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Orbay H, Corcos AC, Ziembicki JA, Egro FM. Challenges in the Management of Large Burns. Clin Plast Surg 2024; 51:319-327. [PMID: 38429052 DOI: 10.1016/j.cps.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Abstract
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.
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Affiliation(s)
- Hakan Orbay
- Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Alain C Corcos
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jenny A Ziembicki
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Francesco M Egro
- Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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2
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Bayuo J, Abu-Odah H, Koduah AO. Components, Models of Integration, and Outcomes Associated with Palliative/ end-of-Life Care Interventions in the Burn Unit: A Scoping Review. J Palliat Care 2023; 38:239-253. [PMID: 35603876 DOI: 10.1177/08258597221102735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To scope the literature to ascertain the components of palliative care (PC) interventions for burn patients, models of integration, and outcomes. Methods: Arksey and O'Malley scoping review design with narrative synthesis was employed and reported following the PRISMA-ScR guidelines. Primary studies reporting PC interventions in the burn unit were considered for inclusion. CINAHL via EBSCO, PubMed, EMBASE via OVID, Web of Science, and gray literature sources were searched from inception to June 2021. Results: Fifteen studies emerging from high-income settings were retained. Data were organized around three concepts: components of palliative/ end of life care in the burn unit; models of integration; and outcomes. The components of interventions based on the Robert Wood Johnson Foundation Critical Care End-of Life Group domains include decision-making, communication, symptom management and comfort care, spiritual support, and emotional and practical support for families. Consultative and integrative models were noted to be the strategies for integrating PC in the burn unit. The outcomes were varied with only few studies reporting healthcare staff related outcomes. Conclusion: PC may have the potential of improving end-of-life care in the burn unit albeit the limited studies and lack of standardized outcomes makes it difficult to draw stronger conclusions regarding what is likely to work best in the burn unit.
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Affiliation(s)
- Jonathan Bayuo
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong
| | - Hammoda Abu-Odah
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong
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3
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Reeder S, Cleland HJ, Gold M, Tracy LM. Exploring clinicians' decision-making processes about end-of-life care after burns: A qualitative interview study. Burns 2022; 49:595-606. [PMID: 36709087 DOI: 10.1016/j.burns.2022.12.001] [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: 07/19/2022] [Revised: 11/02/2022] [Accepted: 12/08/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Little is known about treatment decision-making experiences and how/why particular attitudes exist amongst specialist burn clinicians when faced with patients with potentially non-survivable burn injuries. This exploratory qualitative study aimed to understand clinicians' decision-making processes regarding end-of-life (EoL) care after a severe and potentially non-survivable burn injury. METHODS Eleven clinicians experienced in EoL decision-making were interviewed via telephone or video conferencing in June-August 2021. A thematic analysis was undertaken using a framework approach. RESULTS Decision-making about initiating EoL care was described as complex and multifactorial. On occasions when people presented with 'unsurvivable' injuries, decision-making was clear. Most clinicians used a multidisciplinary team approach to initiate EoL; variations existed on which professions were included in the decision-making process. Many clinicians reported using protocols or guidelines that could be personalised to each patient. The use of pathways/protocols might explain why clinicians did not report routine involvement of palliative care clinicians in EoL discussions. CONCLUSION The process of EoL decision-making for a patient with a potentially non-survivable burn injury was layered, complex, and tailored. Processes and approaches varied, although most used protocols to guide EoL decisions. Despite the reported complexity of EoL decision-making, palliative care teams were rarely involved or consulted.
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Affiliation(s)
- Sandra Reeder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia; Central Clinical School, Monash University, Melbourne, VIC 3004, Australia
| | - Heather J Cleland
- Victorian Adult Burns Service, Alfred Hospital, Melbourne, VIC 3004, Australia
| | - Michelle Gold
- Palliative Care Service, Alfred Health, Melbourne, VIC 3004, Australia
| | - Lincoln M Tracy
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia.
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4
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What do we know about experiencing end-of-life in burn intensive care units? A scoping review. Palliat Support Care 2022:1-17. [PMID: 36254708 DOI: 10.1017/s1478951522001389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES The aim of this article is to review and synthesize the evidence on end-of-life in burn intensive care units. METHODS Systematic scoping review: Preferred Reporting Items for Systemic Reviews extension for Scoping Reviews was used as a reporting guideline. Searches were performed in 3 databases, with no time restriction and up to September 2021. RESULTS A total of 16,287 documents were identified; 18 were selected for analysis and synthesis. Three key themes emerged: (i) characteristics of the end-of-life in burn intensive care units, including end-of-life decisions, decision-making processes, causes, and trajectories of death; (ii) symptom control at the end-of-life in burn intensive care units focusing on patients' comfort; and (iii) concepts, models, and designs of the care provided to burned patients at the end-of-life, mainly care approaches, provision of care, and palliative care. SIGNIFICANCE OF RESULTS End-of-life care is a major step in the care provided to critically ill burned patients. Dying and death in burn intensive care units are often preceded by end-of-life decisions, namely forgoing treatment and do-not-attempt to resuscitate. Different dying trajectories were described, suggesting the possibility to develop further studies to identify triggers for palliative care referral. Symptom control was not described in detail. Palliative care was rarely involved in end-of-life care for these patients. This review highlights the need for early and high-quality palliative and end-of-life care in the trajectories of critically ill burned patients, leading to an improved perception of end-of-life in burn intensive care units. Further research is needed to study the best way to provide optimal end-of-life care and foster integrated palliative care in burn intensive care units.
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5
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Rogers AD, Amaral A, Cartotto R, El Khatib A, Fowler R, Logsetty S, Malic C, Mason S, Nickerson D, Papp A, Rasmussen J, Wallace D. Choosing wisely in burn care. Burns 2022; 48:1097-1103. [PMID: 34563420 DOI: 10.1016/j.burns.2021.09.007] [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: 04/29/2021] [Revised: 08/15/2021] [Accepted: 09/13/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND The Choosing Wisely Campaign was launched in 2012 and has been applied to a broad spectrum of disciplines in almost thirty countries, with the objective of reducing unnecessary or potentially harmful investigations and procedures, thus limiting costs and improving outcomes. In Canada, patients with burn injuries are usually initially assessed by primary care and emergency providers, while plastic or general surgeons provide ongoing management. We sought to develop a series of Choosing Wisely statements for burn care to guide these practitioners and inform suitable, cost-effective investigations and treatment choices. METHODS The Choosing Wisely Canada list for Burns was developed by members of the Canadian Special Interest Group of the American Burn Association. Eleven recommendations were generated from an initial list of 29 statements using a modified Delphi process and SurveyMonkey™. RESULTS Recommendations included statements on avoidance of prophylactic antibiotics, restriction of blood products, use of adjunctive analgesic medications, monitoring and titration of opioid analgesics, and minimizing 'routine' bloodwork, microbiology or radiological investigations. CONCLUSIONS The Choosing Wisely recommendations aim to encourage greater discussion between those involved in burn care, other health care professionals, and their patients, with a view to reduce the cost and adverse effects associated with unnecessary therapeutic and diagnostic procedures, while still maintaining high standards of evidence-based burn care.
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Affiliation(s)
- A D Rogers
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
| | - A Amaral
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - R Cartotto
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - A El Khatib
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - R Fowler
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - S Logsetty
- Manitoba Firefighters Burn Unit, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - C Malic
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - S Mason
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - D Nickerson
- Calgary Firefighters' Burn Treatment Centre, Foothills Medical Centre, Department of Surgery, University of Calgary, Alberta, Canada
| | - A Papp
- BC Professional Firefighters' Burn Unit, Vancouver General Hospital, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - J Rasmussen
- Queen Elizabeth II Health Sciences Centre Burn Unit, Dalhousie University, Halifax, Nova Scotia, Canada
| | - D Wallace
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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6
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Tracy LM, Gold M, Reeder S, Cleland HJ. Treatment Decisions in Patients with Potentially Non-Survivable Burn Injury in Australia and New Zealand: A Registry-based Study. J Burn Care Res 2022; 44:675-684. [PMID: 35170735 PMCID: PMC10152993 DOI: 10.1093/jbcr/irac017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Indexed: 11/13/2022]
Abstract
Whilst burn-related mortality is rare in high-income countries, there are unique features related to prognostication that make examination of decision-making practices important to explore. Compared to other kinds of trauma, burn patients (even those with non-survivable injuries) may be relatively stable after injury initially. Complications or patient comorbidity may make it clear later in the clinical trajectory that ongoing treatment is futile. Burn care clinicians are therefore required to make decisions regarding the withholding or withdrawal of treatment in patients with potentially non-survivable burn injury. There is yet to be a comprehensive investigation of treatment decision practices following burn injury in Australia and New Zealand. Data for patients admitted to specialist burn services between July 2009 and June 2020 were obtained from the Burns Registry of Australia and New Zealand. Patients were grouped according to treatment decision: palliative management, active treatment withdrawn, and active treatment until death. Predictors of treatment initiation and withholding or withdrawing treatment within 24 hours were assessed using multilevel mixed-effects logistic regression. Descriptive comparisons between treatment groups were made. Of the 32,186 patients meeting study inclusion criteria, 327 (1.0%) died prior to discharge. Fifty-six patients were treated initially with palliative intent and 227 patients had active treatment initiated and later withdrawn. Increasing age and burn size reduced the odds of having active treatment initiated. We demonstrate differences in demographic and injury severity characteristics as well as end of life decision-making timing between different treatment pathways pursued for patients who die in-hospital. Our next step into the decision-making process is to gain a greater understanding of the clinician's perspective (e.g., through surveys and/or interviews).
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Affiliation(s)
- Lincoln M Tracy
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Michelle Gold
- Palliative Care Service, Alfred Health, Melbourne, Australia
| | - Sandra Reeder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Monash Partners Academic Health Science Centre, Kanooka Grove Clayton, VIC, Australia
| | - Heather J Cleland
- Victorian Adult Burns Service, Alfred Hospital, Melbourne VIC, Australia
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7
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Carmichael H, Brackett H, Scott MC, Dines MM, Mather SE, Smith TM, Duffy PS, Wiktor AJ, Lambert Wagner A. Early Palliative Care Consultation in the Burn Unit: A Quality Improvement Initiative to Increase Utilization. J Burn Care Res 2021; 42:1128-1135. [PMID: 34302472 DOI: 10.1093/jbcr/irab140] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Despite significant morbidity and mortality for major burns, palliative care consultation (PCC) is underutilized in this population. The purpose of this study is to examine the impact of a protocol using recommended "triggers" for PCC at a single academic burn center. This is a retrospective review of patient deaths over a four-year period. Use of life-sustaining treatments, comfort care (de-escalation of one or more life-sustaining treatments) and do not attempt resuscitation (DNAR) orders were determined. Use of PCC was compared during periods before and after a protocol establishing recommended triggers for early (<72 hrs of admission) PCC was instituted in 2019. A total of 33 patient deaths were reviewed. Most patients were male (n=28, 85%) and median age was 62 years [IQR 42-72]. Median revised Baux score was 112 [IQR 81-133]. Many patients had life-sustaining interventions such as intubation, dialysis, or cardiopulmonary resuscitation, often prior to admission. Amongst patients who survived >24 hrs, 67% (n=14/21) had PCC. Frequency of PCC increased after protocol development, with 100% vs. 36% of these patients having PCC before death (p=0.004). However, even during the later period, less than half of patients had early PCC despite meeting criteria at admission. In conclusion, initiation of life-sustaining measures in severely injured burn patients occurs prior to or early during hospitalization. Thus, value-based early goals of care discussions are valuable to prevent interventions that do not align with patient values and assist with de-escalation of life-sustaining treatment. In this small sample, we found that while there was increasing use of PCC overall after developing a protocol of recommended triggers for consultation, many patients who met criteria at admission did not receive early PCC. Further research is needed to elucidate reasons why providers may be resistant to PCC.
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Affiliation(s)
| | - Hareklia Brackett
- Department of Medicine, Division of General Internal Medicine, University of Colorado School of Medicine.,Palliative Care Service, University of Colorado Hospital
| | - Maurice C Scott
- Department of Medicine, Division of General Internal Medicine, University of Colorado School of Medicine.,Palliative Care Service, University of Colorado Hospital
| | | | - Sarah E Mather
- Department of Spiritual Care Services, University of Colorado Hospital
| | - Tyler M Smith
- Department of Surgery, University of Colorado School of Medicine
| | - Patrick S Duffy
- Department of Surgery, University of Colorado School of Medicine
| | - Arek J Wiktor
- Department of Surgery, University of Colorado School of Medicine
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8
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den Hollander D, Albertyn R, Ambler J. Palliation, end-of-life care and burns; practical issues, spiritual care and care of the family - A narrative review II. Afr J Emerg Med 2020; 10:256-260. [PMID: 33299759 PMCID: PMC7700979 DOI: 10.1016/j.afjem.2020.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 07/21/2020] [Accepted: 07/26/2020] [Indexed: 12/03/2022] Open
Abstract
Palliative care is the turn from cure as the priority of care to symptom relief and comfort care. Although very little is published in the burn literature on palliative care, guidelines can be gleaned from the general literature on palliative care, particularly for acute surgical and critical care patients. This second article discusses practical issues around palliative care for burn patients, such as pain and fluid management, withdrawal of ventilator support and wound care, as well as spiritual and family issues. This paper forms part two, of two narrative reviews on the topic of palliation, end-of-life care and burns. The first part considered concepts, decision-making and communication. It was published in volume 10, issue 2, June 2020, pages 95–98. Mortality of burns presented to a burns unit in Africa is about 10%. Resources in Africa to manage burn patients are scarce and patients with massive burns may not be offered curative burn care. There are no guidelines for palliative care in burn patients.
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Affiliation(s)
- Daan den Hollander
- Burns Unit, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
- Department of Surgery, University of KwaZulu Natal, South Africa
- Corresponding author at: Red Cross Memorial Children's Hospital, Cape Town, South Africa.
| | - Rene Albertyn
- Red Cross Memorial Children's Hospital, Cape Town, South Africa
| | - Julia Ambler
- Palliative Care Practitioner, Department of Paediatrics, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
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9
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Teven CM, Angelos P. Comfort Care after Self-Immolation: Is the Physician Complicit? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:123-125. [PMID: 32757926 DOI: 10.1080/15265161.2020.1782514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
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10
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den Hollander D, Albertyn R, Amber J. Palliation, end-of-life care and burns; concepts, decision-making and communication - A narrative review. Afr J Emerg Med 2020; 10:95-98. [PMID: 32612916 PMCID: PMC7320205 DOI: 10.1016/j.afjem.2020.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 12/31/2019] [Accepted: 01/06/2020] [Indexed: 12/03/2022] Open
Abstract
Palliative care is the turn from cure as the priority of care to symptom relief and comfort care. Although very little is published in the burn literature on palliative care, guidelines can be gleaned from the general literature on palliative care, particularly for acute surgical and critical care patients. Palliative care may be started because of futility, on request of the patient, or because of limited resources. The SPIKES acronym is a useful guide to avoid errors in communication with terminal patients and their relatives.
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Affiliation(s)
- Daan den Hollander
- Burns Unit Inkosi Albert Luthuli Central Hospital, Durban, South Africa
- Department of Surgery, University of KwaZulu Natal, South Africa
| | - Rene Albertyn
- Red Cross Memorial Children's Hospital, South Africa
| | - Julia Amber
- Palliative Care Practitioner, Department of Pediatrics, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
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11
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Bayuo J, Bristowe K, Harding R, Agyei FB, Agbeko AE, Agbenorku P, Baffour PK, Allotey G, Hoyte-Williams PE. The Role of Palliative Care in Burns: A Scoping Review. J Pain Symptom Manage 2020; 59:1089-1108. [PMID: 31733355 DOI: 10.1016/j.jpainsymman.2019.11.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/06/2019] [Accepted: 11/06/2019] [Indexed: 12/25/2022]
Abstract
CONTEXT Patients with severe burns may face distressing symptoms with a high risk of mortality as a result of their injury. The role of palliative care in burns management remains unclear. OBJECTIVE To appraise the literature on the role of palliative care in burns management. METHODS We used scoping review with searches in 12 databases from their inception to August 2019. The citation retrieval and retention are reported in a PRISMA statement. FINDINGS 39 papers comprising of 30 primary studies (26 from high-income and four from middle-income countries), four reviews, two editorials, two guidelines, and one expert board review document were retained in the review. Palliative care is used synonymously with comfort and end-of-life care in burns literature. Comfort care is mostly initiated when active treatment is withheld (early deaths) or withdrawn (late deaths), limiting its overall benefits to burn patients, their families, and health care professionals. Futility decisions are usually complex and challenging, particularly for patients in the late death category, and it is unclear if these decisions result in timely commencement of comfort care measures. Three comfort care pathways were identified, but it remained unclear how these pathways evaluated "good death" or supported the family which creates the need for the development of other evidence-based guidelines. CONCLUSION Palliative care is applicable in burns management, but its current role is mostly confined to the end-of-life period, suggesting that it is not been fully integrated in the management process. Evidence-based guidelines are needed to support the integration and delivery of palliative care in the burn patient population.
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Affiliation(s)
- Jonathan Bayuo
- Department of Nursing, Faculty of Health and Medical Sciences, Presbyterian University College, Agogo, Ghana; School of Nursing, The Hong Kong Polytechnic University, Hong Kong.
| | - Katherine Bristowe
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute, Kings College, London, United Kingdom
| | - Richard Harding
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute, Kings College, London, United Kingdom
| | - Frank Bediako Agyei
- Department of Nursing, Faculty of Health and Medical Sciences, Presbyterian University College, Agogo, Ghana
| | | | - Pius Agbenorku
- School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Plastics, Burns and Reconstructive Surgical Division, Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Prince Kyei Baffour
- Burns Intensive Care Unit, Plastics and Reconstructive Surgical Unit, Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Gabriel Allotey
- Burns Intensive Care Unit, Plastics and Reconstructive Surgical Unit, Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Paa Ekow Hoyte-Williams
- Plastics, Burns and Reconstructive Surgical Division, Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana
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12
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Cook AC, Langston JA, Jaramillo JD, Edwards KE, Wong HN, Aslakson RA. Opportunities for Palliative Care in Patients With Burn Injury-A Systematic Review. J Pain Symptom Manage 2020; 59:916-931.e1. [PMID: 31775021 DOI: 10.1016/j.jpainsymman.2019.11.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 11/12/2019] [Accepted: 11/13/2019] [Indexed: 12/19/2022]
Abstract
CONTEXT Patients with significant burn injuries likely have palliative care needs. OBJECTIVES We performed a systematic review of existing evidence concerning the palliative care needs of burn patients. METHODS Through November 26, 2018, we systematically searched PubMed, CINAHL, Embase, Web of Science, and Scopus, using terms representing burn injuries and the eight domains of quality palliative care as outlined by the National Consensus Project for Quality Palliative Care. Eligible articles involved burn-injured patients treated with an intervention targeting at least one of the eight domains. RESULTS Our searches yielded 7532 unique records, which led to 238 articles for full review and 88 studies that met inclusion criteria. Seventy-five studies addressed the domain physical aspects of care and merit a separate systematic review; 13 studies were included in our final review. Four of the seven domains-processes of care, psychologic symptoms, social aspects, and end of life-were addressed by studies but three domains-spiritual, cultural, or ethics-were unaddressed. Included studies highlight potential benefits from peridischarge self-care education programs, peer support, and group therapy in improving quality of life. In patients with severe injuries, end-of-life decision-making protocols were associated with increased utilization of comfort-focused treatments. CONCLUSION Most existing palliative care-related research in burn patients addresses interventions for physical symptoms with minimal literature concerning other domains. Opportunities exist for further research of palliative care in burn populations with emphasis on addressing interventions for all domains and better standardizing the language and outcomes for the palliative care interventions.
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Affiliation(s)
- Allyson C Cook
- Department of Medicine, University of California San Francisco, San Francisco, California, USA.
| | - Jessica A Langston
- Department of Medicine, VA NorCal Health Care System, Sacramento, California, USA
| | | | - Kristin E Edwards
- Department of Medicine-Palliative Care, Bridgeport Hospital, Yale New Haven Health, Bridgeport, Connecticut, USA
| | - Hong-Nei Wong
- Lane Medical Library & Knowledge Management Center, Stanford University School of Medicine, Stanford, California, USA
| | - Rebecca A Aslakson
- Departments of Medicine & Anesthesiology, Stanford University, Stanford, California, USA
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13
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Ribeiro AF, Martins Pereira S, Gomes B, Nunes R. Do patients, families, and healthcare teams benefit from the integration of palliative care in burn intensive care units? Results from a systematic review with narrative synthesis. Palliat Med 2019; 33:1241-1254. [PMID: 31296110 DOI: 10.1177/0269216319862160] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Burn units are intensive care facilities specialized in the treatment of patients with severe burns. As burn injuries have a major impact in physical, psychosocial, and spiritual health, palliative care can be a strengthening component of integrated care. AIM To review and appraise the existing evidence about the integration of palliative care in burn intensive care units with respect to (1) the concept, model and design and (2) the benefits and outcomes of this integration. DESIGN A systematic review was conducted following PRISMA guidelines. Protocol registered with PROSPERO (CRD42018111676). DATA SOURCES Five electronic databases were searched (PubMed/NLM, Web of Science, MEDLINE/TR, Ovid, and CINAHL/EBSCO) until May 2019. A narrative synthesis of the findings was constructed. Hawker et al.'s tool was used for quality appraisal. RESULTS A total of 299 articles were identified, of which five were included for analysis involving a total of 7353 individuals. Findings suggest that there may be benefits from integrating palliative care in burn units, specifically in terms of patients' comfort, decision-making processes, and family care. Multidisciplinary teams may experience lower levels of burden as result of integrating palliative care in burn units. CONCLUSION This review reflects the challenging setting of burn intensive care units. Evidence from these articles suggests that the integration of palliative care in burn intensive care units improves patients' comfort, decision-making process, and family care. Further research is needed to better understand how the integration of palliative care in burn intensive care units may be fostered and to identify the outcomes of this integration.
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Affiliation(s)
| | - Sandra Martins Pereira
- Instituto de Bioética, Universidade Católica Portuguesa, Porto, Portugal.,UNESCO Chair in Bioethics, Instituto de Bioética, Universidade Católica Portuguesa, Porto, Portugal.,Centro de Estudos em Gestão e Economia (CEGE), Porto Católica Business School, Universidade Católica Portuguesa, Porto, Portugal
| | - Barbara Gomes
- Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal.,Cicely Saunders Institute, King's College London, London, UK
| | - Rui Nunes
- Faculdade de Medicina, Universidade do Porto, Porto, Portugal.,International Network UNESCO Chair in Bioethics
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14
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Bartley CN, Atwell K, Cairns B, Charles A. Predictors of withdrawal of life support after burn injury. Burns 2018; 45:322-327. [PMID: 30442381 DOI: 10.1016/j.burns.2018.10.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 10/05/2018] [Accepted: 10/15/2018] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Discussions regarding withdrawal of life support after burn injury are challenging and complex. Often, providers may facilitate this discussion when the extent of injury makes survival highly unlikely or when the patient's condition deteriorates during resuscitation. Few papers have evaluated withdrawal of life support in burn patients. We therefore sought to determine the predictor of withdrawal of life support (WLS) in a regional burn center. METHODS We conducted a retrospective analysis of all burn patients from 2002 to 2012. Patient characteristics included age, gender, burn mechanism, percentage total body surface area (%TBSA) burned, presence of inhalation injury, hospital length of stay, and pre-existing comorbidities. Patients <17years of age and patients with unknown disposition were excluded. Patients were categorized into three cohorts: Alive till discharge (Alive), death by withdrawal of life support (WLS), or death despite ongoing life support (DLS). DLS patients were then excluded from the study population. Multivariate logistic regression was used to estimate predictors of WLS. RESULTS 8,371 patients were included for analysis: 8134 Alive, 237 WLS. Females had an increased odd of WLS compared to males (OR 2.03, 95% CI 1.18-3.48; p=0.010). Based on higher CCI, patients with pre-existing comorbidities had an increased odd of WLS (OR 1.28, 95% CI 1.08-1.52; p=0.005). There was a significantly increased odds for WLS (OR 1.09, 95% CI 1.06-1.12; p<0.001) with increasing age. Similarly, there was an increased odd for WLS (OR 1.08, 95% CI 1.07-1.51; p<0.001) with increasing %TBSA. An increased odd of WLS (OR 2.47, 95% CI 1.05-5.78; p=0.038) was also found in patients with inhalation injury. CONCLUSION The decision to withdraw life support is a complex and difficult decision. Our current understanding of predictors of withdrawal of life support suggests that they mirror those factors which increase a patient's risk of mortality. Further research is needed to fully explore end-of-life decision making in regards to burn patients. The role of patient's sex, particularly women, in WLS decision making needs to be further explored.
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Affiliation(s)
- Colleen N Bartley
- Department of Surgery, University of North Carolina at Chapel Hill, North Carolina Jaycee Burn Center, United States
| | - Kenisha Atwell
- Department of Surgery, University of North Carolina at Chapel Hill, North Carolina Jaycee Burn Center, United States
| | - Bruce Cairns
- Department of Surgery, University of North Carolina at Chapel Hill, North Carolina Jaycee Burn Center, United States
| | - Anthony Charles
- Department of Surgery, University of North Carolina at Chapel Hill, North Carolina Jaycee Burn Center, United States.
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Coyle S, Elverson J, Harlow T, Jordan A, McNamara P, O'Neill C, Quibell R, Regnard C, Spiller J, Stephenson J. The myth that shames us all. Lancet 2018; 392:1196. [PMID: 30319108 DOI: 10.1016/s0140-6736(18)31876-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 08/07/2018] [Indexed: 11/23/2022]
Affiliation(s)
- Séamus Coyle
- Palliative Care Institute, University of Liverpool and Saint Helens and Knowsley Hospitals Trust, Liverpool, UK
| | - Jo Elverson
- Saint Oswald's Hospice, Newcastle upon Tyne NE31EE, UK
| | - Tim Harlow
- Saint Oswald's Hospice, Newcastle upon Tyne NE31EE, UK
| | | | - Paul McNamara
- Saint Oswald's Hospice, Newcastle upon Tyne NE31EE, UK
| | - Catherine O'Neill
- Saint Oswald's Hospice, Newcastle upon Tyne NE31EE, UK; Hospiscare, Exeter, UK
| | - Rachel Quibell
- Newcastle Upon Tyne NHS Foundation Trust, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Claud Regnard
- Saint Oswald's Hospice, Newcastle upon Tyne NE31EE, UK.
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Zavlin D, Chegireddy V, Boukovalas S, Nia AM, Branski LK, Friedman JD, Echo A. Multi-institutional analysis of independent predictors for burn mortality in the United States. BURNS & TRAUMA 2018; 6:24. [PMID: 30151396 PMCID: PMC6103989 DOI: 10.1186/s41038-018-0127-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 07/16/2018] [Indexed: 11/10/2022]
Abstract
Background Previous reports individually identified different factors that predict death after burns. The authors employed the multi-center American Burn Association's (ABA) National Burn Repository (NBR) to elucidate which parameters have the highest negative impact on burn mortality. Methods We audited data from the NBR v8.0 for the years 2002-2011 and included 137,061 patients in our study. The cases were stratified into two cohorts based on the primary outcome of death/survival and then evaluated for demographic data, intraoperative details, and their morbidity after admission. A multivariable regression analysis aimed to identify independent risk factors associated with mortality. Results A total of 3.3% of patients in this analysis did not survive their burn injuries. Of those, 52.0% expired within 7 days after admission. Patients in the mortality cohort were of older age (p < 0.001), more frequently female (p < 0.001), and had more pre-existing comorbidities (p < 0.001). Total body surface area (TBSA), inhalation injury, hospitalization time, and occurrence of complications were higher compared to survivors (p < 0.001). Lack of insurance (odds ratio (OR) = 1.84, confidence interval (CI) 1.38-2.46), diabetes (OR = 1.24, CI 1.01-1.53), any complication (OR = 4.09, CI 3.27-5.12), inhalation injury (OR = 3.84, CI 3.38-4.36), and the need for operative procedures (OR = 2.60, CI 2.20-3.08) were the strongest independent contributors to mortality after burns (p < 0.001). Age (OR = 1.07, CI 1.06-1.07) and TBSA (OR = 1.09, CI 1.09-1.09) were significant on a continuous scale (p < 0.001) while overall comorbidities were not a statistical risk factor. Conclusion Uninsured status, inhalation injury, in-hospital complications, and operative procedures were the strongest mortality predictors after burns. Since most fatal outcomes (52.0%) occur within 7 days after injury, physicians and medical staff need to be aware of these risk factors upon patient admission to a burn center.
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Affiliation(s)
- Dmitry Zavlin
- 1Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, 6560 Fannin Street, Scurlock Tower, Suite 2200, Houston, TX 77030 USA
| | - Vishwanath Chegireddy
- 1Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, 6560 Fannin Street, Scurlock Tower, Suite 2200, Houston, TX 77030 USA
| | - Stefanos Boukovalas
- 2Division of Plastic Surgery, The University of Texas Medical Branch, Galveston, TX USA
| | - Anna M Nia
- 3School of Medicine, The University of Texas Medical Branch, Galveston, TX USA
| | - Ludwik K Branski
- 2Division of Plastic Surgery, The University of Texas Medical Branch, Galveston, TX USA
| | - Jeffrey D Friedman
- 1Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, 6560 Fannin Street, Scurlock Tower, Suite 2200, Houston, TX 77030 USA
| | - Anthony Echo
- 1Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, 6560 Fannin Street, Scurlock Tower, Suite 2200, Houston, TX 77030 USA
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Sheckter CC, Hung KS, Rochlin D, Maan Z, Karanas Y, Curtin C. Trends and inpatient outcomes for palliative care services in major burn patients: A 10-year analysis of the nationwide inpatient sample. Burns 2018; 44:1903-1909. [PMID: 30115531 DOI: 10.1016/j.burns.2018.07.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 06/18/2018] [Accepted: 07/26/2018] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Despite advances in critical care and the surgical management of major burns, highly moribund patients are unlikely to survive. Little is known regarding the utilization and effects of palliative care services in this population. METHODS All major burn hospitalizations were identified within the Nationwide Inpatient Sample. Patients were characterized by burn, demographic, facility, and diseases factors. Palliative care services were identified with International Classification Disease 9th edition code V6.67. Temporal trends were assessed with Poisson modeling. Inpatient mortality and death without surgical intervention were assessed with logistic regression. Outcomes were stratified by modified Baux scores. RESULTS 7424 major burns were included; 1.9% received palliative care services. Patients receiving palliation had a mean age of 63.6 years (SD 19.6), mean total body surface area of 62.2% (SD 24.9%), and mean modified Baux score of 127.1 (SD 26.7). Adjusting for covariates, the incidence rate ratio was 1.42 over the 10-year period (95% CI, 1.31-1.54, p<0.001). Independent predictors of palliative consultations included older age, larger burns, deeper burns, and higher Elixhauser comorbidity score. Among patients with modified Baux scores between 100-153, those receiving palliative care services were significantly more likely to die without surgery, OR 3.24 (95% CI 1.13-10.39, p=0.029), with no significant difference in mortality, OR 11.72 (95% CI 0.87-22.57, p=0.051) CONCLUSION AND RELEVANCE: Palliative care services were increasingly used during the study period. Palliative care services in highly moribund burn patients do not impact survival and may decrease the likelihood of surgical intervention in select patients.
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Affiliation(s)
- Clifford C Sheckter
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University, Stanford, CA, United States; Clinical Excellence Research Center (CERC), Department of Medicine, Stanford University, Stanford, CA, United States.
| | - Kay S Hung
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University, Stanford, CA, United States
| | - Danielle Rochlin
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University, Stanford, CA, United States; Clinical Excellence Research Center (CERC), Department of Medicine, Stanford University, Stanford, CA, United States
| | - Zeshaan Maan
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University, Stanford, CA, United States
| | - Yvonne Karanas
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University, Stanford, CA, United States; Santa Clara Valley Medical Center-Regional Burn Center, San Jose, CA, United States
| | - Catherine Curtin
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University, Stanford, CA, United States; Division of Plastic Surgery, Palo Alto Veterans Affairs, Palo Alto, CA, United States
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Pompermaier L, Steinvall I, Elmasry M, Thorfinn J, Sjöberg F. Burned patients who die from causes other than the burn affect the model used to predict mortality: a national exploratory study. Burns 2018; 44:280-287. [DOI: 10.1016/j.burns.2017.07.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 05/09/2017] [Accepted: 07/14/2017] [Indexed: 11/25/2022]
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Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Explain the epidemiology of severe burn injury in the context of socioeconomic status, gender, age, and burn cause. 2. Describe challenges with burn depth evaluation and novel methods of adjunctive assessment. 3. Summarize the survival and functional outcomes of severe burn injury. 4. State strategies of fluid resuscitation, endpoints to guide fluid titration, and sequelae of overresuscitation. 5. Recognize preventative measures of sepsis. 6. Explain intraoperative strategies to improve patient outcomes, including hemostasis, restrictive transfusion, temperature regulation, skin substitutes, and Meek skin grafting. 7. Translate updates in the pathophysiology of hypertrophic scarring into novel methods of clinical management. 8. Discuss the potential role of free tissue transfer in primary and secondary burn reconstruction. SUMMARY Management of burn-injured patients is a challenging and unique field for plastic surgeons. Significant advances over the past decade have occurred in resuscitation, burn wound management, sepsis, and reconstruction that have improved outcomes and quality of life after thermal injury. However, as patients with larger burns are resuscitated, an increased risk of nosocomial infections, sepsis, compartment syndromes, and venous thromboembolic phenomena have required adjustments in care to maintain quality of life after injury. This article outlines a number of recent developments in burn care that illustrate the evolution of the field to assist plastic surgeons involved in burn care.
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20
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Partain NS, Subramanian M, Hodgman EI, Isbell CL, Wolf SE, Arnoldo BD, Kowalske KJ, Phelan HA. Characterizing End-of-Life Care after Geriatric Burns at a Verified Level I Burn Center. J Palliat Med 2016; 19:1275-1280. [PMID: 27626364 DOI: 10.1089/jpm.2016.0152] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND End-of-life (EoL) care after geriatric burns (geri-burns) is understudied. OBJECTIVE To examine the practices of burn surgeons for initiating EoL discussions and the impact of decisions made on the courses of geri-burn patients who died after injury. METHODS This retrospective cohort study examined all subjects ≥65 years who died on our Level I burn service from April 1, 2009, to December 31, 2014. Measurements obtained were timing of first EoL discussion (EARLY <24 hours post-admission; LATE ≥24 hours post-admission), decisions made, age, total body surface area burned, and calculated probability of death at admission. RESULTS The cohort consisted of 57 subjects, of whom 54 had at least one documented EoL care discussion between a burn physician and the patient/surrogate. No differences were seen between groups for the likelihood of an immediate decision for comfort care after the first discussion (p = 0.73) or the mean number of total discussions (p = 0.07). EARLY group subjects (n = 38) had significantly greater magnitudes of injury (p = 0.002), calculated probabilities of death at admission (p ≤ 0.001), shorter times to death (p ≤ 0.001), and fewer trips to the operating theater for burn excision and skin grafting (p ≤ 0.001) than LATE subjects (n = 16). LATE subjects' first discussion occurred at a mean of 9.3 ± 10.0 days. DISCUSSION The vast majority of geri-burn deaths on our burn service occur after a discussion about EoL care. The timing of these discussions is driven by magnitude of injury, and it does not lead to higher proportions of an immediate decision for comfort care. The presence and timing of EoL discussions bears further study as a quality metric for geri-burn EoL care.
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Affiliation(s)
- Natalia S Partain
- 1 Division of Burns/Trauma/Critical Care, Parkland Memorial Hospital, University of Texas-Southwestern Medical Center , Dallas, Texas
| | - Madhu Subramanian
- 1 Division of Burns/Trauma/Critical Care, Parkland Memorial Hospital, University of Texas-Southwestern Medical Center , Dallas, Texas
| | - Erica I Hodgman
- 1 Division of Burns/Trauma/Critical Care, Parkland Memorial Hospital, University of Texas-Southwestern Medical Center , Dallas, Texas
| | - Claire L Isbell
- 2 Department of Surgery, Scott and White Hospital, Texas A&M Health Science Center , Temple, Texas
| | - Steve E Wolf
- 1 Division of Burns/Trauma/Critical Care, Parkland Memorial Hospital, University of Texas-Southwestern Medical Center , Dallas, Texas.,3 Department of Surgery, Parkland Memorial Hospital, University of Texas-Southwestern Medical Center , Dallas, Texas
| | - Brett D Arnoldo
- 1 Division of Burns/Trauma/Critical Care, Parkland Memorial Hospital, University of Texas-Southwestern Medical Center , Dallas, Texas.,3 Department of Surgery, Parkland Memorial Hospital, University of Texas-Southwestern Medical Center , Dallas, Texas
| | - Karen J Kowalske
- 4 Department of Physical Medicine and Rehabilitation, Parkland Memorial Hospital, University of Texas-Southwestern Medical Center , Dallas, Texas
| | - Herb A Phelan
- 1 Division of Burns/Trauma/Critical Care, Parkland Memorial Hospital, University of Texas-Southwestern Medical Center , Dallas, Texas.,3 Department of Surgery, Parkland Memorial Hospital, University of Texas-Southwestern Medical Center , Dallas, Texas
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Abstract
Failed burn resuscitation can occur at various points. Early failed resuscitation will be largely caused by prehospital factors. During resuscitation, failure will present as a patient's nonresponse to adjunctive therapy. Late failure will occur in the setting of multiple organ dysfunction syndrome. Burn care providers must be vigilant during the resuscitation to identify a threatened resuscitation so that adjunctive therapies or rescue maneuvers can be used to convert to a successful resuscitation. However, when a patient's resuscitative course becomes unsalvageable, transition to comfort care should be taken to avoid prolongation of suffering.
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Affiliation(s)
- Elisha G Brownson
- Department of Surgery, Harborview Medical Center, 325 Ninth Avenue, Box 359796, Seattle, WA 98104, USA
| | - Tam N Pham
- Department of Surgery, Harborview Medical Center, 325 Ninth Avenue, Box 359796, Seattle, WA 98104, USA.
| | - Kevin K Chung
- United States Army Institute of Surgical Research, 3698 Chambers Pass, JBSA Fort Sam Houston, TX 78234, USA; Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
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Baron R, Binder A, Biniek R, Braune S, Buerkle H, Dall P, Demirakca S, Eckardt R, Eggers V, Eichler I, Fietze I, Freys S, Fründ A, Garten L, Gohrbandt B, Harth I, Hartl W, Heppner HJ, Horter J, Huth R, Janssens U, Jungk C, Kaeuper KM, Kessler P, Kleinschmidt S, Kochanek M, Kumpf M, Meiser A, Mueller A, Orth M, Putensen C, Roth B, Schaefer M, Schaefers R, Schellongowski P, Schindler M, Schmitt R, Scholz J, Schroeder S, Schwarzmann G, Spies C, Stingele R, Tonner P, Trieschmann U, Tryba M, Wappler F, Waydhas C, Weiss B, Weisshaar G. Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 (DAS-Guideline 2015) - short version. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2015; 13:Doc19. [PMID: 26609286 PMCID: PMC4645746 DOI: 10.3205/000223] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Indexed: 02/08/2023]
Abstract
In 2010, under the guidance of the DGAI (German Society of Anaesthesiology and Intensive Care Medicine) and DIVI (German Interdisciplinary Association for Intensive Care and Emergency Medicine), twelve German medical societies published the “Evidence- and Consensus-based Guidelines on the Management of Analgesia, Sedation and Delirium in Intensive Care”. Since then, several new studies and publications have considerably increased the body of evidence, including the new recommendations from the American College of Critical Care Medicine (ACCM) in conjunction with Society of Critical Care Medicine (SCCM) and American Society of Health-System Pharmacists (ASHP) from 2013. For this update, a major restructuring and extension of the guidelines were needed in order to cover new aspects of treatment, such as sleep and anxiety management. The literature was systematically searched and evaluated using the criteria of the Oxford Center of Evidence Based Medicine. The body of evidence used to formulate these recommendations was reviewed and approved by representatives of 17 national societies. Three grades of recommendation were used as follows: Grade “A” (strong recommendation), Grade “B” (recommendation) and Grade “0” (open recommendation). The result is a comprehensive, interdisciplinary, evidence and consensus-based set of level 3 guidelines. This publication was designed for all ICU professionals, and takes into account all critically ill patient populations. It represents a guide to symptom-oriented prevention, diagnosis, and treatment of delirium, anxiety, stress, and protocol-based analgesia, sedation, and sleep-management in intensive care medicine.
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Affiliation(s)
| | | | | | | | - Stephan Braune
- German Society of Internal Medicine Intensive Care (DGIIN)
| | - Hartmut Buerkle
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Peter Dall
- German Society of Gynecology & Obstetrics (DGGG)
| | - Sueha Demirakca
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | | | - Verena Eggers
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Ingolf Eichler
- German Society for Thoracic and Cardiovascular Surgery (DGTHG)
| | | | | | | | - Lars Garten
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | | | - Irene Harth
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | | | | | - Johannes Horter
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Ralf Huth
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | - Uwe Janssens
- German Society of Internal Medicine Intensive Care (DGIIN)
| | | | | | - Paul Kessler
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | | | | | - Matthias Kumpf
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | - Andreas Meiser
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Anika Mueller
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | | | | | - Bernd Roth
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | | | | | | | - Monika Schindler
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | - Reinhard Schmitt
- German Society for Specialised Nursing and Allied Health Professions (DGF)
| | - Jens Scholz
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Stefan Schroeder
- German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN)
| | | | - Claudia Spies
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | | | - Peter Tonner
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Uwe Trieschmann
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Michael Tryba
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Frank Wappler
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Christian Waydhas
- German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI)
| | - Bjoern Weiss
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Guido Weisshaar
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
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Lundy JB, Chung KK, Pamplin JC, Ainsworth CR, Jeng JC, Friedman BC. Update on Severe Burn Management for the Intensivist. J Intensive Care Med 2015; 31:499-510. [PMID: 26112758 DOI: 10.1177/0885066615592346] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Accepted: 06/01/2015] [Indexed: 11/15/2022]
Abstract
Thermal injury of humans causes arguably the most severe perturbations in physiology that can be experienced. These physiologic derangements start immediately and can persist in some form until months or even years after the burn wounds are healed. Burn shock, marked activation of the systemic inflammatory response, multiple-organ failure, infection, and wound failure are just a few of the insults that may require management by the intensivist. The purpose of this article is to review recent advances in the critical care management of thermally injured patients.
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Affiliation(s)
- Jonathan B Lundy
- Burn Center, United States Army Institute of Surgical Research, Fort Sam Houston, TX, USA Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Kevin K Chung
- Burn Center, United States Army Institute of Surgical Research, Fort Sam Houston, TX, USA Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Jeremy C Pamplin
- Burn Center, United States Army Institute of Surgical Research, Fort Sam Houston, TX, USA Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Craig R Ainsworth
- Department of Medicine, William Beaumont Army Medical Center, Fort Bliss, TX, USA
| | - James C Jeng
- Department of Surgery, Mount Sinai Beth Israel Medical Center, New York, NY, USA
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Mark NM, Rayner SG, Lee NJ, Curtis JR. Global variability in withholding and withdrawal of life-sustaining treatment in the intensive care unit: a systematic review. Intensive Care Med 2015; 41:1572-85. [DOI: 10.1007/s00134-015-3810-5] [Citation(s) in RCA: 166] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 04/07/2015] [Indexed: 12/01/2022]
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Abstract
PURPOSE OF REVIEW Decisions to limit life-sustaining therapy (DLLST) in the ICU are used to uphold patients' autonomy, protect them from non-beneficial treatment and fairly distribute resources. The institution of these decisions is complex, with a variety of qualitative and quantitative data published. This review aims to summarize the main issues and review the contemporary research findings on this subject. RECENT FINDINGS DLLST are used in a variety of clinical and non-clinical situations, before and after ICU admission, and are not always part of end-of-life management. There are many dilemmas and barriers that beset their institution. Many ICU physicians feel inadequately trained to carry them out and they are frequently a source of conflict. A variety of strategies have been examined to improve their institution, including advanced directives, intensive communication strategies and family information leaflets, many of which have improved patient and family-centred outcomes. SUMMARY There are a number of uncertainties that beset the institution of DLLST in the ICU; however, a variety of research has improved our ability to understand and implement them. This review frames some of the dilemmas and discusses some of the procedural strategies that have been used to improve outcomes.
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Abstract
BACKGROUND With unprecedented survival rates in modern burn care, there is increasing focus on optimizing long-term functional outcomes. However, 3% to 8% of patients admitted to burn centers still die of injury. Patterns in which these patients progress to death remain poorly characterized. We hypothesized that burn nonsurvivors will follow distinct temporal distributions and patterns of decline, parallel to the trimodality of deaths previously described for trauma. METHODS We retrospectively identified all adult deaths from 1995 to 2007 in the National Burn Repository database (n = 5,975) and at our regional burn center (n = 237). We stratified patients by age and analyzed injury and death characteristics. We used objective criteria to allocate nonsurvivors to one of four trajectories: early rapid decline, early organ failure, late sudden death, or late-onset decline. RESULTS The greatest concentration of deaths in both samples and age groups occurred within 72 hours of injury and decreased subsequently with no later mortality peak. Death was most often caused by burn shock within the first week of injury, cardiogenic shock or lung injury in Weeks 1 to 2, and sepsis/multiorgan failure after Week 2. In decreasing frequency, trajectories to death fit the pattern of early rapid decline (58%), early organ failure (20%), late-onset decline (16%), and late sudden death (6%). CONCLUSION Most burn deaths follow a pattern of early rapid decline or early organ failure manifested by death or critical illness within several days of the burn. These findings indicate that more than three quarters of burn deaths are attributable to failure or significant decompensation beginning in the resuscitation phase. Sporadic deaths later in hospitalization are uncommon. Despite significant advances in burn resuscitation, our data indicate that ongoing efforts to mitigate deaths in modern burn care should still focus on care improvements in the resuscitation phase. LEVEL OF EVIDENCE Epidemiologic study, level III.
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