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Greenhalgh DG. Current Thoughts on Burn Resuscitation. Adv Surg 2024; 58:1-17. [PMID: 39089770 DOI: 10.1016/j.yasu.2024.04.001] [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: 08/04/2024]
Abstract
The optimal treatment of burn shock is still unresolved. The problem of "fluid creep" continues despite modern devices that fail to improve outcomes over hourly urine output. Colloids, especially albumin, reduce fluid requirements. Albumin can be used either immediately at the start of resuscitation, or as a "rescue" when crystalloid use is excessive. Several studies confirm that when crystalloid resuscitation is "out of control" the majority of caregivers will add albumin to reduce fluid rates. A multi-center trial is underway comparing crystalloids with albumin to confirm the benefit of colloids. The next question is whether albumin or plasma is as the better colloid choice.
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Affiliation(s)
- David G Greenhalgh
- Burn Department, Shriners Children's Northern California, 2425 Stockton Boulevard, Sacramento, CA 95817, USA; Emeritus, Department of Surgery, University of California, Davis, CA, USA.
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Greenhalgh DG, Cartotto R, Taylor SL, Fine JR, Lewis GM, Smith DJ, Marano MA, Gibson A, Wibbenmeyer LA, Holmes JH, Rizzo JA, Foster KN, Khandelwal A, Fischer S, Hemmila MR, Hill D, Aballay AM, Tredget EE, Goverman J, Phelan H, Jimenez CJ, Baldea A, Sood R. Burn Resuscitation Practices in North America: Results of the Acute Burn ResUscitation Multicenter Prospective Trial (ABRUPT). Ann Surg 2023; 277:512-519. [PMID: 34417368 PMCID: PMC8857312 DOI: 10.1097/sla.0000000000005166] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES ABRUPT was a prospective, noninterventional, observational study of resuscitation practices at 21 burn centers. The primary goal was to examine burn resuscitation with albumin or crystalloids alone, to design a future prospective randomized trial. SUMMARY BACKGROUND DATA No modern prospective study has determined whether to use colloids or crystalloids for acute burn resuscitation. METHODS Patients ≥18 years with burns ≥ 20% total body surface area (TBSA) had hourly documentation of resuscitation parameters for 48 hours. Patients received either crystalloids alone or had albumin supplemented to crystalloid based on center protocols. RESULTS Of 379 enrollees, two-thirds (253) were resuscitated with albumin and one-third (126) were resuscitated with crystalloid alone. Albumin patients received more total fluid than Crystalloid patients (5.2 ± 2.3 vs 3.7 ± 1.7 mL/kg/% TBSA burn/24 hours), but patients in the Albumin Group were older, had larger burns, higher admission Sequential Organ Failure Assessment (SOFA) scores, and more inhalation injury. Albumin lowered the in-to-out (I/O) ratio and was started ≤12 hours in patients with the highest initial fluid requirements, given >12 hours with intermediate requirements, and avoided in patients who responded to crystalloid alone. CONCLUSIONS Albumin use is associated with older age, larger and deeper burns, and more severe organ dysfunction at presentation. Albumin supplementation is started when initial crystalloid rates are above expected targets and improves the I/O ratio. The fluid received in the first 24 hours was at or above the Parkland Formula estimate.
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Affiliation(s)
- David G. Greenhalgh
- Department of Surgery, University of California, Davis School of Medicine and Shriners Hospitals for Children Northern California, Sacramento, CA
| | - Robert Cartotto
- Department of Surgery, Sunnybrook Medical Center, Toronto, Ontario
| | - Sandra L. Taylor
- Department of Public Health Sciences, School of Medicine, University of California, Davis, Sacramento, CA
| | - Jeffrey R. Fine
- Department of Public Health Sciences, School of Medicine, University of California, Davis, Sacramento, CA
| | | | - David J. Smith
- Department of Surgery, University of South Florida, Tampa, FL
| | | | - Angela Gibson
- Department of Surgery, University of Wisconsin, Madison, WI
| | | | - James H. Holmes
- Department of Surgery, Wake Forrest University, Winston-Salem, NC
| | - Julie A. Rizzo
- Department of Surgery, Institute of Surgical Research, San Antonio, TX
| | | | | | - Sarah Fischer
- Department of Surgery, Ascension Via Christi St. Francis, Wichita, KS
| | - Mark R. Hemmila
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - David Hill
- Department of Pharmacy, University of Tennessee Health Science Center, Memphis, TN
| | | | - Edward E. Tredget
- Department of Plastic Surgery, University of Alberta, Edmonton, Alberta
| | - Jeremy Goverman
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Herbert Phelan
- Department of Surgery, University of Texas, Southwestern Medical Center, Dallas, TX
| | - Carlos J. Jimenez
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Anthony Baldea
- Department of Surgery, University of Loyola, Maywood, IL
| | - Rajiv Sood
- Department of Plastic Surgery, University of Indiana, Indianapolis, IN
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Made in Germany: A Quality Indicator Not Only in the Automobile Industry But Also When It Comes to Skin Replacement: How an Automobile Textile Research Institute Developed a New Skin Substitute. ACTA ACUST UNITED AC 2021; 57:medicina57020143. [PMID: 33562479 PMCID: PMC7914466 DOI: 10.3390/medicina57020143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 01/26/2021] [Accepted: 01/27/2021] [Indexed: 11/17/2022]
Abstract
Successful research and development cooperation between a textile research institute, the German Federal Ministry of Education and Research via the Center for Biomaterials and Organ Substitutes, the University of Tübingen, and the Burn Center of Marienhospital, Stuttgart, Germany, led to the development of a fully synthetic resorbable temporary epidermal skin substitute for the treatment of burns, burn-like syndromes, donor areas, and chronic wounds. This article describes the demands of the product and the steps that were taken to meet these requirements. The material choice was based on the degradation and full resorption of polylactides to lactic acid and its salts. The structure and morphology of the physical, biological, and degradation properties were selected to increase the angiogenetic abilities, fibroblasts, and extracellular matrix generation. Water vapor permeability and plasticity were adapted for clinical use. The available scientific literature was screened for the use of this product. A clinical application demonstrated pain relief paired with a reduced workload, fast wound healing with a low infection rate, and good cosmetic results. A better understanding of the product's degradation process explained the reduction in systemic oxidative stress shown in clinical investigations compared to other dressings, positively affecting wound healing time and reducing the total area requiring skin grafts. Today, the product is in clinical use in 37 countries. This article describes its development, the indications for product growth over time, and the scientific foundation of treatments.
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Intubation in burns patients: a 5-year review of the Manchester regional burns centre experience. Burns 2020; 47:576-586. [PMID: 32861535 DOI: 10.1016/j.burns.2020.07.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/16/2020] [Accepted: 07/24/2020] [Indexed: 12/14/2022]
Abstract
Despite criteria to guide intubation from the American Burn Association (ABA), concerns remain regarding over-intubation of burns patients. The purpose of this study was to review appropriateness of intubation at a UK regional burns centre over a 5-year period. A 5-year retrospective review of adult patients admitted to the Manchester Burns Centre who underwent intubation at or prior to admission was performed. Intubations for non-burn indications or burns >40%TBSA were excluded. Patient demographic and burn characteristics data were extracted from medical records. Indications for intubation were compared to ABA and Denver criteria. 47 patients were identified, of which 40 met inclusion criteria for analysis. 72.5% and 95% of these patients met ABA or Denver criteria respectively. 30.8% of patients were extubated within 48 h. 50% patients extubated within 48 h had ≤1 indication for intubation or negative laryngoscopy. Complications related to intubation and ventilation were noted in 37.5% of patients, with ventilation associated pneumonia (VAP) being the most common occurring in 27.5%. 95% of patients fulfilled recognised criteria for intubation. However, 30% were extubated within 48 h, suggesting potentially avoidable intubation. This study suggests current intubation criteria may over-estimate risk of airway compromise and supports results from non-UK studies that a proportion of patients may be suitable for close observation rather than early intubation.
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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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Lip HTC, Idris MAM, Imran FH, Azmah TN, Huei TJ, Thomas M. Predictors of mortality and validation of burn mortality prognostic scores in a Malaysian burns intensive care unit. BMC Emerg Med 2019; 19:66. [PMID: 31699024 PMCID: PMC6839226 DOI: 10.1186/s12873-019-0284-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 10/24/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Majority burn mortality prognostic scores were developed and validated in western populations. The primary objective of this study was to evaluate and identify possible risk factors which may be used to predict burns mortality in a local Malaysian burns intensive care unit. The secondary objective was to validate the five well known burn prognostic scores (Baux score, Abbreviated Burn Severity Index (ABSI) score, Ryan score, Belgium Outcome Burn Injury (BOBI) score and revised Baux score) to predict burn mortality prediction. METHODS Patients that were treated at the Hospital Sultan Ismail's Burns Intensive Care (BICU) unit for acute burn injuries between 1 January 2010 to 31 December 2017 were included. Risk factors to predict in-patient burn mortality were gender, age, mechanism of injury, total body surface area burn (TBSA), inhalational injury, mechanical ventilation, presence of tracheotomy, time from of burn injury to BICU admission and initial centre of first emergency treatment was administered. These variables were analysed using univariate and multivariate analysis for the outcomes of death. All patients were scored retrospectively using the five-burn mortality prognostic scores. Predictive ability for burn mortality was analysed using the area under receiver operating curve (AUROC). RESULTS A total of 525 patients (372 males and 153 females) with mean age of 34.5 ± 14.6 years were included. There were 463 survivors and 62 deaths (11.8% mortality rate). The outcome of the primary objective showed that amongst the burn mortality risk factors that remained after multivariate analysis were older age (p = 0.004), wider TBSA burn (p < 0.001) and presence of mechanical ventilation (p < 0.001). Outcome of secondary objective showed good AUROC value for the prediction of burn death for all five burn prediction scores (Baux score; AUROC:0.9, ABSI score; AUROC:0.92, Ryan score; AUROC:0.87, BOBI score; AUROC:0.91 and revised Baux score; AUROC:0.94). The revised Baux score had the best AUROC value of 0.94 to predict burns mortality. CONCLUSION Current study evaluated and identified older age, total body surface area burns, and mechanical ventilation as significant predictors of burn mortality. In addition, the revised Baux score was the most accurate burn mortality risk score to predict mortality in a Malaysian burn's population.
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Affiliation(s)
- Henry Tan Chor Lip
- Department of General Surgery, Hospital Sultanah Aminah, Johor Bahru, Malaysia. .,Department of Surgery, Pusat Perubatan Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia.
| | - Mohamad Azim Md Idris
- Department of Surgery, Pusat Perubatan Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Farrah-Hani Imran
- Department of Surgery, Pusat Perubatan Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Tuan Nur' Azmah
- Department of General Surgery, Hospital Sultanah Aminah, Johor Bahru, Malaysia
| | - Tan Jih Huei
- Department of General Surgery, Hospital Sultanah Aminah, Johor Bahru, Malaysia.,Department of Surgery, Pusat Perubatan Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Mathew Thomas
- Department of General Surgery, Hospital Sultan Ismail, Johor Bahru, Malaysia
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Cachafeiro Fuciños L, Sánchez Sánchez M, García de Lorenzo Y Mateos A. Mechanical ventilation in critically ill burn patient with inhalation injury: Can we avoid it? Med Intensiva 2019; 44:54-56. [PMID: 30971340 DOI: 10.1016/j.medin.2019.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 02/26/2019] [Accepted: 02/28/2019] [Indexed: 10/27/2022]
Affiliation(s)
- L Cachafeiro Fuciños
- Grupo de trabajo Disfunción y fallo orgánico en la agresión, Servicio de Medicina Intensiva, Hospital Universitario La Paz, Instituto de Investigación Hospital Universitario La Paz (IdiPaz), Madrid, España.
| | - M Sánchez Sánchez
- Grupo de trabajo Disfunción y fallo orgánico en la agresión, Servicio de Medicina Intensiva, Hospital Universitario La Paz, Instituto de Investigación Hospital Universitario La Paz (IdiPaz), Madrid, España
| | - A García de Lorenzo Y Mateos
- Grupo de trabajo Disfunción y fallo orgánico en la agresión, Servicio de Medicina Intensiva, Hospital Universitario La Paz, Instituto de Investigación Hospital Universitario La Paz (IdiPaz), Madrid, España
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Gigengack RK, van Baar ME, Cleffken BI, Dokter J, van der Vlies CH. Burn intensive care treatment over the last 30 years: Improved survival and shift in case-mix. Burns 2019; 45:1057-1065. [PMID: 30837205 DOI: 10.1016/j.burns.2019.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 02/01/2019] [Accepted: 02/07/2019] [Indexed: 12/21/2022]
Abstract
PURPOSE Mortality in burn intensive care unit (ICU) has been decreasing and treatment appears to be changing. The aims of this study: (1) examine outcome in burn patients, (2) examine changes in ICU indication and (3) explore the influence of a changing case-mix. METHODS Retrospective study in patients admitted to ICU (1987-2016). Four groups were specified: major burns (≥15% TBSA), inhalation injury with small injury (<15% TBSA, inhalation injury), watchful waiting (<15% TBSA, without inhalation injury), tender loving care (patients withheld from treatment). Logistic regression was performed to evaluate the relation between case-mix and outcome. RESULTS Overall mortality decreased to 7%. Mortality of major burns decreased by 15%. The major burn group decreased by 36%. The inhalation injury and watchful waiting group increased by 9% and 21%. The percentage of ventilated patients increased by 14% in the major burn group. 40% of patients were ventilated in the watchful waiting group. CONCLUSIONS After correction for case-mix, survival improved, mainly in the major burn group. Case-mix shifted towards inhalation injury and watchful waiting. Growth of the watchful waiting group is not necessarily harmful. However, the increase of mechanical ventilation could be. We suggest raising awareness for risks and consequences of mechanical ventilation.
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Affiliation(s)
- Rolf K Gigengack
- Department of Trauma and Burn Surgery, Maasstad Hospital, Maasstadweg 21, 3079 DZ Rotterdam, The Netherlands; Department of Anesthesiology, Amsterdam UMC, Location VU Medical Center, Boelelaan 1117, 1081HV Amsterdam, The Netherlands.
| | - Margriet E van Baar
- Association of Dutch Burn Centers, Maasstad Hospital, Maasstadweg 21, 3079 DZ Rotterdam, The Netherlands; Department of Public Health, Erasmus MC, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
| | - Berry I Cleffken
- Department of Trauma and Burn Surgery, Maasstad Hospital, Maasstadweg 21, 3079 DZ Rotterdam, The Netherlands; Department of Intensive Care Medicine, Maasstad Hospital, Maasstadweg 21, 3079 DZ Rotterdam, The Netherlands.
| | - Jan Dokter
- Department of Trauma and Burn Surgery, Maasstad Hospital, Maasstadweg 21, 3079 DZ Rotterdam, The Netherlands.
| | - Cornelis H van der Vlies
- Department of Trauma and Burn Surgery, Maasstad Hospital, Maasstadweg 21, 3079 DZ Rotterdam, The Netherlands; Association of Dutch Burn Centers, Maasstad Hospital, Maasstadweg 21, 3079 DZ Rotterdam, The Netherlands; Trauma Research Unit Department of Surgery, Erasmus MC, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
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Garside TL, Lee RP, Delaney A, Milliss D. Clinical Practice Variation in Acute Severe Burn Injury. Anaesth Intensive Care 2018; 46:321-325. [DOI: 10.1177/0310057x1804600310] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The New South Wales (NSW) Statewide Burn Injury Service Database was reviewed to identify variations in clinical practice with respect to care of severely burn-injured patients in intensive care. We compared differences in practice relating to duration of endotracheal intubation and surgical grafting. In this retrospective observational study, we reviewed all intensive care unit (ICU) admissions to the two NSW adult burns centres, ICU A and ICU B, between January 2008 and December 2015. Data were analysed for association between duration of intubation and outcome. There were 855 admissions to adult ICU, with a significant difference in the percentage total body surface area (% TBSA) of burn and inhalation injury between patients in the two units. There was a significant difference in duration of intubation and ICU length of stay (LOS) between the units, which persisted when adjusted for age, % TBSA and inhalational injury. When analysing patients with more severe burns (>20% TBSA or intubated), the difference in duration of intubation remained significant (median of three days [interquartile range, IQR, 1–11 days] in A and 2 days [IQR 1–6 days] in B, P=0.003) as did ICU LOS (median 3 days [IQR 2–11 days] for A and 2 days [IQR 1–6 days] for B, P <0.0005). There was no significant difference in mortality between the two units for the severe or the more severe subgroup of burns when adjusted for age, % TBSA and inhalational injury (adjusted odds ratio, OR, for mortality 1.17 [95% confidence intervals 0.6 to 2.3, P=0.65]). There were significant differences in clinical practice, including duration of intubation, between the two ICUs. Longer intubation was associated with a longer ICU LOS, but was not associated with a difference in mortality. Large collaborative, prospective multicentre studies in severe burns are needed to identify best practice and variations in practice to determine if they are associated with increased mortality and/or cost.
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Affiliation(s)
- T. L. Garside
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, New South Wales
| | - R. P. Lee
- Intensivist, Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, New South Wales
| | - A. Delaney
- Intensivist, Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, New South Wales
| | - D. Milliss
- Intensivist and Former Director, Intensive Care Services, Concord Hospital, Sydney, New South Wales
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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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Abstract
This article summarizes research conducted over the last decade in the field of inhalation injury in thermally injured patients. This includes brief summaries of the findings of the 2006 State of the Science meeting with regard to inhalation injury, and of the subsequent 2007 Inhalation Injury Consensus Conference. The reviewed studies are categorized in to five general areas: diagnosis and grading; mechanical ventilation; systemic and inhalation therapy; mechanistic alterations; and outcomes.
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Clinical outcomes after burns in elderly patients over 70 years: A 17-year retrospective analysis. Burns 2018; 44:65-69. [DOI: 10.1016/j.burns.2017.09.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 08/27/2017] [Accepted: 09/17/2017] [Indexed: 11/18/2022]
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Cleland H, Greenwood JE, Wood FM, Read DJ, Wong She R, Maitz P, Castley A, Vandervord JG, Simcock J, Adams CD, Gabbe BJ. The Burns Registry of Australia and New Zealand: progressing the evidence base for burn care. Med J Aust 2016; 204:1951e-7. [PMID: 26985850 DOI: 10.5694/mja15.00989] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 01/06/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Analysis of data from the Burns Registry of Australia and New Zealand (BRANZ) to determine the extent of variation between participating units in treatment and in specific outcomes during the first 4 years of its operation. DESIGN BRANZ, an initiative of the Australian and New Zealand Burn Association, is a clinical quality registry developed in accordance with the Australian Commission on Safety and Quality in Healthcare national operating principles. SETTING Patients with burn injury who fulfil pre-defined criteria are transferred to and managed in designated burn units. There are 17 adult and paediatric units in Australia and New Zealand that manage almost all patients with significant burn injury. Twelve of these units treat adult patients. PARTICIPANTS Data on 7184 adult cases were contributed by ten acute adult burn units to the registry between July 2010 and June 2014.Major outcomes: In-hospital mortality, hospital length of stay, skin grafting rates, and rates of admission to intensive care units. RESULTS Considerable variations in unit profiles (including numbers of patients treated), in treatment and in outcomes were identified. CONCLUSIONS Despite the highly centralised delivery of care to patients with severe or complex burn injury, and the relatively small number of specialist burn units, we found significant variation between units in clinical management and in outcomes. BRANZ data from its first 4 years of operation support its feasibility and the value of further development of the registry. Based on these results, the focus of ongoing research is to improve understanding of the reasons for variations in practice and of their effect on outcomes for patients, and to develop evidence-informed clinical guidelines for burn management in Australia and New Zealand.
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Affiliation(s)
| | | | | | - David J Read
- National Critical Care and Trauma Response Centre, Royal Darwin Hospital, Darwin, NT
| | - Richard Wong She
- Auckland Regional Centre for Plastic Reconstructive and Hand Surgery, Auckland, New Zealand
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Walker PF, Buehner MF, Wood LA, Boyer NL, Driscoll IR, Lundy JB, Cancio LC, Chung KK. Diagnosis and management of inhalation injury: an updated review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:351. [PMID: 26507130 PMCID: PMC4624587 DOI: 10.1186/s13054-015-1077-4] [Citation(s) in RCA: 127] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In this article we review recent advances made in the pathophysiology, diagnosis, and treatment of inhalation injury. Historically, the diagnosis of inhalation injury has relied on nonspecific clinical exam findings and bronchoscopic evidence. The development of a grading system and the use of modalities such as chest computed tomography may allow for a more nuanced evaluation of inhalation injury and enhanced ability to prognosticate. Supportive respiratory care remains essential in managing inhalation injury. Adjuncts still lacking definitive evidence of efficacy include bronchodilators, mucolytic agents, inhaled anticoagulants, nonconventional ventilator modes, prone positioning, and extracorporeal membrane oxygenation. Recent research focusing on molecular mechanisms involved in inhalation injury has increased the number of potential therapies.
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Affiliation(s)
- Patrick F Walker
- Department of Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD, 20889, USA
| | - Michelle F Buehner
- Department of General Surgery, San Antonio Military Medical Center, 3551 Roger Brooke Dr., Fort Sam Houston, TX, 78234, USA.
| | - Leslie A Wood
- Department of Medicine, San Antonio Military Medical Center, 3551 Roger Brooke Dr., Fort Sam Houston, TX, 78234, USA
| | - Nathan L Boyer
- Department of Medicine, San Antonio Military Medical Center, 3551 Roger Brooke Dr., Fort Sam Houston, TX, 78234, USA
| | - Ian R Driscoll
- United States Army Institute of Surgical Research, Fort Sam Houston, TX, 78234, USA
| | - Jonathan B Lundy
- United States Army Institute of Surgical Research, Fort Sam Houston, TX, 78234, USA
| | - Leopoldo C Cancio
- United States Army Institute of Surgical Research, Fort Sam Houston, TX, 78234, USA
| | - Kevin K Chung
- United States Army Institute of Surgical Research, Fort Sam Houston, TX, 78234, USA.,Department of Surgery, Uniformed Services University of the Health Sciences, Building A, 4301 Jones Bridge Rd, Bethesda, MD, 20814, USA
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Seo DK, Kym D, Yim H, Yang HT, Cho YS, Kim JH, Hur J, Chun W. Epidemiological trends and risk factors in major burns patients in South Korea: A 10-year experience. Burns 2015; 41:181-7. [DOI: 10.1016/j.burns.2014.05.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 05/05/2014] [Accepted: 05/06/2014] [Indexed: 10/25/2022]
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Wolf SE, Phelan HA, Arnoldo BD. The year in burns 2013. Burns 2014; 40:1421-32. [PMID: 25454722 DOI: 10.1016/j.burns.2014.10.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 10/31/2014] [Indexed: 12/22/2022]
Abstract
Approximately 3415 research articles were published with burns in the title, abstract, and/or keyword in 2013. We have continued to see an increase in this number; the following reviews articles selected from these by the Editor of one of the major journals (Burns) and colleagues that in their opinion are most likely to have effects on burn care treatment and understanding. As we have done before, articles were found and divided into the following topic areas: epidemiology of injury and burn prevention, wound and scar characterization, acute care and critical care, inhalation injury, infection, psychological considerations, pain and itching management, rehabilitation and long-term outcomes, and burn reconstruction. The articles are mentioned briefly with notes from the authors; readers are referred to the full papers for details.
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Affiliation(s)
- Steven E Wolf
- Division of Burn, Trauma, and Critical Care, Department of Surgery, University of Texas - Southwestern Medical Center, United States.
| | - Herbert A Phelan
- Division of Burn, Trauma, and Critical Care, Department of Surgery, University of Texas - Southwestern Medical Center, United States
| | - Brett D Arnoldo
- Division of Burn, Trauma, and Critical Care, Department of Surgery, University of Texas - Southwestern Medical Center, United States
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You K, Yang HT, Kym D, Yoon J, HaejunYim, Cho YS, Hur J, Chun W, Kim JH. Inhalation injury in burn patients: establishing the link between diagnosis and prognosis. Burns 2014; 40:1470-5. [PMID: 25406889 DOI: 10.1016/j.burns.2014.09.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Revised: 09/13/2014] [Accepted: 09/16/2014] [Indexed: 01/10/2023]
Abstract
This study was to re-evaluate inhalation injury as a prognostic factor in burn patients and to determine the factors that should be considered when refining the definition of inhalation injury. A total of 192 burn patients (152 men, 40 women; mean age, 46.1±13.8 years) who were suspected to have an inhalation injury and underwent bronchoscopy between January 2010 and June 2012 were included in this prospective observational study. All patients underwent bronchoscopy within 24h of sustaining the burn. The bronchoscopic findings were classified as normal, mild, moderate, and severe. Mechanical ventilation was administered, when required. Age, percentage of TBSA burned, ABSI score, requirement of mechanical ventilation and PF ratio, but not inhalation injury, COHb level, and bronchoscopic grades, significantly differed between the survivors and non-survivors (p<0.05). Mechanical ventilation (adjusted odds ratio [OR]: 9.787) and severe inhalation injury on bronchoscopy (adjusted OR: 45.357) were independent predictors of mortality on multivariate logistic regression analysis. Inhalation injury diagnosed through history does not predict mortality from burns. Other components such as severity of inhalation injury determined using bronchoscopy, and administration of mechanical ventilation might help predict the morbidity and mortality of burn patients with inhalation injury and all of the factors should be considered when the definition of inhalation injury is refined.
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Affiliation(s)
- Kicheol You
- Department of Emergency Medicine, Burn Center, Hangang Sacred Heart Hospital, College of Medicine, Hallym University, 12, Beodeunaru-ro 7-gil (Youngdeungpo-dong 2-ga), Youngdeungpo-gu, Seoul 150-719, Republic of Korea
| | - Hyeong-Tae Yang
- Department of Surgery, Burn Center, Hangang Sacred Heart Hospital, College of Medicine, Hallym University, 12, Beodeunaru-ro 7-gil (Youngdeungpo-dong 2-ga), Youngdeungpo-gu, Seoul 150-719, Republic of Korea; Department of Surgery, Kangwon National University College of Medicine, Kangwondaehak 1 gil, Chuncheon-si, Gangwon-do 200-701, Republic of Korea
| | - Dohern Kym
- Department of Surgery, Burn Center, Hangang Sacred Heart Hospital, College of Medicine, Hallym University, 12, Beodeunaru-ro 7-gil (Youngdeungpo-dong 2-ga), Youngdeungpo-gu, Seoul 150-719, Republic of Korea.
| | - Jaechul Yoon
- Department of Surgery, Burn Center, Hangang Sacred Heart Hospital, College of Medicine, Hallym University, 12, Beodeunaru-ro 7-gil (Youngdeungpo-dong 2-ga), Youngdeungpo-gu, Seoul 150-719, Republic of Korea
| | - HaejunYim
- Department of Surgery, Burn Center, Hangang Sacred Heart Hospital, College of Medicine, Hallym University, 12, Beodeunaru-ro 7-gil (Youngdeungpo-dong 2-ga), Youngdeungpo-gu, Seoul 150-719, Republic of Korea
| | - Yong-Suk Cho
- Department of Surgery, Burn Center, Hangang Sacred Heart Hospital, College of Medicine, Hallym University, 12, Beodeunaru-ro 7-gil (Youngdeungpo-dong 2-ga), Youngdeungpo-gu, Seoul 150-719, Republic of Korea
| | - Jun Hur
- Department of Surgery, Burn Center, Hangang Sacred Heart Hospital, College of Medicine, Hallym University, 12, Beodeunaru-ro 7-gil (Youngdeungpo-dong 2-ga), Youngdeungpo-gu, Seoul 150-719, Republic of Korea
| | - Wook Chun
- Department of Surgery, Burn Center, Hangang Sacred Heart Hospital, College of Medicine, Hallym University, 12, Beodeunaru-ro 7-gil (Youngdeungpo-dong 2-ga), Youngdeungpo-gu, Seoul 150-719, Republic of Korea
| | - Jong-Hyun Kim
- Department of Surgery, Burn Center, Hangang Sacred Heart Hospital, College of Medicine, Hallym University, 12, Beodeunaru-ro 7-gil (Youngdeungpo-dong 2-ga), Youngdeungpo-gu, Seoul 150-719, Republic of Korea
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18
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Toussaint J, Singer AJ. The evaluation and management of thermal injuries: 2014 update. Clin Exp Emerg Med 2014; 1:8-18. [PMID: 27752547 PMCID: PMC5052819 DOI: 10.15441/ceem.14.029] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Revised: 08/21/2014] [Accepted: 08/28/2014] [Indexed: 11/23/2022] Open
Abstract
Burns are among the most common injuries presenting to the emergency department. While burns, especially large ones, may be associated with significant morbidity and mortality, most are minor and can be managed by emergency practitioners and discharged home with close follow-up. In contrast, patients with large burns require aggressive management of their airway, breathing and circulation in order to reduce mortality and morbidity. While early endotracheal intubation of patients with actual or impending airway compromise and aggressive fluid resuscitation have been emphasized, it appears that the pendulum may have swung a bit too far towards the extreme. The current review will briefly cover the epidemiology, pathogenesis and diagnosis of burn injuries with greater emphasis on airway and fluid management. We will also discuss the local management of the burn wound, which is all that is required for most burn patients in the emergency department.
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Affiliation(s)
- Jimmy Toussaint
- Department of Emergency Medicine, Stony Brook University, Stony Brook, NY, USA
| | - Adam J Singer
- Department of Emergency Medicine, Stony Brook University, Stony Brook, NY, USA
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