An integrative literature review of factors contributing to hypothermia in adults during the emergent (ebb) phase of a severe burn injury

BACKGROUND

During the emergent (ebb) phase (first 72 h), the adult person with a severe burn experiences loss of body heat, decreased metabolism, and poor tissue perfusion putting them at risk of hypothermia, increased morbidity, and mortality. Therefore, timely and targeted care is imperative.

AIM

The aim of this integrative literature review was to develop a framework of the factors contributing to hypothermia in adults with a severe burn injury during the emergent (ebb) phase.

METHODS

An integrative review of research literature was undertaken as it provides an orderly process in the sourcing and evaluation of the literature. Only peer reviewed research articles, published in scholarly journals were selected for inclusion (n = 26). Research rigor and quality for each research article was determined using JBI Global appraisal tools relevant to the methodology of the selected study.

FINDINGS

Contributing factors were classified under three key themes: Individual, Pre-hospital, and In-hospital factors.

CONCLUSION

The structured approach enabled the development of an evidence-based framework identifying factors contributing to hypothermia in adults with a severe burn injury during the emergent (ebb) phase and adds knowledge to improve standardized care of the adult person with a severe burn injury.

Postoperative hypothermia is associated with reduced length of stay in adult acute burn survivors

BACKGROUND

The hypermetabolic response after a burn predisposes patients to hypothermia due to dysfunction of thermoregulation. Traditionally, hypothermia is avoided actively in burn care due to reported complications associated with low body temperature. The likelihood of hypothermia with acute burn surgery is compounded by general anesthesia, exposure of wound areas and prolonged operation times. However, we find limited studies exploring the effects of perioperative hypothermia on length of stay in the adult burn population.

OBJECTIVE

To determine associations between postoperative hypothermia and hospital length of stay in adult burns patients.

METHOD

This retrospective cohort study involved patients admitted to the State Adult Burn Unit in Western Australia between 1st January 2015 to 28th February 2021. All adults who underwent surgery for acute burn, and had postoperative recovery room body temperature recorded, were included in the study. In this study, we defined normothermia as >36.5C and hypothermia as < 36.0 °C with mild, moderate, and severe hypothermia being 35.0-35.9 °C, 34.0-34.9 °C and < 34.0 °C, respectively. Patients with hyperthermia were excluded. Multivariable general linear models explored if hypothermia was independently associated with length of stay.

RESULTS

Among 1486 adult patients, 1338 (90%) were normothermic postoperatively, with temperatures >36.0C. We included 148 (10%) patients with hypothermia (temperature <36.0 °C) postoperatively. Most burns in the study population were minor: 96% had burns < 15% TBSA. Data modelling demonstrated that hypothermia was associated with a shorter length of hospital stay (coefficient = -0.129, p = 0.041).

CONCLUSION

In adult acute burn patients, postoperative hypothermia was associated with reduced length of stay after surgery. The positive results of this study indicate that a review of the core temperature targets with acute burn surgery, and timing of burn patient cooling practices in general is warranted.

An Overview of Recent Developments in the Management of Burn Injuries

According to the World Health Organization (WHO), around 11 million people suffer from burns every year, and 180,000 die from them. A burn is a condition in which heat, chemical substances, an electrical current or other factors cause tissue damage. Burns mainly affect the skin, but can also affect deeper tissues such as bones or muscles. When burned, the skin loses its main functions, such as protection from the external environment, pathogens, evaporation and heat loss. Depending on the stage of the burn, the patient's condition and the cause of the burn, we need to choose the most appropriate treatment. Personalization and multidisciplinary collaboration are key to the successful management of burn patients. In this comprehensive review, we have collected and discussed the available treatment options, focusing on recent advances in topical treatments, wound cleansing, dressings, skin grafting, nutrition, pain and scar tissue management.

Changes in coagulation and temperature management in burn patients - A survey of burn centers in Switzerland, Austria and Germany

BACKGROUND

Severely burned patients suffer from both coagulopathy and hypothermia, with a lack of international consensus and appropriate treatment guidelines. This study examines recent developments and trends in coagulation and temperature management in European burn centers.

METHODS

A survey was sent to burn centers in Switzerland, Austria and Germany in 2016 and again in 2021. The analysis was performed using descriptive statistics, with categorical data reported in absolute numbers (n) and percentages (%) and numerical data reported as mean and standard deviation.

RESULTS

The rate of completed questionnaires was 84 % (16 of 19 questionnaires) in 2016 and 91 % (21 of 22 questionnaires) in 2021. The number of global coagulation tests performed has decreased over the observation period in favor of single factor determination and bed-side point-of-care coagulation tests. This has also led to increased administration of single factor concentrates in therapy. Although many centers had a defined treatment protocol for hypothermia in 2016, coverage increased such that in 2021 all centers surveyed had such a protocol. The body temperature was measured more consistently in 2021; thus, hypothermia was more actively sought, detected and treated.

CONCLUSION

A point-of-care guided, factor-based coagulation management and the maintenance of normothermia have gained importance in the care of burn patients in recent years.

Ambient Room Temperatures in a Burn Intensive Care Unit-A Quality Improvement Project

Introduction: Patients with major burn injuries are particularly susceptible to hypothermia. The ability to maintain and rapidly increase ambient temperatures may reduce the impact of hypothermia and the hypermetabolic response. The purpose of this study was to determine ambient patient room temperatures in a burn intensive care unit (ICU) and to evaluate our ability to adjust these temperatures. Methods: The ambient temperatures of 9 burn ICU patient rooms were recorded hourly over a 6-month period in an American Burn Association-verified burn centre. Temperatures were recorded using wall-mounted smart sensors, transmitted to a mobile smartphone application via Bluetooth, and then exported to Excel for analysis. On 2 predetermined dates, thermostats in all rooms were simultaneously set to maximum, and monitored over 3 h. This represented a sound change initiative, and replicated a medical order to increase the ambient temperature during critical stages of patient care. Results: We recorded 4394 individual hourly temperature measurements for each of the 9 rooms. The mean ambient temperature was 23.5 ± 0.3 °C (range 22.8-24). After intervention 1, ambient temperatures increased <2 °C in 7 rooms and by only 2 °C-3 °C in the other 2 rooms. The overall mean increase in temperature over 3 h across all rooms was 1.03 °C ± 1.19 °C (range -0.88 to 3.26). Following intervention 2, temperatures could be increased by ≥2 °C in only 2 rooms with an overall mean increase in temperature of only 0.76 °C ± 0.99 °C (range -0.29 to 2.43) across all rooms. Conclusions: The burn ICU rooms were relatively cool and our ability locally to adjust ambient temperatures quickly was limited. Burn centres should have regular facility assessments to assess whether ambient temperatures can be adjusted expeditiously when required.

Perioperative targeted temperature management of severely burned patients by means of an oesophageal temperature probe

BACKGROUND

Hypothermia in severely burned patients is associated with a significant increase in morbidity and mortality. The use of an oesophageal heat exchanger tube (EHT) can improve perioperative body temperatures in severely burned patients. The aim of this study was to investigate the intraoperative warming effect of oesophageal heat transfer in severe burn patients.

METHODS

Single-centre retrospective study performed at the Burns Centre of the University Hospital Zurich. Between January 2020 and May 2021 perioperative temperature management with EHT was explored in burned patients with a total body surface area (TBSA) larger than 30%. Data from patients, who received perioperative temperature management by EHT, were compared to data from the same patients during interventions performed under standard temperature management matching for length and type of intervention.

RESULTS

A total of 30 interventions (15 with and 15 without EHT) in 10 patients were analysed. Patient were 38 [26-48] years of age, presented with severe burns covering a median of 50 [42-64] % TBSA and were characterized by an ABSI of 10 [8-12] points. When receiving EHT management patients experienced warming at 0.07 °C per minute (4.2 °C/h) compared to a temperature loss of - 0.03 °C per minute (1.8 °C/h) when only receiving standard temperature management (p < 0.0001). No adverse or serious adverse events were reported.

CONCLUSION

The use of an oesophageal heat transfer device was effective and safe in providing perioperative warming to severely burned patients when compared to a standard temperature management protocol. By employing an EHT as primary temperature management device perioperative hypothermia in severely burned patients can possibly be averted, potentially leading to reduced hypothermia-associated complications.

Current understanding of thermo(dys)regulation in severe burn injury and the pathophysiological influence of hypermetabolism, adrenergic stress and hypothalamic regulation—a systematic review

Background

In this systematic review, we summarize the aetiology as well as the current knowledge regarding thermo(dys)regulation and hypothermia after severe burn trauma and aim to present key concepts of pathophysiology and treatment options. Severe burn injuries with >20% total body surface area (TBSA) affected commonly leave the patient requiring several surgical procedures, prolonged hospital stays and cause substantial changes to body composition and metabolism in the acute and long-term phase. Particularly in severely burned patients, the loss of intact skin and the dysregulation of peripheral and central thermoregulatory processes may lead to substantial complications.

Methods

A systematic and protocol-based search for suitable publications was conducted following the PRISMA guidelines. Articles were screened and included if deemed eligible. This encompasses animal-based in vivo studies as well as clinical studies examining the control-loops of thermoregulation and metabolic stability within burn patients

Results

Both experimental animal studies and clinical studies examining thermoregulation and metabolic functions within burn patients have produced a general understanding of core concepts which are, nonetheless, lacking in detail. We describe the wide range of pathophysiological alterations observed after severe burn trauma and highlight the association between thermoregulation and hypermetabolism as well as the interactions between nearly all organ systems. Lastly, the current clinical standards of mitigating the negative effects of thermodysregulation and hypothermia are summarized, as a comprehensive understanding and implementation of the key concepts is critical for patient survival and long-term well-being.

Conclusions

The available in vivo animal models have provided many insights into the interwoven pathophysiology of severe burn injury, especially concerning thermoregulation. We offer an outlook on concepts of altered central thermoregulation from non-burn research as potential areas of future research interest and aim to provide an overview of the clinical implications of temperature management in burn patients.

Increasing the Effectiveness of Targeted Temperature Management

TOPIC

Targeted temperature management and therapeutic hypothermia are essential components of the multimodal approach to caring for compromised patients after cardiac arrest and severe traumatic brain injury.

CLINICAL RELEVANCE

The continuously evolving science necessitates summation of individual facets and concepts to enhance knowledge and application for optimally delivering care. Targeted temperature management is a complex therapy that requires fine-tuning the most effective interventions to maintain high-quality targeted temperature management and maximize patient outcomes.

PURPOSE

To describe the underlying pathophysiology of fever and the importance of manipulating water temperature and of preventing and treating shivering during that process.

CONTENT COVERED

This article discusses nursing considerations regarding the care of patients requiring targeted temperature management that are necessary to improve patient outcomes.

The Impact of Ambient Temperature Control Across Various Care Settings on Outcomes in Burn Patients: A Review Article

Ambient/room temperature settings in burn treatment areas vary greatly due to a lack of evidence-based guidelines to direct care. While it is generally understood that ambient/room temperature impacts patient body temperature and metabolism, the ideal settings for optimizing patient outcomes are unclear. The literature assessing this topic is scarce, with many of the articles having significant limitations. We aim to summarize the current evidence for ambient/room temperature control, to address gaps in current reviews addressing this topic, and to elucidate topics requiring further research. PubMed and Google Scholar databases were queried for studies which evaluated the effect of the ambient/room temperature on burn patient core body temperature, patient metabolism, and outcomes among those treated in trauma bays, burn ICUs, and operating rooms. Although existing literature lacks sufficient patient outcome data regarding specific ambient/room temperatures, we highlight physiological processes that are impacted by changes in room temperatures in an effort to describe strategies that can allow for improved patient core body temperature control and outcomes in burn care settings.

Factors contributing to the restoration of normothermia after hypothermia in people with a major burn injury in the first 24 h of hospital admission

BACKGROUND

People with burn injury experiencing hypothermia are at risk of serious complications such as shock, multisystem organ failure, and death. There is limited information available for health professionals with regard to factors that contribute to restoration of normothermia after hypothermia in people with a major burn injury.

OBJECTIVE

The aim of the study was to identify factors that contribute to normothermia restoration after hypothermia in people with 10% or more total body surface area (TBSA) burn in the first 24 h of admission to a burn care hospital.

METHODS

The study was guided by the Gearing Framework for retrospective chart audit. The sample comprised medical charts of all adult people (n = 113) with a burn injury more than 10% of their TBSA admitted to a single-site burn care hospital intensive care unit in Victoria, Australia, between May 31, 2013, and June 1, 2015. Descriptive statistics were used to describe the sample, and logistic regression was conducted to predict variables contributing to return to normothermia in people with burn injury. Charts with incomplete data were excluded.

FINDINGS

The sample (n = 50) recorded a median initial temperature on admission to the emergency department (ED) of 35.4°C (range = 31.9-37.2°C) and took on an average of 6.2 (standard deviation [SD] = 4.96) hours to return to normothermia (36.5°C). Women took around 6 h longer than men to return to normothermia (mean = 11.14 h, SD = 5.58; mean = 5.38 h, SD = 4.41). Positive correlations were noted between TBSA%, the length of time between admission to the ED and the intensive care unit, and the hours taken to reach normothermia. Regression analysis suggests the initial recorded temperature on admission to the ED was the main predictor of the time body temperature takes to return to normothermia (β = .513, p < .001).

CONCLUSION

This study provides information for practice changes by highlighting the need for guidelines and education programs for health professionals to ensure the delivery of optimum care to people with burn injury.

[Target Temperature Control in Patients with Burns]

Severe burns lead to a persistent hypermetabolic response of the organism with significantly increased resting energy turnover, multi-organ dysfunction, muscle breakdown and increased risk of infection. Elevated core and skin temperatures are characteristic. A further increase in the metabolic rate can be triggered by heat losses, for which these patients are particularly predisposed due to high heat dissipation via evaporation of moisture and impairment of the thermoregulatory and insulating properties of the burnt skin. This is especially true in all treatment situations with exposure to large, uncovered skin surfaces, such as primary care, dressing changes in the intensive care unit and surgery with extensive sterile operating field. It has been shown that hypothermia is associated with numerous risks for the burn patient. Consistent heat management with measurement of the core body temperature and application of external and internal heat protection measures is recommended. Traditionally, an increase in room temperature is used here. However, this effective measure is limited by the resilience of the intensive care practitioners and the surgeons. To avoid perioperative hypothermia, strict surgical planning with limitation of the duration of surgery and close intraoperative communication about the risk of hypothermia are of particular importance.The differentiation between accepted temperature increase and infectious fever is often only possible by the inclusion of further examination findings. The criterion for sepsis is a temperature above 39 °C or below 36.5 °C.

Challenges in anaesthesia and pain management for burn injuries

Burn-injured patients provide unique challenges to those providing anaesthesia and pain management. This review aims to update both the regular burn anaesthetist and the anaesthetist only occasionally involved with burn patients in emergency settings. It addresses some aspects of care that are perhaps contentious in terms of airway management, fluid resuscitation, transfusion practices and pharmacology. Recognition of pain management failures and the lack of mechanism-specific analgesics are discussed along with the opioid crisis as it relates to burns and nonpharmacological methods in the management of distressed patients.