correlation between changes in coagulation and fibrinolysis and the extent of burn injury. CONCLUSIONS Patients with burn injuries and inhalation trauma requiring mechanical ventilation show a distinct and sustained procoagulant and antifibrinolytic shift in the pulmonary compartment. Pulmonary coagulopathy could be an important therapeutic target in these patients.
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Abstract
BACKGROUND Young women have been reported to be more likely to survive than men after severe trauma. Girls also have less inflammation and hypermetabolism after major burns. Yet burned women have been found to have a twofold greater risk of death than men. Our aim was to find out if there is a sex-related difference in mortality after thermal injury, particularly in the age group between 16 years and 49 years, when hormonal differences would be most influential. METHODS All patients admitted to the Linköping University Hospital Burn Unit with thermal injuries during the years 1993-2008 were included and the variables percentage burned total body surface area (TBSA%), age, type of burn, mechanical ventilation, and year were included in a multiple regression (Poisson log) model. RESULTS Of 1,119 patients with thermal injury, 792 (71%) were men. Crude mortality was 5% among men, and 8% among women (p = 0.04). After adjustment for age and TBSA%, there was no correlation between mortality and sex, in any age group. Eight men and four women died in the group of young adults (16-49 years) in which TBSA% correlated with mortality (p < 0.01) but age did not. Mortality was 14% (32 of 221) among the men and 23% (23 of 102) of women in the group of older adults (50 years and older), and both age and TBSA% correlated with mortality (p < 0.001). CONCLUSIONS There is no relevant sex-related difference in survival after thermal injury. The conclusion is, however, tempered by the few deaths, particularly among younger adults.
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Oppeltz RF, Rani M, Zhang Q, Schwacha MG. Burn-induced alterations in toll-like receptor-mediated responses by bronchoalveolar lavage cells. Cytokine 2011; 55:396-401. [PMID: 21696980 DOI: 10.1016/j.cyto.2011.05.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Revised: 04/26/2011] [Accepted: 05/02/2011] [Indexed: 01/09/2023]
Abstract
UNLABELLED Burn is associated with profound inflammation and activation of the innate immune system in multiple organ beds, including the lung. Similarly, toll-like receptors (TLR) are associated with innate immune activation. Nonetheless, it is unclear what impact burn has on TLR-induced inflammatory responses in the lung. METHODS Male C57BL/6 mice were subjected to burn (3rd degree, 25% TBSA) or sham procedure and 1, 3 or 7 days thereafter, bronchoalveolar lavage (BAL) fluid was collected and cells were isolated and cultured in vitro with specific TLR agonists as follows: Zymosan (TLR-2), LPS (TLR-4) and CpG-ODN (TLR-9). Supernatants were collected 48 h later and assayed for inflammatory cytokine levels (IL-1β, IL-6, IL-10, IL-17, TNF-α, KC, MCP-1, MIP-1α, MIP-1β and RANTES) by Bioplex. RESULTS BAL fluid from sham and burn mice did not contain detectable cytokine levels. BAL cells, irrespective of injury, were responsive to TLR-2 and TLR-4 activation. Seven days after burn, TLR-2 and TLR-4 mediated responses by BAL cells were enhanced as evidenced by increased production of IL-6, IL-17, TNF-α, MCP-1, MIP-1β and RANTES. CONCLUSIONS Burn-induced changes in TLR-2 and TLR-4 reactivity may contribute to the development of post-burn complications, such as acute lung injury (ALI) and adult respiratory distress syndrome (ARDS).
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Affiliation(s)
- Richard F Oppeltz
- Department of Surgery, The University of Texas Health Science Center, San Antonio, TX 78229, USA.
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