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Coston TD, Gaskins D, Bailey A, Minus E, Arbabi S, West TE, Stewart BT. Severity of Inhalation Injury and Risk of Nosocomial Pneumonia: A Retrospective Cohort Study. Chest 2024:S0012-3692(24)04572-0. [PMID: 38964672 DOI: 10.1016/j.chest.2024.06.3770] [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: 12/21/2023] [Revised: 06/12/2024] [Accepted: 06/16/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND The impact of inhalation injury on risk of nosocomial pneumonia (NP), an important complication in patients with burns, is not well established. RESEARCH QUESTION Is more severe inhalation injury associated with increased risk of NP? STUDY DESIGN AND METHODS We performed a retrospective cohort study of patients with suspected inhalation injury admitted to a regional burn center from 2011 to 2022 who underwent diagnostic bronchoscopy within 48 h of admission. We estimated the association of high-grade inhalation injury (Abbreviated Injury Scale score 3 and 4) vs low-grade inhalation injury (Abbreviated Injury Scale score 1 and 2) with NP adjusted for age, burn size, and comorbid obstructive lung disease. Death and hospital discharge were considered competing risks. RESULTS Of the 245 patients analyzed, 51 (21%) had high-grade injury, 180 (73%) had low-grade injury, and 14 (6%) had no inhalation injury. Among the 236 patients hospitalized for ≥ 48 h, NP occurred in 24 of 50 patients (48%) in the high-grade group, 54 of 172 patients (31%) in the low-grade group, and two of 14 patients (14%) in the no inhalation injury group. High-grade (vs low-grade) inhalation injury was associated with higher hazard of NP in both the proportional cause-specific hazard model (cause-specific hazard ratio, 2.04; 95% CI, 1.26-3.30; P = .004) and Fine-Gray subdistribution hazard model (subdistribution hazard ratio for NP, 2.24; 95% CI, 1.38-3.64; P = .001). INTERPRETATION Among patients with inhalation injury, more severe injury was associated with higher hazard of NP in competing risk analysis. Additional research is needed to investigate mechanisms that may explain the relationship between inhalation injury and NP and to identify more effective risk reduction strategies.
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Affiliation(s)
- Taylor D Coston
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Devin Gaskins
- University of Washington School of Medicine, Seattle, WA
| | - Austin Bailey
- University of Washington School of Medicine, Seattle, WA
| | - Emily Minus
- Department of Biostatistics, University of Washington School of Public Health, Seattle, WA
| | - Saman Arbabi
- Division of Trauma, Critical Care, and Burn, Department of Surgery, University of Washington, Seattle, WA
| | - T Eoin West
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Barclay T Stewart
- Division of Trauma, Critical Care, and Burn, Department of Surgery, University of Washington, Seattle, WA.
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Tuncer HB, Akın M, Çakırca M, Erkılıç E, Yıldız HF, Yastı AÇ. Do pre-burn center management algorithms work? Evaluation of pre-admission diagnosis and treatment adequacy of burn patients referred to a burn center. J Burn Care Res 2024; 45:180-189. [PMID: 37527451 PMCID: PMC11023132 DOI: 10.1093/jbcr/irad116] [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: 05/22/2023] [Indexed: 08/03/2023]
Abstract
Interventions for burn management until the patient is transferred to a burn center affect mortality and morbidity. Therefore, adherence to the developed algorithms is an important issue. This study aimed to determine deficiencies in different aspects of the implementation of these algorithms during the pre-admission diagnosis and treatment processes of patients referred to our burn center. This study involved a 4-year review of patients referred to our burn center. One hundred and seventy burn cases admitted by referral were enrolled in the study. Adequacy of resuscitation within the first 24 hours, adherence to guidelines, and mortality were investigated. Resuscitation performed within the first 24 hours was found to be inadequate in 88 patients (51.8%). When the burned surface area percentages were evaluated all percentages were calculated higher before arrival. There were 78 major burn cases (45.9%), and the frequency of inhalation burns, intubation requirements and renal failure were more common in this group compared to the minor burn group (P < .001). The frequency of intubation without accurate indications was found to be 70.58%. Inadequate escharotomy was detected at a rate of 52.9%, and inadequate fasciotomy at a rate of 66.6%. The mortality rate was 22.4% among all patients. Interventions undertaken during the period until the patients' referral to these centers affect mortality and morbidity. In this study, it was found that the pre-hospital applications generated were insufficient, and it was proposed that burn patient care algorithms be developed with in-service training throughout the country.
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Affiliation(s)
| | - Merve Akın
- Ankara City Hospital, General Surgery, Burn Treatment Center, Cankaya, Turkey
| | - Müge Çakırca
- Ankara Etlik City Hospital, Anesthesiology and Reanimation, Cankaya, Turkey
| | - Ezgi Erkılıç
- Ankara City Hospital, Anesthesiology and Reanimation, Cankaya, Turkey
| | | | - Ahmet Çınar Yastı
- Health Sciences University, Department of General Surgery, Ankara City Hospital, Burn Treatment Center, Cankaya, Turkey
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Milton-Jones H, Soussi S, Davies R, Charbonney E, Charles WN, Cleland H, Dunn K, Gantner D, Giles J, Jeschke M, Lee N, Legrand M, Lloyd J, Martin-Loeches I, Pantet O, Samaan M, Shelley O, Sisson A, Spragg K, Wood F, Yarrow J, Vizcaychipi MP, Williams A, Leon-Villapalos J, Collins D, Jones I, Singh S. An international RAND/UCLA expert panel to determine the optimal diagnosis and management of burn inhalation injury. Crit Care 2023; 27:459. [PMID: 38012797 PMCID: PMC10680253 DOI: 10.1186/s13054-023-04718-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 10/31/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Burn inhalation injury (BII) is a major cause of burn-related mortality and morbidity. Despite published practice guidelines, no consensus exists for the best strategies regarding diagnosis and management of BII. A modified DELPHI study using the RAND/UCLA (University of California, Los Angeles) Appropriateness Method (RAM) systematically analysed the opinions of an expert panel. Expert opinion was combined with available evidence to determine what constitutes appropriate and inappropriate judgement in the diagnosis and management of BII. METHODS A 15-person multidisciplinary panel comprised anaesthetists, intensivists and plastic surgeons involved in the clinical management of major burn patients adopted a modified Delphi approach using the RAM method. They rated the appropriateness of statements describing diagnostic and management options for BII on a Likert scale. A modified final survey comprising 140 statements was completed, subdivided into history and physical examination (20), investigations (39), airway management (5), systemic toxicity (23), invasive mechanical ventilation (29) and pharmacotherapy (24). Median appropriateness ratings and the disagreement index (DI) were calculated to classify statements as appropriate, uncertain, or inappropriate. RESULTS Of 140 statements, 74 were rated as appropriate, 40 as uncertain and 26 as inappropriate. Initial intubation with ≥ 8.0 mm endotracheal tubes, lung protective ventilatory strategies, initial bronchoscopic lavage, serial bronchoscopic lavage for severe BII, nebulised heparin and salbutamol administration for moderate-severe BII and N-acetylcysteine for moderate BII were rated appropriate. Non-protective ventilatory strategies, high-frequency oscillatory ventilation, high-frequency percussive ventilation, prophylactic systemic antibiotics and corticosteroids were rated inappropriate. Experts disagreed (DI ≥ 1) on six statements, classified uncertain: the use of flexible fiberoptic bronchoscopy to guide fluid requirements (DI = 1.52), intubation with endotracheal tubes of internal diameter < 8.0 mm (DI = 1.19), use of airway pressure release ventilation modality (DI = 1.19) and nebulised 5000IU heparin, N-acetylcysteine and salbutamol for mild BII (DI = 1.52, 1.70, 1.36, respectively). CONCLUSIONS Burns experts mostly agreed on appropriate and inappropriate diagnostic and management criteria of BII as in published guidance. Uncertainty exists as to the optimal diagnosis and management of differing grades of severity of BII. Future research should investigate the accuracy of bronchoscopic grading of BII, the value of bronchial lavage in differing severity groups and the effectiveness of nebulised therapies in different severities of BII.
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Affiliation(s)
| | - Sabri Soussi
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), University of Paris Cité, Paris, France
| | - Roger Davies
- Department of Intensive Care and Anaesthesia, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Emmanuel Charbonney
- Department of Médicine, Critical Care Division, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
- Department of Medicine, Université de Montréal, Montréal, Canada
| | - Walton N Charles
- Department of Surgery and Cancer, Imperial College London, London, UK
- Intensive Care National Audit and Research Centre, London, UK
| | - Heather Cleland
- Victorian Adult Burns Service, Alfred Health, Melbourne, Australia
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia
| | - Ken Dunn
- University Hospital South Manchester, Wythenshawe, UK
| | - Dashiell Gantner
- Department of Intensive Care, Alfred Health, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Julian Giles
- Department of Anaesthesia, Queen Victoria Hospital NHS Foundation Trust, East Grinstead, UK
| | - Marc Jeschke
- Ross Tilley Burn Center, Department of Surgery, Sunnybrook Health Science Center, Toronto, ON, Canada
- Departments of Surgery and Immunology, University of Toronto, Toronto, ON, Canada
| | - Nicole Lee
- Department of Burns, Plastic and Reconstructive Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Matthieu Legrand
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, University of California, San Francisco, USA
- Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists Network, Nancy, France
| | - Joanne Lloyd
- Department of Anaesthesia and Burns Intensive Care, St Andrew's Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, UK
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James Hospital, Dublin, Ireland
- Department of Respiratory Medicine, Hospital Clinic, IDIBAPS, CIBERes, Barcelona, Spain
- Universitat Barcelona, Barcelona, Spain
| | - Olivier Pantet
- Service of Adult Intensive Care, Lausanne University Hospital, Lausanne, Switzerland
| | - Mark Samaan
- Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Odhran Shelley
- Trinity College, Dublin, Ireland
- Department of Plastic and Reconstructive Surgery, St James' Hospital, Dublin, Ireland
| | - Alice Sisson
- Department of Intensive Care and Anaesthesia, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Kaisa Spragg
- Burns Unit, Queen Victoria Hospital NHS Foundation Trust, East Grinstead, UK
| | - Fiona Wood
- Fiona Stanley Hospital, Perth, Australia
- Perth Children's Hospital, Perth, Australia
- University of Western Australia, Perth, Australia
| | - Jeremy Yarrow
- Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea, UK
| | - Marcela Paola Vizcaychipi
- Department of Intensive Care and Anaesthesia, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Department of Médicine, Critical Care Division, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Andrew Williams
- Department of Médicine, Critical Care Division, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
- Department of Burns, Plastic and Reconstructive Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Jorge Leon-Villapalos
- Department of Médicine, Critical Care Division, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
- Department of Burns, Plastic and Reconstructive Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Declan Collins
- Department of Médicine, Critical Care Division, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
- Department of Burns, Plastic and Reconstructive Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Isabel Jones
- Department of Médicine, Critical Care Division, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
- Department of Burns, Plastic and Reconstructive Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Suveer Singh
- Faculty of Medicine, Imperial College London, London, UK.
- Department of Intensive Care and Anaesthesia, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.
- Department of Médicine, Critical Care Division, Centre Hospitalier de l'Université de Montréal, Montréal, Canada.
- Department of Research and Development, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.
- Academic Department of Anaesthesia, Pain Management and Intensive Care (APMIC), Imperial College London, London, UK.
- Royal Brompton Hospital, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK.
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Chotalia M, Pirrone C, Ali M, Mullhi R, Torlinska B, Mangham T, England K, Torlinski T. The utility of arterial blood gas parameters and chest radiography in predicting appropriate intubations in burn patients with suspected inhalation injury-A retrospective cohort study. Burns 2021; 47:1793-1801. [PMID: 33707087 DOI: 10.1016/j.burns.2021.02.018] [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: 10/19/2020] [Revised: 02/16/2021] [Accepted: 02/22/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND This study evaluates the utility of arterial blood gas (ABG) parameters and chest radiography in predicting intubation need in patients with burn injuries with suspected inhalation injury. METHODS Patients with suspected inhalation injury admitted to a single centre, Burn Intensive Care Unit, between April 4th 2016 and July 5th 2019, were included. Admission ABG parameters and chest radiograph opacification were compared with whether the patient received an appropriate intubation: defined as intubation for a duration of over 48 h. Area under the receiver operator characteristic curve was calculated (AUROC). RESULTS Eighty-nine patients were included. The majority (84%; n = 75) were intubated, of which 81% (n = 61) received appropriate intubations. pH had an AUROC of 0.88 and a pH of <7.30 had an 80% sensitivity and specificity for detecting appropriate intubation. P/F ratio had an AUROC of 0.81 and a P/F ratio of <40 had a 70% sensitivity and specificity for appropriate intubation. Chest radiograph opacification had poor utility in this regard (AUROC = 0.69). Adding pH and P/F ratio to the ABA criteria improved their sensitivity in detecting appropriate intubations (sensitivity: ABA + pH + P/F = 0.97 vs ABA = 0.86; p = 0.013), without altering their specificity. CONCLUSIONS In patients suspected inhalation injury, pH and P/F ratio were good predictors for appropriate intubations. Incorporating the parameters into the ABA criteria improved their clinical utility.
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Affiliation(s)
- Minesh Chotalia
- Department of Anaesthetics and Critical Care, West Midlands Burn Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK; Birmingham Acute Care Research Group, University of Birmingham, UK
| | - Christine Pirrone
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Muzzammil Ali
- Department of Anaesthetics and Critical Care, West Midlands Burn Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Randeep Mullhi
- Department of Anaesthetics and Critical Care, West Midlands Burn Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Barbara Torlinska
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, UK
| | - Thomas Mangham
- Department of Anaesthetics, Royal Preston Hospital, Lancashire Teaching Hospitals, UK
| | - Kaye England
- Department of Anaesthetics and Critical Care, West Midlands Burn Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Tomasz Torlinski
- Department of Anaesthetics and Critical Care, West Midlands Burn Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK.
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