American Burn Association practice guidelines burn shock resuscitation. J Burn Care Res. 2008;29:257-266. [PMID: 18182930 DOI: 10.1097/BCR.0b013e31815f3876]

Precursors to oliguria during major burn resuscitation: An analysis of a prospective observational trial at 5 major US burn centers

Currently, urine output is the leading variable used to tailor fluid resuscitation in patients with large TBSA burns. However, this metric often lags with respect to resuscitation. Our group sought to identify derangements in variables that precede development of oliguria (<30 cc/hr) that we hypothesize will aid in more efficient resuscitation. We performed a retrospective analysis of 146 adult patients admitted within 4 h of a large TBSA (>20%) burn. We then divided them into two cohorts: those who developed oliguria within 6 h of admission and those who did not. Patients who experienced early oliguria had a higher incidence of invasive SBP < 90 (p = 0.02) or DBP < 40 (p = 0.009), lower minimum bicarbonate level (p = 0.04), more full thickness burns (p = 0.004), and higher TBSA (p = 0.01). More female patients were found in the oliguric group (p = 0.003). Multivariate analysis was used to develop a model to predict development of oliguria. When evaluated together, minimum DBP, sex, TBSA (or percent full thickness burn), and maximum base deficit constituted the most parsimonious model that significantly predicted oliguria (AUC = 0.92). Interestingly, the model lost significance when DBP was omitted, highlighting the importance of diastolic pressure in the development of oliguria.

Deciphering AKI in Burn Patients: Correlations between Clinical Clusters and Biomarkers

Acute kidney injury (AKI) is a significant complication in burn patients, impacting outcomes substantially. This study explores the heterogeneity of AKI in burn patients by analyzing creatinine time-series data to identify distinct AKI clusters and evaluating routine biomarkers' predictive values. A retrospective cohort analysis was performed on 2608 adult burn patients admitted to Hangang Sacred Heart Hospital's Burn Intensive Care Unit (BICU) from July 2010 to December 2022. Patients were divided into four clusters based on creatinine trajectories, ranging from high-risk, severe cases to lower-risk, short-term care cases. Cluster A, characterized by high-risk, severe cases, showed the highest mortality and severity, with significant predictors being PT and TB. Cluster B, representing intermediate recovery cases, highlighted PT and albumin as useful predictors. Cluster C, a low-risk, high-resilience group, demonstrated predictive values for cystatin C and eGFR cys. Cluster D, comprising lower-risk, short-term care patients, indicated the importance of PT and lactate. Key biomarkers, including albumin, prothrombin time (PT), cystatin C, eGFR cys, and total bilirubin (TB), were identified as significant predictors of AKI development, varying across clusters. Diagnostic accuracy was assessed using area under the curve (AUC) metrics, reclassification metrics (NRI and IDI), and decision curve analysis. Cystatin C and eGFR cys consistently provided significant predictive value over creatinine, with AUC values significantly higher (p < 0.05) in each cluster. This study highlights the need for a tailored, biomarker-driven approach to AKI management in burn patients, advocating for the integration of diverse biomarkers in clinical practice to facilitate personalized treatment strategies. Future research should validate these biomarkers prospectively to confirm their clinical utility.

Efficacy of transfer form implementation for adult burn patients between institutions to the Israeli National Burn Center

Burns are serious injuries associated with significant morbidity and mortality. In Israel, burn patients are often transferred between facilities. However, unstructured and non-standardized transfer processes can compromise the quality of patient care and outcomes. In this retrospective study, we assessed the impact of implementing a transfer form for burn management, comparing two populations: those transferred before and after the transfer form implementation. This study included 47 adult patients; 21 were transferred before and 26 after implementing the transfer form. We observed a statistically significant improvement in reporting rates of crucial information obtained by Emergency Room clinicians and inpatient management indicators. Introducing a standardized transfer form for burn patients resulted in improved communication and enhanced primary management, transfer processes, and emergency room preparation. The burns transfer form facilitated accurate and comprehensive information exchange between clinicians, potentially improving patient outcomes. These findings highlight the importance of structured transfer processes in burn patient care and emphasize the benefits of implementing a transfer form to streamline communication and optimize burn management during transfers to specialized burn centers.

Factor XIII in major burns coagulation

BACKGROUND

In the days following a burn injury, major burn patients (MBP) present a multifactorial coagulation disorder known as acute burn-induced coagulopathy. Several studies have investigated coagulation in MBPs; however, Factor XIII (FXIII), which converts fibrin monomers into a stable clot and promotes wound healing, has not yet been studied.

OBJECTIVE

To determine the kinetics of FXIII and other coagulation factors and cofactors in MBPs in order to clarify coagulopathy in these patients and its potential relationship with surgical bleeding.

METHODS

Prospective observational pilot study of the kinetics of FXIII and other coagulation factors and cofactors in MBPs during the first 30 days of burn injury.

RESULTS

FXIII levels show a significant decline of 75.10% in the interval between the burn injury and surgery, and a decline of 87.70% in the 24 h following surgery. Patients undergo surgery with a median antigenic FXIII of 32%. Plasma levels of most factors decrease significantly 24 h after the burn injury.

CONCLUSION

MBPs experience a significant decrease in plasma levels of FXIII from the time of admission up to 24 h after surgery. Abnormally low levels were observed at the time of surgery that could not be detected by other coagulation tests. The decrease in most factors at 24 h seems to be associated with dilution due to intensive fluid resuscitation.

American Burn Association Clinical Practice Guidelines on Burn Shock Resuscitation

This Clinical Practice Guideline (CPG) addresses the topic of acute fluid resuscitation during the first 48 hours following a burn injury for adults with burns ≥20% of the total body surface area (%TBSA). The listed authors formed an investigation panel and developed clinically relevant PICO (Population, Intervention, Comparator, Outcome) questions. A systematic literature search returned 5978 titles related to this topic and after 3 levels of screening, 24 studies met criteria to address the PICO questions and were critically reviewed. We recommend that clinicians consider the use of human albumin solution, especially in patients with larger burns, to lower resuscitation volumes and improve urine output. We recommend initiating resuscitation based on providing 2 mL/kg/% TBSA burn in order to reduce resuscitation fluid volumes. We recommend selective monitoring of intra-abdominal and intraocular pressure during burn shock resuscitation. We make a weak recommendation for clinicians to consider the use of computer decision support software to guide fluid titration and lower resuscitation fluid volumes. We do not recommend the use of transpulmonary thermodilution-derived variables to guide burn shock resuscitation. We are unable to make any recommendations on the use of high-dose vitamin C (ascorbic acid), fresh frozen plasma (FFP), early continuous renal replacement therapy, or vasopressors as adjuncts during acute burn shock resuscitation. Mortality is an important outcome in burn shock resuscitation, but it was not formally included as a PICO outcome because the available scientific literature is missing studies of sufficient population size and quality to allow us to confidently make recommendations related to the outcome of survival at this time.

Morphine concentrations in fatalities after palliative treatment of acute burn injury

The evaluation of a morphine concentration in postmortem blood is routine for a forensic toxicologist. We here report three fatal cases where we found high morphine concentrations with 7.96, 4.30, and 5.82 mg/l in femoral blood that have to be estimated as unusually high. All these individuals died due to severe burn injuries and obtained morphine in the context of their palliative care in the last hours of their lives. According to the autopsy results, the cause of death in case 1 was burn disease with burns of about 90% of the body surface area (BSA), case 2 burn trauma, and case 3 burn shock. Besides morphine, propofol, fentanyl, sufentanil, midazolam, diazepam, lorazepam, cefazolin, and rocuronium were detected in femoral blood. The findings fitted well with the detailed clinical documentation. Further evidence of therapeutic concentrations of quetiapine, duloxetine, and melperone could be matched to preexisting medication of the individuals. Physiologically based pharmacokinetic modelling (PBPK) was applied, developed for the intravenous administration of morphine, to find an explanation for the high morphine concentrations in femoral blood. Quantification of morphine in body fluids and tissue was performed to calculate morphine tissue concentration ratios to the morphine concentration in femoral blood. The presented cases show that pharmacokinetic simulations can reflect decreased renal clearance and decreased hepatic metabolism in general. However, this prediction is not sufficient to explain the high morphine concentrations in femoral blood measured here. It can be assumed that burn shock in particular leads to altered pharmacokinetics, namely decreased distribution of morphine.

Fluid Resuscitation and Cardiovascular Support in Acute Burn Care

Acute burn injury creates a complex and multifactorial local response which may have systemic sequelae such as hypovolemia, hypothermia, cardiovascular collapse, hypercoagulability, and multi-system organ failure. Understanding the underlying pathophysiology of burn shock, the initial burn triage and assessment, calculation of fluid requirements, and the means of tailoring ongoing interventions to optimize resuscitation are critical for overcoming the wide spectrum of derangements which this condition creates. As a result, this article discusses the various key points in order to garner a greater understanding of these nuances and the optimal pathway to take when tackling these challenging issues.

Challenges in the Management of Large Burns

Large burns provoke profound pathophysiological changes. Survival rates of patients with large burns have improved significantly with the advancement of critical care and adaptation of early excision protocols. Nevertheless, care of large burn wounds remains challenging secondary to limited donor sites, prolonged time to wound closure, and immunosuppression. The development of skin substitutes and new grafting techniques decreased time to wound closure. Individually, these methods have limited success, but a combination of them may yield more successful outcomes. Early identification of patients with likely poor prognosis should prompt goals of care discussion and involvement of a palliative care team when possible.

Effect of Hydroxyethyl starch (HES) versus 5% albumin solution on intra-abdominal pressure in severe burn patients: A prospective randomized clinical trial

INTRODUCTION

Massive burn patients are at risk of developing intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) as a complication of resuscitation.

OBJECTIVE

This study aimed to evaluate the effect of Hydroxyethyl starch (HES) versus 5% albumin solution on intra-abdominal pressure (IAP) in massive burn patients.

METHODS

This was a prospective randomized clinical trial carried on at Ain Shams University (ASU) burn unit for 2 years. Where adult patients with burns more than 20% of TBSA were equally randomized into HES group or albumin group.

RESULTS

Fifty-two patients were equally randomized into 2 groups. We found no difference in age, sex, weight, type of burn, and TBSA between the two groups. The mean total resuscitation fluid volume in the first 48 h was 213 ml/kg and 206.2 ml/kg for the HES group and the albumin group respectively (p = 0.674). IAP statistically was non-significantly higher in the HES group. We found no statistical difference between the two groups as regards the renal function tests.

CONCLUSION

Both HES and 5% albumin solution are effective and safe colloids for burn resuscitation. As regards the IAP, it seems that both 5% albumin and HES have comparable effect regarding IAH in severely burn patients. Both HES and 5% albumin were partially equal in terms of renal involvement and vital data stability.

Evaluation of hydroxocobalamin use for the treatment of suspected cyanide toxicity secondary to smoke inhalation

Hydroxocobalamin is used for cyanide toxicity after smoke inhalation, but diagnosis is challenging. Retrospective studies have associated hydroxocobalamin with acute kidney injury (AKI). This is a retrospective analysis of patients receiving hydroxocobalamin for suspected cyanide toxicity. The primary outcome was the proportion of patients meeting predefined appropriate use criteria defined as ≥1 of the following: serum lactate ≥8 mmol/L, systolic blood pressure (SBP) <90 mmHg, new-onset seizure, cardiac arrest, or respiratory arrest. Secondary outcomes included incidence of AKI, pneumonia, resolution of initial neurologic symptoms, and in-hospital mortality. Forty-six patients were included; 35 (76%) met the primary outcome. All met appropriate use criteria due to respiratory arrest, 15 (43%) for lactate, 14 (40%) for SBP, 12 (34%) for cardiac arrest. AKI, pneumonia, and resolution of neurologic symptoms occurred in 30%, 21%, and 49% of patients, respectively. In-hospital mortality was higher in patients meeting criteria, 49% vs. 9% (95% CI 0.16, 0.64). When appropriate use criteria were modified to exclude respiratory arrest in a post-hoc analysis, differences were maintained, suggesting respiratory arrest alone is not a critical component to determine hydroxocobalamin administration. Predefined appropriate use criteria identify severely ill smoke inhalation victims and provides hydroxocobalamin treatment guidance.

Case report of the first Caucasian burn patient transplanted with Cutimed Sorbact®-based cultured epithelial autografts technique at Tygerberg Hospital, Cape Town, South Africa: An 8-year follow-up

Cultured epithelial autograft applications are limited by the associated cost and time constraints in resource-limited settings. A modified composite technique using the patients' own tissue and Cutimed Sorbact dressing was employed as a life-saving emergency measure. Since the non-Caucasian population was more commonly treated at the center, it was important to report the first Caucasian patient outcome, as the graft-take outcome for all populations was unknown. A 54-year-old male with extensive flame burns and a low chance of survival was admitted to the Tygerberg Burn Center. He received traditional skin grafts and cultured epithelial cells, after the 2 week-culture period using the current technique. Short- (⩽2 weeks) and long-term graft take (⩽8 years) was inspected. Good graft take and complete epithelialization was observed during short-term inspection with partially healed areas initially attributed to extensive burn depth and dressing removal. Long-term follow-up indicated a near normal tissue appearance and excellent pliability.

Vital indicators in predicting burn mortality: A comparison of shock indices and burn shock indices

Background/aim

In many studies, shock indices have proven to be good tools for predicting mortality. In the present study, burn shock index (BSI), percentage of total body surface area burned (TBSA%) multiplied by shock index; burn modified shock index (BMSI), TBSA% multiplied by modified shock index; burn age shock index (BASI), TBSA% multiplied by age shock index; burn rivers shock index (BrSI), TBSA% multiplied by rivers shock index; burn rivers shock index multiplied by Glasgow Coma Scale score (BrSIG) were examined in burn patients. We defined these burn shock indices for the first time. This study aimed to evaluate the effectiveness of shock indices and burn shock indices in predicting mortality in burn patients.

Materials and methods

This study examines retrospectively of burn patients admitted to the emergency department of Dicle University Hospital between January 2010 and December 2022. The patients' vital signs were obtained at the time of presentation to the emergency department, and shock indices were calculated. The effectiveness of shock indices in predicting mortality was compared.

Results

A total of 2445 patients were included in the study. Of the patients, 1793 were pediatric, and 652 were adults. BSI (AUC: 0.872, 95% confidence interval (CI): 0.812-0.931, p < 0.001) had the highest area under the curve (AUC) value in predicting mortality in children. The optimal cut-off value for BSI in children was 21.79 and its was sensitivity 83.05%, specificity 79.64%, positive predictive value (PPV) 12.19%, negative predictive value (NPV) 99.28%. In adults, BASI had the highest value of AUC (AUC: 0.936, 95% CI: 0.887-0.984, p < 0.001). The optimal cut-off value for BASI in adults was 62.5 and its sensitivity was 86.49%, specificity was 91.71%, PPV was 38.55%, and NPV was 99.12%.

Conclusion

Shock indices are easy to calculate and effective in predicting mortality in burn patients admitted to the emergency department. Among the shock indices in the study, BSI was the best in predicting mortality in children, and BASI was the best in adults.

Higher Initial Formula for Resuscitation After Severe Burn Injury Means Higher 24-Hour Volumes

Initial fluid infusion rates for resuscitation of burn injuries typically use formulas based on patient weight and total body surface area (TBSA) burned. However, the impact of this rate on overall resuscitation volumes and outcomes have not been extensively studied. The purpose of this study was to determine the impact of initial fluid rates on 24-hour volumes and outcomes using the Burn Navigator (BN). The BN database is composed of 300 patients with ≥20% TBSA, >40 kg that were resuscitated utilizing the BN. Four study arms were analyzed based on the initial formula-2 ml/kg/TBSA, 3 ml/kg/TBSA, 4 ml/kg/TBSA or the Rule of Ten. Total fluids infused at 24 hours after admission were compared as well as resuscitation-related outcomes. A total of 296 patients were eligible for analysis. Higher starting rates (4 ml/kg/TBSA) resulted in significantly higher volumes at 24 hours (5.2 ± 2.2 ml/kg/TBSA) than lower rates (2 ml/kg/TBSA resulted in 3.9 ± 1.4 ml/kg/TBSA). No shock was observed in the high resuscitation cohort, whereas the lowest starting rate exhibited a 12% incidence, lower than both the Rule of Ten and 3 ml/kg/TBSA arms. There was no difference in 7-day mortality across groups. Higher initial fluid rates resulted in higher 24-hour fluid volumes. The choice of 2ml/kg/TBSA as initial rate did not result in increased mortality or more complications. An initial rate of 2ml/kg/TBSA is a safe strategy.

Quality indicators in burn care: An international burn care professionals survey to define them

INTRODUCTION

Quality indicators (QIs) are tools for improving and maintaining the standard of care. Although burn injuries are a major global health threat, requiring standardized management, there is a lack of worldwide accepted quality indicators for burn care. This study aims to identify the best burn care-specific QIs as perceived by worldwide burn practitioners.

METHODS

The ISBI Burn Care Committee developed a survey to analyze which burn care- specific QIs were relevant to international burn care professionals. The questionnaire was based on the three dimensions of the Donabedian model (i.e., Structure, Process, and Outcome) to evaluate the quality of care. The study was conducted from April to September 2021 and analyzed and reported following the Checklist for Reporting Results of Internet E-Surveys (CHERRIES).

RESULTS

According to the 124 worldwide respondents, the most relevant QIs were: access to intensive care, burn surgeons, and dedicated burn care nurses (Structure category), 24-hours access to burn services, local protocols based on documented guidelines (Process category), and in-hospital mortality and incidence of severe infections (Outcome category).

CONCLUSIONS

Specific QIs related to structures, clinical processes, and outcomes are needed to monitor the treatment of burn patients globally, assess the efficiency of the provided treatment, and harmonize the worldwide standard of burn care.

Pattern, Cause of Childhood Burn injuries and their Management Outcome At Jimma Medical Center, Jimma Zone, Oromia Region, Southwest Ethiopia

Purpose

Burn injuries are prevalent worldwide, especially in developing countries; and there are significant pediatric burn injuries in Ethiopia. This study was performed to analyze the pattern, cause, and management outcome of burn injuries in Jimma Medical Center.

Methods

A hospital‑based retrospective cross‑sectional study was conducted at Jimma university medical center burn unit. Data were collected through chart review of pediatric patients aged 0 to 14 years who were admitted to the burn unit with a burn injury. A total of 92 hospitalized children were studied from Jan 1, 2020 to Dec 31, 2021 GC. Data were analyzed using SPSS version 25. The statistical significance was determined using odds ratio (OR) with a 95% confidence interval (CI) and the corresponding P-value of less than 0.05.

Results

The majority of the patients were males (52.2%). Scald burn was the most common cause of burn in 57(62.0%). The TBSA of majority of the patients (52.2%) was found to be between 11% and 20%. After adjusting for possible confounders in the multivariate analysis, preexisting illness and time of presentation to care were found to have a statistically significant association with the outcome of burn at discharge (P= 0.007) (P= 0.021) respectively.

Conclusion

The most common cause of burn in our setup was scald burn; upper extremities were also the most affected site. According to our study, the factors associated with the outcome of burn injury were preexisting illness and late presentation to health facilities.

Identifying temporal variations in burn admissions

BACKGROUND

Variations in admission patterns have been previously identified in non-elective surgical services, but minimal data on the subject exists with respect to burn admissions. Improved understanding of the temporal pattern of burn admissions could inform resource utilization and clinical staffing. We hypothesize that burn admissions have a predictable temporal distribution with regard to the time of day, day of week, and season of year in which they present.

STUDY DESIGN

A retrospective, cohort observational study of a single burn center from 7/1/2016 to 3/31/2021 was performed on all admissions to the burn surgery service. Demographics, burn characteristics, and temporal data of burn admissions were collected. Bivariate absolute and relative frequency data was captured and plotted for all patients who met inclusion criteria. Heat-maps were created to visually represent the relative admission frequency by time of day and day of week. Frequency analysis grouped by total body surface area against time of day and relative encounters against day of year was performed.

RESULTS

2213 burn patient encounters were analyzed, averaging 1.28 burns per day. The nadir of burn admissions was from 07:00 and 08:00, with progressive increase in the rate of admissions over the day. Admissions peaked in the 15:00 hour and then plateaued until midnight (p<0.001). There was no association between day of week in the burn admission distribution (p>0.05), though weekend admissions skewed slightly later (p = 0.025). No annual, cyclical trend in burn admissions was identified, suggesting that there is no predictable seasonality to burn admissions, though individual holidays were not assessed.

CONCLUSION

Temporal variations in burn admissions exist, including a peak admission window late in the day. Furthermore, we did not find a predictable annual pattern to use in guiding staffing and resource allocation. This differs from findings in trauma, which identified admission peaks on the weekends and an annual cycle that peaks in spring and summer.

Can we predict critical care mortality with non-conventional inflammatory markers in SARS-CoV-2 infected patients?

BACKGROUND

Severe COVID-19 disease is associated with multiple organ involvement,then failure and often fatal outcomes.In addition,inflammatory mechanisms and cytokine storms,documented in many COVID-19 patients,are responsible for the progression of the disease and high mortality rates.Inflammatory parameters,such as procalcitonin(PCT) and C-reactive protein(CRP), are widely used in clinical practice.

OBJECTIVE

To evaluate the predictive power of non-conventional inflammatory markers regarding mortality risk.

METHODS

In our prospective study 52 patients were followed for 5 days after admission to an intensive care unit immediately with severe SARS-CoV-2 infection.We compared leukocyte-,platelet antisedimentation rate (LAR, PAR),neutrophil lymphocyte ratio(NLR), CRP, PCT levels.

RESULTS

In non-surviving(NSU) patients LAR remained largely constant from D1 to D4 with a statistically significant drop(p <  0.05) only seen on D5.The NSU group showed statistically significant(p <  0.05) elevated LAR medians on D4 and D5, compared to the SU group.NLR values were continually higher in the non-survivor group.The difference between the SU and NSU groups were statistically significant on every examined day.PAR, CRP and PCT levels didn't show any significant differences between the SU and NSU groups.

CONCLUSIONS

In conclusion, this study suggests that LAR and NLR are especially worthy of further investigation as prognostic markers.LAR might be of particular relevance as it is not routinely obtained in current clinical practice.It would seem beneficial to include LAR in data sets to train prognostic artificial intelligence.

Review of Burn Resuscitation: Is Plasmalyte® a Comparable Alternative to Ringer's Lactate?

Ringer's lactate has been the most widely used fluid for burn resuscitation for decades. Plasmalyte® (PL), a newer balanced crystalloid, is gaining popularity for use in the critically ill, including patients with burns. This popularity is partly due to the fact that PL theoretically offers a favorable metabolic profile, but may also be attributed to its relatively lower cost. Patients who are critically ill with large burns receive enormous volumes of fluids, especially during the resuscitation period. The choice of balanced crystalloid solution used is likely to have an impact on the metabolic status of patients and their overall outcomes. The choice of fluid for burn resuscitation has been one of the most researched topics in burn care and various types of fluids have been superseded based on research findings. This narrative review examines the evidence guiding fluid management in burns and explores the data supporting the use of balanced crystalloid solutions, in particular PL for burn resuscitation. Our literature search revealed only one study that focused on a direct comparison between PL and standard Ringer's Lactate for burn resuscitation. Based on the limited literature on the use of PL in burns, it is difficult to draw meaningful conclusions. Further research, into the suitability of PL for use in burns, is needed before formulary changes are instituted widely.

Adherence to Burn Resuscitation Guidelines Reduces Resuscitation Fluids and Mortality

In our province, regional recommendations for optimal fluid resuscitation were published in 2011 to improve the management of acute burn patients prior to transfer to a specialized burn center. The purpose of this study was to determine compliance with these provincial burn resuscitation guidelines and their subsequent impact on patient outcomes. A retrospective review of patients transferred to the provincial burn center after being initially managed at peripheral sites was performed from 2011 to 2019. Patients were included if their burn injury was greater than 20% TBSA and they were transferred within 24 hours postburn injury. Charts were reviewed for the amount of fluid patients received and resuscitation associated outcomes. A total of 72 patients met the inclusion criteria, 37 of which were treated in accordance with the 2011 guidelines. For patients that followed the 2011 provincial guidelines, they received on average 3.2 cc/kg/TBSA of fluid during the first 24 hours postburn injury. Significantly more fluids were given when guidelines were not followed with an average of 4.4 cc/kg/TBSA (P = .03). Mortality rates were found to be significantly lower during the primary admission with guidelines compliance (16.2% vs 2.7%, P = .04). No significant differences were found between the remaining evaluated complications including abdominal compartment syndrome (8.1% vs 2.7%) and need for escharotomy (35.2% vs 21.6%). The use of clinical practice guidelines decreased excess IV fluid administration in additional to decreasing mortality rates for patients initially assessed in peripheral low volume centers.

A practical formula for fluid resuscitation in acute paediatric burns in a low resource setting: A pilot study

BACKGROUND

Appropriate fluid resuscitation of acute burn injury is critical and there are recognized challenges with fluid resuscitation, including those with relevance to low resource settings. We developed a practical protocol that guides burn resuscitation and sought to evaluate the safety of our modified resuscitation formula through a small pilot study that particularly addresses the problems we have experienced in a low resource setting.

METHODS

Children with burns more than 15% total body surface area admitted within 24 h of injury to Edendale Hospital between 1 June 2021 and 31 August 2021 were included. The resuscitation formula used was 2 mls of Ringers Lactate per bodyweight in kilograms per% total body surface area (TBSA) given over 24 h and adjusted according to urine output. Data analysed included age, weight, mechanism, TBSA, hours post burn at presentation to hospital, total fluid given in the first 24 h of admission, total urine output in the first 24 h of admission, number of fluid adjustments made during the first 24 h and complications related to fluid resuscitation.

RESULTS

Ten children were included. The median age was 3 (IQR 2-5) years old, with a mean weight of 14.9 (SD 5.07) kilograms, a median TBSA of 17.4 (IQR 16-26)%, presenting at a median of 12 (6.5-18) hours post burn injury. Mechanism of burn was scald in all cases, with 9 being hot water and hot food in one. In the first 24 h a mean of 2.05 (SD 0.58) mls/kg of fluid was received with a mean urine output of 1.66 (SD 0.57) mls/kg/hr.

CONCLUSION

The results of this pilot study to evaluate the safety of our protocol seem reasonable. It is limited by the lack of larger injuries as well as adult patients and a larger prospective study is pertinent.

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.

Advantages of pyruvate-based fluids in preclinical shock resuscitation-A narrative review

This review focuses on the innate beneficial effects of sodium pyruvate-based fluids, including pyruvate in intravenous solutions, oral rehydration solutions, and peritoneal dialysis solutions, on shock resuscitation with various animal models relative to current commercial fluids over the last two decades. Due to its superior pharmacological properties, pyruvate effectively sustains cytosolic glycolytic pathways and mitochondrial oxidative phosphorylation by restoration of redox potentials and reactivation of pyruvate dehydrogenase in hypoxia, even anoxia, and diabetes, reversing the Warburg effect and diabetic glucometabolic aberration. Pyruvate has been demonstrated to protect against multiorgan dysfunction and metabolic disturbance in numerous preclinical studies with various pathogenic injuries. The unique features of pyruvate potential clinical benefits encompass to efficiently correct lethal lactic acidosis via metabolically rapid consumption of intracellular [H⁺] and robustly protect multiorgan metabolism and function, particularly visceral organs in addition to the heart and brain, significantly prolonging survival in various animal models. Pyruvate protection of red blood cell function and preservation of the partial pressure of arterial oxygen should be highly concerned in further studies. Pyruvate is much advantageous over existing anions such as acetate, bicarbonate, chloride, and lactate in commercial fluids. Pyruvate-based fluids act as a therapeutic agent without causing iatrogenic resuscitation injury in addition to being a volume expander, indicating a potential novel generation of resuscitation fluids, including crystalloids and colloids. Pyruvate-based fluids have an enormous potential appeal for clinicians who face the ongoing fluid debate to readily select as the first resuscitation fluid. Clinical trials with pyruvate-based fluids in shock resuscitation are urgently warranted.

Fluid Management, Intra-Abdominal Hypertension and the Abdominal Compartment Syndrome: A Narrative Review

Background: General pathophysiological mechanisms regarding associations between fluid administration and intra-abdominal hypertension (IAH) are evident, but specific effects of type, amount, and timing of fluids are less clear. Objectives: This review aims to summarize current knowledge on associations between fluid administration and intra-abdominal pressure (IAP) and fluid management in patients at risk of intra-abdominal hypertension and abdominal compartment syndrome (ACS). Methods: We performed a structured literature search from 1950 until May 2021 to identify evidence of associations between fluid management and intra-abdominal pressure not limited to any specific study or patient population. Findings were summarized based on the following information: general concepts of fluid management, physiology of fluid movement in patients with intra-abdominal hypertension, and data on associations between fluid administration and IAH. Results: We identified three randomized controlled trials (RCTs), 38 prospective observational studies, 29 retrospective studies, 18 case reports in adults, two observational studies and 10 case reports in children, and three animal studies that addressed associations between fluid administration and IAH. Associations between fluid resuscitation and IAH were confirmed in most studies. Fluid resuscitation contributes to the development of IAH. However, patients with IAH receive more fluids to manage the effect of IAH on other organ systems, thereby causing a vicious cycle. Timing and approach to de-resuscitation are of utmost importance, but clear indicators to guide this decision-making process are lacking. In selected cases, only surgical decompression of the abdomen can stop deterioration and prevent further morbidity and mortality. Conclusions: Current evidence confirms an association between fluid resuscitation and secondary IAH, but optimal fluid management strategies for patients with IAH remain controversial.

Vasoactive and/or inotropic drugs in initial resuscitation of burn injuries: A systematic review

BACKGROUND

According to current guidelines, initial burn resuscitation should be performed with fluids alone. The aims of the study were to review the frequency of use of vasoactive and/or inotropic drugs in initial burn resuscitation, and assess the benefits and harms of adding such drugs to fluids.

METHODS

A systematic literature search was conducted in PubMed, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, UpToDate, and SveMed+ through 3 December 2021. The search included studies on critically ill burn patients receiving vasoactive and/or inotropic drugs in addition to fluids within 48 h after burn injury.

RESULTS

The literature search identified 1058 unique publications that were screened for inclusion. After assessing 115 publications in full text, only two retrospective cohort studies were included. One study found that 16 out of 52 (31%) patients received vasopressor(s). Factors associated with vasopressor use were increasing age, burn depth, and % total body surface area (TBSA) burnt. Another study observed that 20 out of 111 (18%) patients received vasopressor(s). Vasopressor use was associated with increasing age, Baux score, and %TBSA burnt in addition to more frequent dialysis treatment and increased mortality. Study quality assessed by the Newcastle-Ottawa quality assessment scale was considered good in one study, but uncertain due to limited description of methods in the other.

CONCLUSION

This systematic review revealed that there is a lack of evidence regarding the benefits and harms of using vasoactive and/or inotropic drugs in addition to fluids during early resuscitation of patients with major burns.

A Nonlethal Full-Thickness Flame Burn Produces a Seroma Beneath the Forming Eschar, Thereby Promoting Pseudomonas aeruginosa Sepsis in Mice

The World Health Organization estimates ~180,000 deaths occur annually from burn-related injuries. Many victims who survive the initial burn trauma succumb to bacterial infections that lead to sepsis during treatment. Although advancements in burn care continue to improve in high-income countries due to their burn centers and advanced research, low and middle-income countries continue to see high frequencies of burn injuries and burn-related deaths due to secondary infections. Bacterial-derived sepsis is the most life-threatening danger for people that survive burn injuries. Here we provide evidence for the first time that a subeschar seroma forms postburn even in the absence of infection in mice. The seroma fills with a volume estimated at 500 µL of fluid, 25% of the blood supply, free of red blood cells. The seroma fluid supports robust Pseudomonas aeruginosa (PA) growth and contains inflammatory cytokines and chemokines, which recruit immature neutrophils and monocytes to the seroma in the absence of endothelial breakdown. These immune cells fail to contain PA expansion and dissemination. This recruitment of monocytes and immature neutrophils may result in sequestering these critical immune cells away from other tissues during a pivotal time during bacterial dissemination, promoting PA-mediated sepsis.

Pediatric Perioperative Clinical Pharmacy Practice: Clinical Considerations and Management: An Opinion of the Pediatrics and Perioperative Care Practice and Research Networks of the American College of Clinical Pharmacy

Pediatric perioperative clinical pharmacists are uniquely positioned to provide therapeutic and medication management expertise at a particularly vulnerable transition of care from the preoperative space, through surgery, and postoperative setting. There are many direct-patient care activities that are included in the role of the pediatric perioperative pharmacist, as well as many opportunities to develop effective, optimized, and safe medication use processes. This article outlines many of the areas in which a pediatric perioperative clinical pharmacist may intervene.

Care of the Critically Injured Burn Patient

Care of the critically injured burn patient presents unique challenges to the intensivist. Certified burn centers are rare and geographically sparse, necessitating that much of the initial management of patients with severe burn injuries must happen in the pre-burn center setting.1 Severe burn injuries often lead to a wide range of complications that extend beyond the loss of skin integrity and require specialized care. As such, medical intensivists are often called upon to stabilize these critically injured patients. This focused review outlines the clinical care of these medically complex patients, including airway management, post-burn complications, volume resuscitation, nutrition, and end-of-life care.

Late-Onset Acute Kidney Injury is a Poor Prognostic Sign for Severe Burn Patients

Background

Acute kidney injury (AKI) is a morbid complication and the main cause of multiple organ failure and death in severely burned patients. The objective of this study was to explore epidemiology, risk factors, and outcomes of AKI for severely burned patients.

Methods

This retrospective study was performed with prospectively collected data of severely burned patients from the Institute of Burn Research in Southwest Hospital during 2011–2017. AKI was diagnosed according to Kidney Disease Improving Global Outcomes (KDIGO) criteria (2012), and it was divided into early and late AKIs depending on its onset time (within the first 3 days or &gt;3 days post burn). The baseline characteristics, clinical data, and outcomes of the three groups (early AKI, late AKI and non-AKI) were compared using logistic regression analysis. Mortality predictors of patients with AKI were assessed.

Results

A total of 637 adult patients were included in analysis. The incidence of AKI was 36.9% (early AKI 29.4%, late AKI 10.0%). Multiple logistic regression analysis revealed that age, gender, total burn surface area (TBSA), full-thickness burns of TBSA, chronic comorbidities (hypertension or/and diabetes), hypovolemic shock of early burn, and tracheotomy were independent risk factors for both early and late AKIs. However, sepsis was only an independent risk factor for late AKI. Decompression escharotomy was a protective factor for both AKIs. The mortality of patients with AKI was 32.3% (early AKI 25.7%, late AKI 56.3%), and that of patients without AKI was 2.5%. AKI was independently associated with obviously increased mortality of severely burned patients [early AKI, OR = 12.98 (6.08–27.72); late AKI, OR = 34.02 (15.69–73.75)]. Compared with patients with early AKI, patients with late AKI had higher 28-day mortality (34.9% vs. 19.4%, p = 0.007), 90-day mortality (57.1% vs. 27.4%, p &lt; 0.0001).

Conclusions

AKI remains prevalent and is associated with high mortality in severely burned patients. Late-onset acute kidney injury had greater severity and worse prognosis.

Burn Shock and Resuscitation: Review and State of the Science

Burn shock and acute fluid resuscitation continue to spark intense interest and debate among burn clinicians. Following a major burn injury, fluid resuscitation of burn shock is life-saving, but paradoxically can also be a source of increased morbidity and mortality because of the unintended consequence of systemic edema formation. Considerable research over the past two decades has been devoted to understanding the mechanisms of edema formation, and to develop strategies to curb resuscitation fluids and limit edema development. Recognition of burn endotheliopathy - injury to the endothelium's glycocalyx layer- is one of the most important recent developments in our understanding of burn shock pathophysiology. Newer monitoring approaches and resuscitation endpoints, along with alternative resuscitation strategies to crystalloids alone, such as administration of albumin, or plasma, or high dose ascorbic acid, have had mixed results in limiting fluid creep. Clear demonstration of improvements in outcomes with all of these approaches remains elusive. This comprehensive review article on burn shock and acute resuscitation accompanies the American Burn Association's State of the Science meeting held in New Orleans, LA on November 2-3, 2021 and the Proceedings of that conference published in this journal.

Body mapping chart for estimation of percentage of body surface area in mesocephalic dogs

OBJECTIVE

To create a chart for estimating body surface area (BSA) for use in canine burn victims, similar to the human Rule of Nines.

DESIGN

Prospective study, from 2016 to 2017.

SETTING

University teaching hospital.

ANIMALS

Nine adult, medium-sized, mesocephalic dogs (5 females, 4 males).

INTERVENTIONS

Sedated dogs and fresh cadavers underwent full-body computed tomography (CT) scans. A 3-dimensional technique was used to calculate the surface area of specific body parts, as well as the surface area of the whole body. With the obtained measurements, a BSA chart was created.

MEASUREMENTS AND MAIN RESULTS

Estimates for percent of total BSA obtained with CT images were as follows: head and abdomen 14%, respectively, neck and each of the thoracic limbs 9%, thorax 18%, pelvic limbs 11% each, and pelvis including the tail 5%. The most considerable differences between dogs and people in respect to the Rule of Nines chart were noticed in the head, the pelvic limbs, as well as in the groin region in people as compared with the pelvic/tail area in dogs. The surface areas of the front legs and thorax were the only body parts that corresponded with that of human body surfaces.

CONCLUSIONS

A chart for estimating canine body surface was created. Given the diversity of dog breeds, sizes, and body conformation, our results cannot be generalized to all dogs. Studies of more diverse populations are warranted.

Early Transcriptomic Response to Burn Injury: Severe Burns Are Associated With Immune Pathway Shutdown

Burn injury induces a systemic hyperinflammatory response with detrimental side effects. Studies have described the biochemical changes induced by severe burns, but the transcriptome response is not well characterized. The goal of this work is to characterize the blood transcriptome after burn injury. Burn patients presenting to a regional center between 2012 and 2017 were prospectively enrolled. Blood was collected on admission and at predetermined time points (hours 2, 4, 8, 12, and 24). RNA was isolated and transcript levels were measured with a gene expression microarray. To identify differentially regulated genes (false-discovery rate ≤0.1) by burn injury severity, patients were grouped by TBSA above or below 20% and statistically enriched pathways were identified. Sixty-eight patients were analyzed, most patients were male with a median age of 41 (interquartile range, 30.5-58.5) years, and TBSA of 20% (11%-34%). Thirty-five patients had % TBSA injury ≥20%, and this group experienced greater mortality (26% vs 3%, P = .008). Comparative analysis of genes from patients with </≥20% TBSA revealed 1505, 613, 380, 63, 1357, and 954 differentially expressed genes at hours 0, 2, 4, 8, 12, and 24, respectively. Pathway analysis revealed an initial up-regulation in several immune/inflammatory pathways within the ≥20% TBSA groups followed by shutdown. Severe burn injury is associated with an early proinflammatory immune response followed by shutdown of these pathways. Examination of the immunoinflammatory response to burn injury through differential gene regulation and associated immune pathways by injury severity may identify mechanistic targets for future intervention.

Meropenem pharmacokinetics in critically ill patients with or without burn treated with or without continuous veno-venous hemofiltration

Introduction

Severe burn injury involves widespread skin and tissue damage leading to systemic inflammation, hypermetabolism and multi‐organ failure. The hypermetabolic phase of burn injury has been associated with increased systemic antibiotic clearance; however, critical illness in the absence of burn may also induce similar physiologic changes. Continuous renal replacement therapy (CRRT) is often implemented in critically ill patients and may also affect antibiotic clearance. Although the pharmacokinetics (PK) of meropenem has been described in both the burn and non‐burn critically ill populations, direct comparative data is lacking.

Methods

For this study, we evaluated PK parameters of meropenem from 23 critically ill patients, burn or non‐burn, treated with or without continuous veno‐venous haemofiltration (CVVH) to determine the contribution of burn and CVVH to the variability of therapeutic meropenem levels.

Results

A two‐compartment model best described the data and revealed creatinine clearance (CrCl) and total burn surface area (TBSA) as significant covariates on clearance (CL) and peripheral volume of distribution (Vp), respectively. Of interest, non‐burn patients on CVVH displayed an overall lower inherent CL as compared to burn patients on CVVH (6.43 vs. 12.85 L/h). Probability of target attainment (PTA) simulations revealed augmented renal clearance (ARC) may necessitate dose adjustments, but TBSA and CVVH would not.

Conclusions

We recommend a standard dose of 1000 mg every 8 hours; however, if ARC is suspected, or the severity of illness requires a more stringent therapeutic target, we recommend a loading dose of 1000–2000 mg infused over 30 minutes to 1 hour followed by continuous infusion (3000–6000 mg over 24 hours), or intermittent infusion of 2000 mg every 8 hours.

Initial Results of the American Burn Association (ABA) Observational Multi-Center Evaluation on the Effectiveness of the Burn Navigator

The objective of this multi-center observational study was to evaluate resuscitation volumes and outcomes of patients who underwent fluid resuscitation utilizing the Burn Navigator (BN), a resuscitation clinical decision support tool. Two analyses were performed: examination of the first 24 hours of resuscitation, and the first 24 hours post-burn regardless of when the resuscitation began, to account for patients who presented in a delayed fashion. Patients were classified as having followed the BN (FBN) if all hourly fluid rates were within ±20 mL of BN recommendations for that hour at least 83% of the time, otherwise they were classified as not having followed BN (NFBN). Analysis of resuscitation volumes for FBN patients in the first 24 hours resulted in average volumes for primary crystalloid) and total fluids administered of 4.07 ± 1.76 mL/kg/TBSA (151.48 ± 77.46 mL/kg), and 4.68 ± 2.06 mL/kg/TBSA (175.01 ± 92.22 mL/kg), respectively. Patients who presented in a delayed fashion revealed average volumes for primary and total fluids of 5.28 ± 2.54 mL/kg/TBSA (201.11 ± 106.53 mL/kg), 6.35 ± 2.95 mL/kg/TBSA (244.08 ± 133.5 mL/kg), respectively. There was a significant decrease in the incidence of burn shock in the FBN group (p< 0.05). This study shows that the BN provides comparable resuscitation volumes of primary crystalloid fluid to the Parkland Formula, recommends total fluid infusion less than the Ivy Index, and was associated with a decreased incidence of burn shock. Early initiation of the BN device resulted in lower overall fluid volumes.

Characterization of severely burned patients and evaluation of factors associated to mortality. An observational retrospective cohort study in San Vicente Fundación Hospital

Introduction

Burns are common in developing countries and place a large burden on the medical and social care systems. However, information about management and outcomes from such countries is scarce. The purpose of this study was to analyze the epidemiology and main factors related to the mortality in severely burned patients at the Hospital Universitario San Vicente Fundación in Medellín, Colombia.

Methods

An observational retrospective cohort study was conducted. To establish prognostic factors associated with mortality, we analyzed variables such as age, sex, burned surface, and degree of burn, among others. Demographic, clinic, and management features as well as complications and factors associated with mortality were analyzed using logistic regression.

Results

4516 clinical histories were reviewed, 225 were included in the study. 76.9% were men, with a median age of 35 years; 64.9% were fire burns. The median burned body surface area was 42%. There were inhalation injuries in 135 patients and ocular in 106 patients. The main complication was infection followed by rhabdomyolysis. The overall hospital stay was 27 days, and the median length of stay at the intensive care unit was 7 days with in-hospital mortality of 30.7%. The variables associated with mortality were age, burned body surface area, degree of burn, and kidney injury. Surgical intervention was protective.

Conclusions

Severely burned patients in our hospital have similar outcomes and, in some cases, better outcomes than those reported in the literature in countries with similar characteristics, and we have seen that in the last years, there has been a better experience in the management of these patients. Elderly, extension, and depth of burnt tissue are markers of poor outcomes. Early surgery and intubation have shown better outcomes, probably due to infection control and removal of necrotic tissue, airway management, and ventilatory support for metabolic and hemodynamic derangement.

Gut Microbial Changes and their Contribution to Post-Burn Pathology

ABSTRACT

Burn injuries are a common form of traumatic injury that leads to significant morbidity and mortality worldwide. Burn injuries are characterized by inflammatory processes and alterations in numerous organ systems and functions. Recently, it has become apparent that the gastrointestinal bacterial microbiome is a key component of regulating the immune response and recovery from burn and can also contribute to significant detrimental sequelae after injury, such as sepsis and multiple organ failure. Microbial dysbiosis has been linked to multiple disease states; however, its role in exacerbating acute traumatic injuries, such as burn, is poorly understood. In this article, we review studies that document changes in the intestinal microbiome after burn injury, assess the implications in post-burn pathogenesis, and the potential for further discovery and research.

Microbiology and Infection Profile of Electric Burned Patients in a Referral Burn Hospital in Mexico City

Electrical burn injuries are one of the most severe forms of trauma. This study aims to investigate the infection complications in electrical burn patients in a referral hospital in Mexico City. A longitudinal retrospective study was conducted, involving electrical burn patients admitted from April 2011 to December 2016. Demographic and clinical data including type of electric burns, infection complications, and mortality was sought. Data were collected at admission and daily until discharge. Number and type of infections and microorganism isolations were sought. Risk factors for death were analyzed. A total of 111 patients were included, of which 96.4% were males, mean age of 31.6±16.22, most injuries were high voltage associated. The total body surface area average was 27.8% ± 19.63. The overall infection rate was 72.9 cases per 100 patients. Mortality was observed in 4 (3.6%) patients. About 59.1% (443/749) had growth for Gram-negative bacteria. Multidrug-resistant Pseudomonas aeruginosa was the most frequent microorganism isolated. Fungi were present in 4.9% of cases. Electrical burn injuries occurred in young males in our study. Infection was frequent, most of them caused by Gram-negative rods with an important rate of antimicrobial resistance; however, an important microbial diversity was present.

The status quo of early burn wound excision: Insights from the German burn registry

BACKGROUND

There is a common, well-known and established recommendation to excise burn wounds within 24-72 h in order to mitigate the systemic inflammatory and immunomodulatory response, shorten length of hospitalization through early grafting and optimize patient survival. Despite this apparent consensus, surprisingly few systematic studies have evaluated the actual adherence to this practice and its implications on patient outcomes. In this registry study, we sought to objectify the current status of early burn wound excision, its influencing factors and impact on patient outcomes for all German burn centers.

METHODS

The German burn registry ('Deutsches Verbrennungsregister') was queried for 3 consecutive years for all patients, who received at least one surgical intervention. Patients were stratified based on whether the first surgical procedure was performed early (EE, within 72 h) or late (LE, after 72 h) post-burn. Descriptive statistics and univariate regressions were performed to quantify fraction of EE vs. LE and to evaluate factors which might favor one over the other (i.e. age, inhalation injury, burn severity by total body surface area (TBSA), scald vs. other burns, obesity, time of admission). Key patient outcomes were analyzed for each group (i.e. mortality, length of hospitalization, number of surgeries) and multifactorial regression analyses were carried out to model the impact of EE on mortality. Statistical significance was accepted at p < 0.05.

RESULTS

After initial screening, 1494 complete records were included for final analysis and were stratified into EE and LE. Only 670 (44%) underwent EE within 72 h. Increasing TBSA burned (i.e. [TBSA > 30%]: 53.8% EE, [TBSA < 30%]: 43.5% EE, p < 0.01) and admission on a weekday between Sunday and Wednesday were associated with higher probability of EE (51.5% EE) versus Thursday to Sunday (37.3%, p < 0.001). Age, inhalation injury, cause of burn, and obesity had no effect on EE vs. LE. Patients with EE had significantly shorter median lengths of hospitalization (EE: 18 d, LE: 21 d, p < 0.01). The median number of operations was comparable for both groups. Gross mortality appeared higher in the EE group, but turned out to be comparable to LE after correction for age, TBSA and sex in multifactorial regression analysis.

CONCLUSION

Despite apparent consensus among burn physicians, early excision of burn wounds is performed in less than 50% of cases in German burn centers. The relationship of EE to TBSA burned is expected and clinically sound, while a dependence on admission weekday raises administrative and infrastructural questions, especially when patients who receive EE have significantly shorter hospital stays. More analyses from other burn repositories are needed to compare and benchmark the international status quo of early burn wound excision.

Early Initiation of Renal Replacement Therapy Among Burned Patients With Acute Kidney Injury

BACKGROUND

Burned patients with acute kidney injury (AKI) requiring renal replacement therapy (RRT) have exceedingly high mortality rates of 73% to 100%. Since January 2011, we have been adopting an early RRT approach in managing burned patients with AKI. Our hypothesis was that early initiation of RRT leads to improved outcome and survival among burned patients with AKI.

METHODOLOGY

We conducted a retrospective analysis of Burns Database in Singapore General Hospital from January 2011 to February 2016. Indications for dialysis included serum creatinine of greater than 1.5 times baseline or urine output of less than 0.5 mL/kg per hour for at least 6 consecutive hours. Patients with similar condition from January 2006 to December 2010 were recruited for comparison.

RESULT

A total of 27 patients with burns and AKI were recruited from January 2011 to February 2016. The mean age was 45.4 years and 88.9% were male. The mean total burn surface area (TBSA) was 54.8%. The total volume of fluid resuscitation was 2.7 mL/kg per TBSA. The time from onset of burn to RRT was 6.4 days. Most patients presented with stage 1 AKI (51.9%), whereas 22.2% and 25.9% had stage 2 and stage 3 AKI, respectively. Most patients (74.1%) received CRRT and 18.5% received SLED. The mortality rate was 37.0% with majority of death (70%) due to sepsis/multiorgan failure. Only 1 patient required long-term RRT after discharge, and there was no occurrence of abdominal compartment syndrome. The mean age of 15 patients from 2006 to 2010 was 47.8 years. The mean TBSA was 49.5%. Only 26.7% of patients were started on RRT. The mortality rate was 66.7%, which was higher than that of subjects from 2011 to 2016 (37.0%) (P = 0.039).

CONCLUSIONS

Optimal timing of RRT for burned patients with AKI has not been established and data on early RRT approach are scarce. The findings of our study suggested that early RRT was associated with lower mortality rates among burned victims with AKI.

Early abnormal fibrinolysis and mortality in patients with thermal injury: a prospective cohort study

INTRODUCTION

Abnormal fibrinolysis early after injury has been associated with increased mortality in trauma patients, but no studies have addressed patients with burn injury. This prospective cohort study aimed to characterize fibrinolytic phenotypes in burn patients and to see if they were associated with mortality.

METHODS

Patients presenting to a regional burn centre within 4 h of thermal injury were included. Blood was collected for sequential viscoelastic measurements using thromboelastography (RapidTEG™) over 12 h. The percentage decrease in clot strength 30 min after the time of maximal clot strength (LY30) was used to categorize patients into hypofibrinolytic/fibrinolytic shutdown (SD), physiological (PHYS) and hyperfibrinolytic (HF) phenotypes. Injury characteristics, demographics and outcomes were compared.

RESULTS

Of 115 included patients, just over two thirds were male. Overall median age was 40 (i.q.r. 28-57) years and median total body surface area (TBSA) burn was 13 (i.q.r. 6-30) per cent. Some 42 (36.5 per cent) patients had severe burns affecting over 20 per cent TBSA. Overall mortality was 18.3 per cent. At admission 60.0 per cent were PHYS, 30.4 per cent were SD and 9.6 per cent HF. HF was associated with increased risk of mortality on admission (odds ratio 12.61 (95 per cent c.i. 1.12 to 142.57); P = 0.041) but not later during the admission when its incidence also decreased. Admission SD was not associated with mortality, but incidence increased and by 4 h and beyond, SD was associated with increased mortality, compared with PHYS (odds ratio 8.27 (95 per cent c.i. 1.16 to 58.95); P = 0.034).

DISCUSSION

Early abnormal fibrinolytic function is associated with mortality in burn patients.

Direct Peritoneal Resuscitation Improves Survival in a Murine Model of Combined Hemorrhage and Burn Injury

INTRODUCTION

Combined burn injury and hemorrhagic shock are a common cause of injury in wounded warfighters. Current protocols for resuscitation for isolated burn injury and isolated hemorrhagic shock are well defined, but the optimal strategy for combined injury is not fully established. Direct peritoneal resuscitation (DPR) has been shown to improve survival in rats after hemorrhagic shock, but its role in a combined burn/hemorrhage injury is unknown. We hypothesized that DPR would improve survival in mice subjected to combined burn injury and hemorrhage.

MATERIALS AND METHODS

Male C57/BL6J mice aged 8 weeks were subjected to a 7-second 30% total body surface area scald in a 90°C water bath. Following the scald, mice received DPR with 1.5 mL normal saline or 1.5 mL peritoneal dialysis solution (Delflex). Control mice received no peritoneal solution. Mice underwent a controlled hemorrhage shock via femoral artery cannulation to a systolic blood pressure of 25 mm Hg for 30 minutes. Mice were then resuscitated to a target blood pressure with either lactated Ringer's (LR) or a 1:1 ratio of packed red blood cells (pRBCs) and fresh frozen plasma (FFP). Mice were observed for 24 hours following injury.

RESULTS

Median survival time for mice with no DPR was 1.47 hours in combination with intravascular LR resuscitation and 2.08 hours with 1:1 pRBC:FFP. Median survival time significantly improved with the addition of intraperitoneal normal saline or Delflex. Mice that received DPR followed by 1:1 pRBC:FFP required less intravascular volume than mice that received DPR with LR, pRBC:FFP alone, and LR alone. Intraperitoneal Delflex was associated with higher levels of tumor necrosis factor alpha and macrophage inflammatory protein 1 alpha and lower levels of interleukin 10 and intestinal fatty acid binding protein. Intraperitoneal normal saline resulted in less lung injury 1 hour postresuscitation, but increased to similar severity of Delflex at 4 hours.

CONCLUSIONS

After a combined burn injury and hemorrhage, DPR leads to increased survival in mice. Survival was similar with the use of normal saline or Delflex. DPR with normal saline reduced the inflammatory response seen with Delflex and delayed the progression of acute lung injury. DPR may be a valuable strategy in the treatment of patients with combined burn injury and hemorrhage.

Lack of early platelet and leukocyte activation can indicate complications after major burn injury

BACKGROUND

Major burn injury causes massive tissue destruction consequently enhanced platelet function and leukocyte-mediated inflammatory response.

METHODS

In a prospective, observational study 23 consecutive patients with more than 20% body surface burn injury were followed for five days (T1-T5) after admission to a university intensive care (ICU). Platelet and leukocyte antisedimentation rate (PAR and LAR) was measured by one-hour gravity sedimentation. It detects the percentage of total platelet and leukocyte number crossed the half line of blood sample column, therefore, they can be regarded as cells of decreased specific gravity. We aimed to investigate the time course of PAR and LAR after burn injury, as the trend of platelet and the leukocyte activation in the early post-burn period.

RESULTS

Daily mean PAR and LAR values continuously increased in the observation period (T1 to T5). Daily mean PAR and LAR were lower in ICU non-survivors (n = 7) compared to survivors (n = 16) between T2 and T4 (p < 0.05 and p < 0.01). PAR values of septic patients (n = 10) were lower than that of non-septic ones (n = 13, p < 0.01 at T5).

CONCLUSIONS

Both PAR and LAR, as novel bedside test can predict septic complications and unfavorable outcome after major burn injury. Further studies with higher sample size are warranted.