The ABSI is dead, long live the ABSI - reliable prediction of survival in burns with a modified Abbreviated Burn Severity Index

The prognostic relevance of full-thickness burns on ABSI

INTRODUCTION

The Abbreviated Burn Severity Index (ABSI) by Tobiasen, which is commonly used to estimate the mortality risk of severely burned patients, calculates an additional point for the existence of full-thickness (third-degree) burns. [1] However, the score does not consider the extent of the body surface affected by third-degree burns. To understand whether there is a way to improve ABSI prediction power, this study aims to determine the influence of full-thickness burns on survival rates and how it affects the predictive precision of the ABSI.

MATERIAL AND METHODS

In this study, the statistical evaluation of 2538 patients collected prospectively in the context of the German Burn Registry was carried out. A linear regression analysis was carried out to show the prognostic relevance of full-thickness burns. Age, sex, total body surface area burned (TBSA), and the presence of inhalation injury were also observed as further influencing factors.

RESULTS

Among the 2538 patients meeting our inclusion criteria, full-thickness burns were found in 1233 patients. In patients with a TBSA below 20 %, the extent of full-thickness burns is not relevant to the prognosis in terms of survival probability (p = 0.124). With more than 20 % TBSA, the extent of third-degree burns is of significant relevance (p = 0.000). In patients without full-thickness burns and calculated ABSI values ≥ 12 the survival rate of 46 % was noticeably better than the predicted survival rate of < 10 % according to the ABSI Score, whereas the predicted survival rate in patients with third-degree burns (< 10 %), closely matched the observed survival rate of 11 %.

CONCLUSION

For patients with a TBSA < 20 %, the presence of full-thickness burns is not relevant for survival. In contrast to this observation, the percentage of full-thickness burns is of crucial prognostic importance for patients with a TBSA of > 20 %. By adjusting the ABSI and taking into account the exact percentage of third-degree burns, an improvement in the prognostic precision of the score could be achieved.

Epidemiology and first aid measures in pediatric burn patients in northern China during 2016-2020: A single-center retrospective study

Background and Aims

Burn and scald injuries are the fourth most common type of trauma. Pediatric burns account for a high proportion of the total number of burn patients and impose a high burden on public health. Understanding the epidemiology of pediatric burns can help improve science education and reduce the incidence of burn injuries.

Methods

This study is a single-center retrospective study. One thousand five hundred and twenty-seven pediatric burn patients admitted to our burn center from January 2016 to December 2020 were included. Demographic and epidemiological data of included patients were extracted and analyzed. The correlations of categorical data were tested by the Chi-square tests, and differences of continuous data were tested by the Kruskal-Wallis tests. A p-value of less than 0.05 was considered to be statistically significant.

Results

The results showed that children under 3 years of age were most susceptible to burn and scald injuries. Burn injuries were most likely to occur in the season of winter and at the place of home. 56.6% of included patients did receive first aid measures, while 1.8% received gold-standard first aid. Clinical variables related to the severity of injuries were statistically different between patients with and without cooling measures in first aid. Linear regression models showed that emergency treatment of burns in children and adolescents was associated with outcome indicators, including number of operations, total operation duration per total burn surface area (TBSA), cost per TBSA, and length of stay per TBSA.

Conclusions

This study summarized the epidemiology and outcomes of pediatric burn patients admitted to a burn center in northern China. Adopting cooling measures in first aid can reduce the severity of injuries and reduce the burden on the medical system. Education on burn prevention and first aid measures to caregivers of children, especially preschool children, should be strengthened.

Revalidating the prognostic relevance of the Abbreviated Burn Severity Index (ABSI): A twenty-year experience examining the performance of the ABSI score in consideration of progression and advantages of burn treatments from a single center in Vienna

BACKGROUND

The Abbreviated Burn Severity Index (ABSI) is a five-variable scale to help evaluate burn severity upon initial assessment. As other studies have been conducted with comparatively small patient populations, the purpose of this study is to revalidate the prognostic relevance of the ABSI in our selected population (N = 1193) 4 decades after its introduction, considering the progress in the treatment of severe burn injuries over the past decades. In addition, we evaluate whether comorbidities influence the survival probability of severely burned patients.

METHODS

This retrospective study presents data from the Center for Severely Burned Patients of the General Hospital in Vienna. We included 1193 patients for over 20 years. Regression models were used to describe the prognostic accuracy of the ABSI.

RESULTS

The ABSI can still be used as a prognostic factor for the probability of survival of severely burned patients. The odds of passing increases by a factor of 2.059 for each unit increase in the ABSI with an area under the curve value of 0.909. Over time, the likelihood of survival increased. The existence of chronic kidney disease negatively impacts the survival probability of severely burned patients.

CONCLUSION

The ABSI can still be used to provide accurate information about the chances of survival of severely burned patients; however, further exploration of the impact of chronic kidney disease on the survival probability and adding variables to the ABSI scale should be considered. The probability of survival has increased over the last 20 years.

Chronic kidney disease and cardiovascular disease reduce survival rates after burn injury: A retrospective study over 20 years

BACKGROUND

The Abbreviated Burn Severity Index and comparable scores are used to assess the probability of survival in burned patients. These scores may be useful during the initial management of the patient and in addition to the clinical evaluation. As current models do not include the influence of chronic diseases, we evaluated the impact of comorbidities on survival probability, aiming to improve the existing scoring systems and survival probability accuracy further.

METHODS

In this retrospective single-center study, patient data from a center for Severe Burn Injury were collected. Over a period of 20 years (2000-2019), a total of 1,193 patients were recorded. The influence of comorbidities (chronic kidney disease, diabetes mellitus type II, and cardiovascular diseases) on the survival probability was analyzed using regression models. These analyses were stratified for sex and period.

RESULTS

Pre-existing chronic kidney disease, as well as pre-existing cardiovascular disease, had a significant influence on the survival of patients. For chronic kidney disease, the influence was stronger in men than in women. Women were more likely to survive a burn injury with a history of chronic renal insufficiency. An improved Abbreviated Burn Severity Index model, which assigns an additional point for chronic kidney disease, best-described survival probability in our patient cohort.

CONCLUSION

Cardiovascular disease and chronic kidney disease both have an impact on the survival probability of severely burned patients, but this impact is more severe for chronic kidney disease. An additional Abbreviated Burn Severity Index point for chronic kidney disease would be a proposed adaptation to predict the outcome of burn patients better.

Machine learning models for early prediction of mortality risk in patients with burns: A single center experience

Mortality rate is considered as the most important outcome measure for assessing the severity of burn injury. A scale or model that accurately predicts burn mortality can be useful to determine the clinical course of burn injuries, discuss treatment options and rehabilitation with patients and their families, and evaluate novel, innovative interventions for the injuries. This study aimed to use machine learning models to predict the mortality risk of patients with burns after their first admission to the center and to compare the performances of these models. Overall, 1064 patients hospitalized in burn intensive care and burn service units between 2016 and 2022 were included in the study. In total, 40 parameters, including demographic characteristics and biochemical parameters of all patients, were analyzed in the study. Furthermore, the dataset was randomly divided into two clusters with 70% of the data used for artificial neural networks (ANNs) training and 30% for model success testing. The ANN model proposed in this study showed high success across all machine learning methods tried in different variants, with an accuracy of 95.92% in the test set. Machine learning models can be used to predict the mortality risk of patients with burns. This study may help validate the use of machine learning models for applications in clinical practice. Conducting multicenter studies will further contribute to the literature.

Better among the two for Burn Mortality Prediction in Developing Nations: Revised Baux or Modified Abbreviated Burn Severity Index?

Background

Burns is one of the leading causes of mortality in developing countries like India. Most of the major burns requiring hospital care are not triaged adequately for the use of medical resources. An efficient mortality predicting scale would not only help in better care to those who will benefit the most but also make it easy to explain to patient's attendants. Among the various tools, revised Baux (rBaux) and modified Abbreviated Burn Severity Index (ABSI) are two most commonly used scales in developed nations. We proposed this study to analyze the reliability of these two scoring scales in our burn population.

Aim

This study aimed to retrospectively study the two scoring systems and analyze them for their reliability in predicting mortality compared to actual observed mortality in each case.

Materials and Methods

This study was conducted on all burn patients admitted to the intensive care unit of our hospital. Data on their demographic profile, total burn surface area, thickness of burns, inhalational injury, and other comorbidities were collected from files. rBaux and modified ABSI (mABSI) were calculated. The end result in the form of survival or nonsurvival was also recorded. Appropriate statistical analysis using Mann-Whitney U-test, Chi-square test, and receiver operator characteristic curve was done to look for a better scoring system out of the two.

Results

A total of 504 patients were included in the study, out of which 337 were survivors. Female gender was not a risk factor for mortality in our study. The median rBaux score in the survivor group was 100 (80-110) and in nonsurvivor group was 111 (103-123). The median mABSI score in the survivor group was 8 (7-9) and in nonsurvivor group was 10 (9-11). The area under the receiver operating characteristic curve shows mABSI having better specificity for predicting mortality. rBAUX, though more sensitive, overestimates mortality than actual observed mortality.

Conclusion

mABSI predicts mortality better than rBaux. A multicentric prospective study is recommended for mABSI to be used as a standard mortality predictor in burns in India.

Predictive value of perioperative peripheral blood cells counts for bacteremia and 90-day mortality in severe burn patients

OBJECTIVE

Burn bacteremia is related to immune barrier damage, but whether the level of circulating immune cells predicts outcomes in severe burns is still not clear. This study aimed to explore the predictive value of perioperative blood cells of the first surgery after burn for bacteremia and 90-day death.

METHODS

Data from severe burn patients treated at the First Affiliated Hospital of Sun Yat-sen University from 2011 to 2020 were retrospectively analyzed. Data on monocytes (M), lymphocytes (L), white blood cell-to-platelet ratio (WPR), neutrophil-to-lymphocyte ratio (NLR) in peripheral blood and changes in temperature (T-37) were collected at one day before(X0), the first day after (X1) and the third day after (X3) the primary surgery.Univariate and multivariate logistic regression were used to identify the independent risk factors of bacteremia and death within 90 days, which were used to establish the risk prediction models (xbac and x90d-m) in severely burned patients. Severe burn cases from two other burn centers were selected to verify the prediction models.

RESULTS

We analyzed 169 severe burn cases in the training dataset, with a 90-day mortality of 21.3% (36/169); 56 (33.1%) patients experienced burn bacteremia. Higher M0, WPR0, NLR0, NLR3, T3-37, ∆M (M0-M3) and lower M3, L3 were associated with higher risk of bacteremia (P < 0.05). Multivariate regression analysis showed that SOFA0, WPR0, M3, and T3-37 were independently associated with bacteremia. The prediction model for bacteremia Xbac = 0.1809 × SOFA0 + 6.532 × WPR0-1.171 × M3 + 0.6987 × T3-37- 2.297. TBSAB, SOFA0, and ∆M (M0-M3) were independently correlated with 90-day mortality. The risk prediction model X90d-m= 0.055 × TBSAB + 0.301 ×SOFA0 + 1.508 × ∆M - 7.196. External validation suggested that the specificity, sensitivity and AUC of the prediction model Xbac was 90.7%, 62.5% and 0.797, respectively; of the prediction model X90d-m was 69.2%, 90.0% and 0.873, respectively.

CONCLUSION

Peripheral M3, WPR0 and ∆M (M0-M3) during the primary surgery has reasonable predictive ability for bacteremia and 90-day mortality in severe burn patients, which could inform clinical antimicrobial judgment and prognostication.

Improvement of Predictive Scores in Burn Medicine through Different Machine Learning Approaches

The mortality of severely burned patients can be predicted by multiple scores which have been created over the last decades. As the treatment of burn injuries and intensive care management have improved immensely over the last years, former prediction scores seem to be losing accuracy in predicting survival. Therefore, various modifications of existing scores have been established and innovative scores have been introduced. In this study, we used data from the German Burn Registry and analyzed them regarding patient mortality using different methods of machine learning. We used Classification and Regression Trees (CARTs), random forests, XGBoost, and logistic regression regarding predictive features for patient mortality. Analyzing the data of 1401 patients via machine learning, the factors of full-thickness burns, patient's age, and total burned surface area could be identified as the most important features regarding the prediction of patient mortality following burn trauma. Although the different methods identified similar aspects, application of machine learning shows that more data are necessary for a valid analysis. In the future, the usage of machine learning can contribute to the development of an innovative and precise predictive score in burn medicine and even to further interpretations of relevant data regarding different forms of outcome from the German Burn registry.

The predictive probability of mortality in the presence of full-thickness burns

INTRODUCTION

Prognostication of burn injury mortality is challenging. Recent mortality prognostication tools have incorporated the percent of full-thickness surface area (FTSA). We hypothesize that the presence of full-thickness burn injury independently increases in-hospital mortality.

METHODS

We performed a retrospective review of the National Trauma Data Bank (NTDB) from 2007 to 2019 of adults (≥16 years old) with burn injuries. Variables evaluated included basic demographics, presence of inhalation injury, percent TBSA, and percent FTSA burned. The primary outcome was in-hospital mortality. We performed modified Poisson regression modeling adjusting for significant variables to estimate the relative mortality risk.

RESULTS

75,816 patients met inclusion criteria. When controlling for TBSA, the presence of a full-thickness burn had a relative risk of in-hospital mortality of 1.42 (95% CI 1.09-1.85, p = 0.008). The predicted probability of mortality was 100% at 50% FTSA.

CONCLUSION

The presence of full-thickness burns and the proportion of full-thickness burns independently and significantly increased in-hospital mortality. Therefore, clinicians should utilize prognostication models incorporating percent full-thickness burn area to predict mortality more accurately.

The BUrn Mortality Prediction (BUMP) Score - An improved mortality prediction score based on data of the German burn registry

BACKGROUND

Burn injuries constitute the fourth most common injuries globally. Patient outcomes must be currently assessed to provide appropriate patient care with high quality standards. However, existing mortality prediction scoring methods have been shown to lack accuracy in current burn patient populations. Therefore, this study aimed to validate existing scores using current patient data and assess whether new prediction parameters can provide better accuracy.

METHODS

A retrospective analysis of the patient data from the German Burn Registry between 2016 and 2019 was performed to evaluate all Abbreviated Burn Severity Index (ABSI) score parameters. All patients over 16 years of age who received intensive care were included. Descriptive statistics and logistic regression analysis were used to identify novel prediction parameters based on the parameters documented at admission and establish a new prediction score, the BUrn Mortality Prediction (BUMP) score. The quality of the new score was subsequently compared to that of the original ABSI, modified ABSI, Galeiras, Revised Baux score and TIMM. The new prediction score was then validated using patient data collected in the German Burn Registry in 2020.

RESULTS

In total, 7276 patients were included. Age; the presence of at least two comorbidities; burn injuries caused by work-related accidents, traffic accidents and suicide attempts; total burn surface area; inhalation trauma and full-thickness burns were identified as independent significant predictors of mortality (p < 0.001). Additionally, we evaluated new age groups to improve prediction accuracy. The number of comorbidities (p < 0.001) and the aetiology (burns occurring at work [p = 0.028], burns caused by traffic accidents [p < 0.001] or burns due to attempted suicide [p < 0.001]) had a significant influence on mortality. The BUMP score, which was developed based on these parameters, showed the best fitness and showed more accurate mortality prediction than all the above-mentioned scores (area under the receiver operating characteristic curve: 0.947 [0.939-0.954] compared to 0.926 [0.915-0.936], 0.928 [0.918-0.939], 0.937 [0.928-0.947], 0.939 [0.930-0.948], 0.940 [0.932-0.949] respectively).

CONCLUSIONS

A novel score (BUMP score) was developed for the purpose of external quality assessment of burn centres participating in the German burn registry, where observed and expected outcomes are compared on a hospital level, and for scientifically applications. The clinical impact of this score and its generalisability to other patient populations needs to be evaluated.

Establishment of the German Burn Registry - five years of prospective data collection

BACKGROUND

From 1991-2014, all major burn centers of the German-speaking countries participated in a multicenter study in which essentially demographic data were collected. Individual patient data was located at the particular burn centers and only cumulated data were summarized annually for presentation. Retrospective statistical analysis of the entire data collection and identification of subgroups was not possible. In 2015 the German Burn Registry was established for prospective collection of individual patient data as a tool for quality management (QM) and for scientific analyses.

METHODS

A working group was formed to ensure the development and administration of the registry. From the official start of the German Burn Registry at the beginning of the year 2015 prospective data collection was realized with an individualized, web-based data collection software in a pseudonymized way. Selected data analysis was performed for the first 5 years of data collection. Severely burned adults and all hospitalized children with burn injuries were documented in the registry.

RESULTS

The German Burn Registry was successfully established. 64 burn divisions have already been registered. 18,891 patients were documented over 5 years, of which 58% where children (<16 years). Mean ABSI Score was 4 (children: 3, adults: 6) with a mortality rate of 3.8.0% (children: 0.2%, adults: 9.3%). Children were hospitalized for an average of 7 days, whereas adults were discharged after 18 days.

CONCLUSION

A registry is mandatory for quality assurance in burn medicine, since realization of randomized studies is difficult due to the heterogeneity of burn injuries. The German Burn Registry already is one of the biggest burn registries in Europe. Several scientific projects, based on the registry database, are in working process or have already been published.

Survival and analysis of prognostic factors for severe burn patients with inhalation injury: based on the respiratory SOFA score

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.

Risk Models to Predict Mortality in Burn Patients: A Systematic Review and Meta-analysis

The predictive capability of various risk assessment models (RAMs) in evaluating the risk of mortality in burn patients is not well established. It is also unclear which RAM provides the highest discriminative ability and presents the highest clinical utility. We pooled all available studies to establish this validity and compare the predictive capability of the various RAMs.

Methods

We reviewed PubMed, MEDLINE, and Embase from their inception up until December 2021 for studies evaluating risk of mortality in burn patients as stratified by RAMs. Data were pooled using random-effect models and presented as area under the receiver operating characteristic (AUROC) curve.

Results

Thirty-four studies, comprising of a total of 98,610 patients, were included in our analysis. Most studies were found to have a low risk of bias and a good measure of applicability. Nine RAMs were evaluated. We discovered that the classic Baux; the revised Baux; and the Fatality by Longevity, APACHE II score, Measured Extent of burn, and Sex (FLAMES) scores presented with the highest discriminative power with there being no significant difference between the results presented by them [AUROCs (95% CI), 0.92 (0.90-0.95), 0.92 (0.90-0.93), 0.94 (0.91-0.97), respectively, with P < 0.00001 for all].

Conclusions

Many RAMs exist with no consensus on the optimal model to utilize and assess risk of mortality for burn patients. This study is the first systematic review and meta-analysis to compare the current RAMs' discriminative ability to predict mortality in patients with burn injuries. This meta-analysis demonstrated that RAMs designed for assessing mortality in individuals with burns have acceptable to great discriminative capacity, with the classic Baux, revised Baux, and FLAMES demonstrating superior discriminative performance in predicting death. FLAMES exhibited the highest discriminative ability among the RAMs studied.

Burn Registries State of Affairs: A Scoping review

Registry science allows for the interpretation of disease-specific patient data from secondary databases. It can be utilized to understand disease and injury, answer research questions, and engender benchmarking of quality-of-care indicators. Numerous burn registries exist globally, however, their contributions to burn care have not been summarized. The objective of this study is to characterize the available literature on burn registries. The authors conducted a scoping review, having registered the protocol a priori. A thorough search of the English literature, including grey literature, was carried out. Publications of all study designs were eligible for inclusion provided they utilized, analyzed, and/or critiqued data from a burn registry. Three hundred twenty studies were included, encompassing 16 existing burn registries. The most frequently used registries for peer-reviewed publications were the American Burn Association Burn Registry, Burn Model System National Database, and the Burns Registry of Australia and New Zealand. The main limitations of existing registries are the inclusion of patients admitted to burn centers only, deficient capture of outpatient and long-term outcome data, lack of data standardization across registries, and the paucity of studies on burn prevention and quality improvement methodology. Registries are an invaluable source of information for research, delivery of care planning, and benchmarking of processes and outcomes. Efforts should be made to stimulate other jurisdictions to build burn registries and for existing registries to be improved through data linkage with administrative databases, and by standardizing one international minimum dataset, in order to maximize the potential of registry science in burn care.

The effect of self-inflicted burns on ABSI score prediction power: A four-year prospective multicenter study of the German Burn Registry

BACKGROUND

Suicide attempted by self-inflicted burns are associated with lower survival rates compared to accident related burns.

OBJECTIVE

We investigate the relation between self-inflicted burns (SIB) and survival rates and how this relation is moderated by variables used to predict survival rates in the ABSI score, a widely used measure. Additionally, we compare the predicted survival rates by the ABSI score to the actual rates in our sample for SIB and accident patients.

METHODS

In this prospective multicenter study data from the German Burn Registry are statistically analyzed using two sided t-test and multivariate linear regression models.

RESULTS

5330 patients (214 with SIB) met our inclusion criteria. We find a 6.8 percentage points lower survival rate for patients with SIB when we control for patient condition with the five ABSI components as covariates. These higher mortality rates can be explained by the higher rate of therapy restrictions for patients with self-inflicted burns. Additionally, different ABSI modifications can improve the predictive power of the score.

CONCLUSION

Patients with SIB have lower survival rates compared to accident patients. Recently proposed modifications of the ABSI score can improve the accuracy of survival rate prediction for SIB.

Acute respiratory failure and burn patient outcomes

PURPOSE OF REVIEW

Advances in the care of inhalational injuries have not kept pace with advances that have been seen in the treatment of cutaneous burns. There is not yet a standard of care for best outcomes for airway management of patients with known or suspected inhalational injuries. Clinicians must decide if to intubate the patient, and if so, whether to intubate early or late in their presentation. Unnecessary intubation affects morbidity and mortality. This review will summarize literature that highlights present practices in the treatment of patients with inhalation injuries.

RECENT FINDINGS

There have been promising investigations into biomarkers that can be used to quantify a patient's risk and better target therapies. Grading systems serve to better stratify the burn victim's prognosis and then direct their care. Special ventilator modes can assist in ventilating burn patients with inhalation injuries that experience difficulties in oxygenating.

SUMMARY

Inhalational injuries are a significant source of morbidity and mortality in thermally injured patients. Treatment modalities, such as modified ventilator settings, alteration in fluid resuscitation, and a standardized grading system may improve morbidity and mortality.