Occurrence of multiorgan dysfunction in pediatric burn patients: incidence and clinical outcome

CytoSorb® in burn patients with septic shock and Acute Kidney Injury on Continuous Kidney Replacement Therapy is associated with improved clinical outcome and survival

BACKGROUND

In burn patients, septic shock and acute kidney injury (AKI) with use of continuous renal replacement therapy (CRRT) severely increase morbidity and mortality. Sorbent therapies could be an adjunctive therapy to address the underlying metabolic changes in inflammatory and anti-inflammatory cytokines dysregulated production.

METHODS

A retrospectively observational study of 35 severe burn patients admitted to the Burn Center (Turin, Italy, from January 2017 to December 2022), who underwent CRRT for AKI-associated septic shock. Out of 35 patients, 11 were treated with CytoSorb® as adjunctive therapy to CRRT (Sorbent group) and 24 patients only with CRRT (Control group).

RESULTS

The application of CytoSorb® took place in a very dispersed way. Out of 11 patients, 7 started the CRRT together with the sorbent application. The patients of the sorbent group exhibited a significant reduction in norepinephrine use compared to that of the control group. A clinical improvement over the first 4 days of Cytosorb® was observed in both survivors and no survivors of the sorbent group, with significant norepinephrine decreased use on day 4 compared to day 1. In-hospital mortality was 45.4% and 70.8% in the sorbent and control group, respectively, and significantly better at Kaplan-Meier survival analysis at 270 days (p = 0.0445). In both groups, all survivor patients recovered renal function at discharge, whereas no survivors did not.

CONCLUSIONS

Adjunctive treatment with CytoSorb® for burn patients with AKI-CRRT and septic shock poorly responsive to standard therapy led to a significant clinical improvement, and was associated with a lower mortality rate compared to CRRT alone.

Health-related quality of life after burn injury due to bioethanol-fueled fireplaces

OBJECTIVE

Commercially available bioethanol-fueled fireplaces are a potential source of burns and are commonly used for home use. The present study aimed to evaluate the quality of life following burn injuries that were caused by bioethanol-related accidents.

METHODS

Burned patients who were admitted to our burn unit with burn injury due to bio-ethanol fueled fire places between January 2010 and December 2021 were contacted to ask for their willingness to participate in this study. They were asked to answer questions regarding the circumstances of the accident and three questionnaires to capture burn specific and general health related quality of life (Burn Specific Health Scale-Brief (BSHS-B), Short-Form Health Survey 36 (SF-36)) and general information about the accident. Patients were matched and compared to a group of patients suffering comparable burns from other burn mechanisms, which were also admitted to our burn unit at the same time.

RESULTS

Of 35 patients that met the inclusion criteria, 19 answered the questionnaire and were compared to 38 patients with other burn mechanisms. There were no statistical differences regarding age (bioethanol: 37.4 ± 14.7 years vs. control: 36.2 ± 14.3 years, p = 0.777), TBSA (9.9 ± 6.8% vs. 8.9 ± 10.4, p = 0.715), and sex (42.1% females vs. 36.8% females, p = 0.882). Most patients in the bioethanol-group reported that they did not follow the manual instructions (68.4%) and that the accident happened during the refilling process (52.6%). There was no significant difference in any subscale of the BSHS-B or the SF-36.

DISCUSSION

Burns related to bioethanol-fueled fireplaces are rare compared to other typical burn mechanisms. However, as they are used for personal pleasure and interior design, psychological impairment following burn may be even more critical. Detailed education on the use of these fireplaces needs to take place in order to reduce the risk of accidents.

An eighteen-year review of intensive care requirements for paediatric burns in a regional burns service

INTRODUCTION

Advances in burns management have reduced mortality. Consequently, efficient resource management plays an increasingly important role in improving paediatric burns care. This study aims to assess the support requirements and outcomes of paediatric burns patients admitted to a burns centre intensive care unit in comparison to established benchmarks in burns care.

METHOD

A retrospective review of burns patients under the age of 16 years old, admitted to a regional burns service intensive care unit between March 1998 and March 2016 was conducted.

RESULTS

Our analysis included 234 patients, with the percentage of TBSA affected by burn injury ranging from 1.5% to 95.0%. The median (IQR) %TBSA was 20.0% (11.0-30.0), and the observed mortality rate was 2.6% (6/234). The median (IQR) length of stay was 0.7 days/%TBSA burn (0.4-1.2), 17.9% (41/229) required circulatory support and 2.6% (6/234) required renal replacement. Mortality correlated with smoke inhalation injury (P < 0.001), %TBSA burn (P = 0.049) and complications (P = 0.004) including infections (P = 0.013).

CONCLUSIONS

Among children with burn injuries who require intensive care, the presence of inhalational injury and the diagnosis of infection are positively correlated with mortality. Understanding the requirements for organ support can facilitate a more effective allocation of resources within a burns service.

Lung Protection After Severe Thermal Burns With Adenosine, Lidocaine, and Magnesium (ALM) Resuscitation and Importance of Shams in a Rat Model

The management of severe burns remains a complex challenge. Adenosine, lidocaine, and magnesium (ALM) resuscitation therapy has been shown to protect against hemorrhagic shock and traumatic injury. The aim of the present study was to investigate the early protective effects of small-volume ALM fluid resuscitation in a rat model of 30% total body surface area (TBSA) thermal injury. Male Sprague-Dawley rats (320-340 g; n = 25) were randomly assigned to: 1) Sham (surgical instrumentation and saline infusion, without burn, n = 5), 2) Saline resuscitation group (n = 10), or 3) ALM resuscitation group (n = 10). Treatments were initiated 15-min after burn trauma, including 0.7 mL/kg 3% NaCl ± ALM bolus and 0.25-0.5 mL/kg/h 0.9% NaCl ± ALM drip, with animals monitored to 8.25-hr post-burn. Hemodynamics, cardiac function, blood chemistry, hematology, endothelial injury markers and histopathology were assessed. Survival was 100% for Shams and 90% for both ALM and Saline groups. Shams underwent significant physiological, immune and hematological changes over time as a result of surgical traums. ALM significantly reduced malondialdehyde levels in the lungs compared to Saline (P = .023), and showed minimal alveolar destruction and inflammatory cell infiltration (P < .001). ALM also improved cardiac function and oxygen delivery (21%, P = .418 vs Saline), reduced gut injury (P < .001 vs Saline), and increased plasma adiponectin (P < .001 vs baseline). Circulating levels of the acute phase protein alpha 1-acid glycoprotein (AGP) increased 1.6-times (P < .001), which may have impacted ALM's therapeutic efficacy. We conclude that small-volume ALM therapy significantly reduced lung oxidative stress and preserved alveolar integrity following severe burn trauma. Further studies are required to assess higher ALM doses with longer monitoring periods.

Cardiometabolic disease risk markers are increased following burn injury in children

Introduction

Burn injury in children causes prolonged systemic effects on physiology and metabolism leading to increased morbidity and mortality, yet much remains undefined regarding the metabolic trajectory towards specific health outcomes.

Methods

A multi-platform strategy was implemented to evaluate the long-term immuno-metabolic consequences of burn injury combining metabolite, lipoprotein, and cytokine panels. Plasma samples from 36 children aged 4-8 years were collected 3 years after a burn injury together with 21 samples from non-injured age and sex matched controls. Three different ¹H Nuclear Magnetic Resonance spectroscopic experiments were applied to capture information on plasma low molecular weight metabolites, lipoproteins, and α-1-acid glycoprotein.

Results

Burn injury was characterized by underlying signatures of hyperglycaemia, hypermetabolism and inflammation, suggesting disruption of multiple pathways relating to glycolysis, tricarboxylic acid cycle, amino acid metabolism and the urea cycle. In addition, very low-density lipoprotein sub-components were significantly reduced in participants with burn injury whereas small-dense low density lipoprotein particles were significantly elevated in the burn injured patient plasma compared to uninjured controls, potentially indicative of modified cardiometabolic risk after a burn. Weighted-node Metabolite Correlation Network Analysis was restricted to the significantly differential features (q <0.05) between the children with and without burn injury and demonstrated a striking disparity in the number of statistical correlations between cytokines, lipoproteins, and small molecular metabolites in the injured groups, with increased correlations between these groups.

Discussion

These findings suggest a 'metabolic memory' of burn defined by a signature of interlinked and perturbed immune and metabolic function. Burn injury is associated with a series of adverse metabolic changes that persist chronically and are independent of burn severity and this study demonstrates increased risk of cardiovascular disease in the long-term. These findings highlight a crucial need for improved longer term monitoring of cardiometabolic health in a vulnerable population of children that have undergone burn injury.

VARIABLES INFLUENCING THE DIFFERENTIAL HOST RESPONSE TO BURNS IN PEDIATRIC AND ADULT PATIENTS

ABSTRACT

Burn injury is a significant source of morbidity and mortality in the pediatric population. Although 40,000 pediatric patients in the United States are admitted to the hospital with burn wounds annually, significant differences exist in the management and treatment of these patients, even among highly specialized burn centers. Some aspects of pediatric burn research, such as metabolic changes and nutritional support after burn injury, have been studied extensively; however, in many aspects of burn care, pediatric research lags behind the study of adult populations. This review compares and contrasts a wide array of physiologic and immune responses between children and adults after burn injury. Such a review elucidates where robust research has been conducted, where adult research is applicable to pediatric patients, and where additional pediatric burn research needs to be conducted.

Long-Term Effects of Severe Burns on the Kidneys: Research Advances and Potential Therapeutic Approaches

Burns are a seriously underestimated form of trauma that not only damage the skin system but also cause various complications, such as acute kidney injury (AKI). Recent clinical studies have shown that the proportion of chronic kidney diseases (CKD) in burn patients after discharge is significantly higher than that in the general population, but the mechanism behind this is controversial. The traditional view is that CKD is associated with hypoperfusion, AKI, sepsis, and drugs administered in the early stages of burns. However, recent studies have shown that burns can cause long-term immune dysfunction, which is a high-risk factor for CKD. This suggests that burns affect the kidneys more than previously recognized. In other words, severe burns are not only an acute injury but also a chronic disease. Neglecting to study long-term kidney function in burn patients also results in a lack of preventive and therapeutic methods being developed. Furthermore, stem cells and their exosomes have shown excellent comprehensive therapeutic properties in the prevention and treatment of CKD, making them increasingly the focus of research attention. Their engineering strategy further improved the therapeutic performance. This review will focus on the research advances in burns on the development of CKD, illustrating the possible mechanism of burn-induced CKD and introducing potential biological treatment options and their engineering strategies.

Fire burns matter: A case-control study of severe accidental burns in pediatric patients

<b>Objective: </b>We aimed to identify factors associated with severe accidental burns in patients ≤12 years old.<br /> <b>Materials and methods: </b>We conducted a matched case-control study, in which we retrospectively reviewed the medical records of children treated in a single institution from 2014-2016. We classified the cases (patients with severe burns) and controls (patients with non-severe burns) according to the criteria of the American Burn Association. We used multivariate conditional logistic regression analysis to identify the relationship between the etiology of burns and their severity.<br /> <b>Results: </b>We reviewed 180 cases and 90 controls. The most common etiology of burns was boiling water in both cases (65.6%) and controls (83.3%). Most burns occurred inside the home (84.1%) and in the afternoon (37.4%). Multivariate analysis identified that severe burns were mainly due to exposure to fire (odds ratio [OR]: 3.22, 95% confidence interval [CI]: 1.53-6.81). Similarly, these patients were more likely to live in a rural area (OR: 2.96, 95% CI: 1.17-6.19).<br /> <b>Conclusions: </b>In pediatric patients ≤12 years of age severe accidental burns are more likely to be caused by fire compared to boiling water. Public health interventions should focus on populations located in rural areas.

Systemic anti-inflammatory effects of mesenchymal stem cells in burn: A systematic review of animal studies

Background

Despite the advances in burn care, severe burns still impose significant morbidity and mortality. Severe burns are associated with an inflammatory response that ranges from alterations in vital signs to shock, multiorgan failure, and death. Mesenchymal stem cells (MSCs) are known for their anti-inflammatory and immunomodulatory effects. Therefore, MSCs were investigated for their potential benefits in modulating burn-induced inflammation and organ damage in several studies.

Aim

We have conducted a systematic review of the literature to evaluate the efficacy of MSCs in modulating burn-induced systemic inflammation and organ damage in animal models.

Methods

Four databases were searched: PubMed, Cumulative Index of Nursing and Allied Health Literature, Scopus, and Web of Science. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis as our basis of organization.

Results

Eight studies were included in the study. Bone marrow derived MSCs, umbilical cord derived MSCs (UC-MSCs), and UC-MSCs exosomes were used to modulate the burn-induced inflammation. MSCs therapy reduced serum levels of pro-inflammatory cytokines, improved renal function, inhibited tissue damage, and improved survival after burn. Furthermore, MSCs reversed all the burn-induced pathological changes in blood brain barrier (BBB).

Conclusion

MSCs may attenuate the burn-induced inflammation by decreasing serum levels of inflammatory cytokines. However, the effect on anti-inflammatory cytokines is conflicting and mandates more substantial evidence. Furthermore, MSCs reduce tissue inflammation, tissue damage, and apoptosis in the lungs and kidneys. In addition, MSCs reversed the burn-induced pathophysiologic changes in the BBB. The underlying mechanisms of these effects are poorly understood and should be the focus of future stem cell research.

Relevance to Patients

Severe burn patients are liable to systemic inflammation due to the release of inflammatory cytokines into the circulation. This inflammatory response has a broad spectrum of severity that ranges from alterations in vital signs to multiorgan failure and death. Despite the advances in burn care, burn-induced inflammation still imposes significant morbidity and mortality. This systematic review evaluates the potential benefits of stem cells in modulating burn-induced systemic inflammation in animal burn models.

Tranexamic acid reduced blood transfusions in acute burn surgery: A retrospective case-controlled trial

OBJECTIVE

Early excision and grafting of burn wounds are key for reducing prevalence of infection and sepsis. However, it is associated with massive blood loss and patients frequently require large numbers of blood transfusions. This study aimed to evaluate the effect of tranexamic acid (TXA) on blood transfusion requirements in acute burn surgery.

METHODS

Patients admitted to the burn intensive care unit between January 2018 and May 2021 and received TXA before first surgery for wound excision and grafting were matched in a 1:2 ratio to patients that did not receive TXA (confounders age,sex,total body surface area (TBSA) burned). Primary endpoint of the analysis was the total number of transfused units of red blood cells (RBC) intra- and postoperatively up to 48 h. Fresh frozen plasma (FFP) and platelets were evaluated. Endpoints were compared between groups using van Elteren tests adjusting for strata variable age, gender, TBSA.

RESULTS

Twenty-six TXA patients were matched with 52 control patients resulting in similar distributions of gender (77.9%(TXA)vs. 82.7%(control) males, p=0.542), age (51.7±21.3vs.48.3 ±17.4years,p = 0.459) and %TBSA burned (33.5%(IQR34)vs. 38.5% (IQR 30.5),p = 1.000). TXA group received significantly less RBC units intraoperatively (2.5(IQR 2.0)vs.4.0 units (IQR4.0), p = 0.038) and in total (4.0(IQR3.0)vs.6.0(IQR4.0),p = 0.017). TXA patients also received less blood products in general (RBC, FFP, platelets) in each period and in total. We found no significant difference in length of stay (24.0(IQR26.0)vs.33.0 days (IQR 0.5),p = 0.367) or mortality (15.4%vs.21.2%, p = 0.542).

DISCUSSION

This study shows that necessity for blood transfusions in acute burn surgery may be reduced significantly by administration of TXA perioperatively. Randomized-controlled trials are needed to prove these findings.

Lytic cocktail: An effective method to alleviate severe burn induced hyper-metabolism through regulating white adipose tissue browning

Background

Browning of white adipose tissue is associated with elevated resting metabolic rates and is considered to be one of the indispensable causes of hypermetabolism in burn patients. Hypermetabolism means increased resting energy expenditure, raised body temperature and acute-phase proteins. Persistently elevated levels of circulating stress hormones have been reported to induce browning of subcutaneous white adipose tissue. The lytic cocktail is a combination of medicines pethidine, chlorpromazine, and promethazine that has been used clinically in sedation for the management of patients. As reported this sedative treatment can reduce the expression of catecholamines in major burn rats. Thus, in this paper we focused on the effects of lytic cocktail in the regulation of white adipose tissue browning and hypermetabolism and we further investigated the underlying mechanism.

Methods

A 30% total body surface area (TBSA) Ⅲ degree scald rat model was used for this study. The rats were randomly divided into a sham scald group, a scalding with immediate resuscitation group, and a group of scalding with immediate resuscitation and lytic cocktail treatment. The levels of norepinephrine and epinephrine in plasma were dynamically detected. Changes of the rat body weight and food intake were recorded and compared as indexes of metabolism responses after post-scalding. For the study of white adipose tissue browning, inguinal adipose tissue was used. Metabolic changes, while indicatives of white fat browning were measured by PET/CT. The expression of white adipose browning related proteins and the changes of mitochondria number were used to assess browning of inguinal adipose.

Results

The level of plasma catecholamines norepinephrine and epinephrine in the lytic cocktail-treated group was significantly lower than the other two groups. Morphology and PET/CT showed that the inguinal white adipose browning was inhibited in the lytic cocktail treated group, whereas scalding with immediate resuscitation group showed browning of white adipose. The number of mitochondria, the expressions of white adipose browning related proteins in the lytic cocktail group were also significantly lower than that of the group of scalding with immediate resuscitation.

Conclusion

By reducing expression of heat-related proteins, the application of lytic cocktail medicines inhibits the white adipose tissue browning, which suppresses hypermetabolism in scalded rats. The mechanism might be related to decreased expression levels of stress hormones induced by lytic cocktail. This research suggests that lytic cocktails may be an effective treatment for hypermetabolism after severe burn injury.

Hepatic functional pathophysiology and morphological damage following severe burns: a systematic review and meta-analysis

INTRODUCTION

Severe burns are devastating injuries affecting multiple organ systems. Little is known about the influence on the hepatic system and its physiology. This systematic review aimed to assess the current state of research on morphologic liver damage following severe burns.

METHODS

A search was conducted in Pubmed, Web of Science and Cochrane databases using PRISMA guidelines. Outcomes included serum levels of transaminases, fatty infiltration and necrosis. Weighted individual study estimates were used to calculate pooled transaminase levels and necrosis/fatty infiltration rates using a random-effects approach. Risk ratios (RRs) or Odds ratios (ORs) and 95% confidence intervals (CIs) were used to describe pooled estimates for risk factors.

RESULTS

The literature search retrieved 2548 hits, of which 59 studies were included into qualitative synthesis, and finally ten studies were included into meta-analysis. Studies were divided into those reporting autopsies and those reporting changes of serum transaminase levels. The majority of liver autopsies showed fatty infiltration 82% (95% CI39%-97%) or necrosis of the liver 18% (95% CI13%-24%).

DISCUSSION

Heterogeneity in studies on hepatic functional damage following severe burns was high. Only few were well-designed and published in recent years. Many studies could not be included because of insufficient numerical data. There is a high number of patients deceasing from burns that present with fatty infiltration or necrosis of hepatic tissue. Transaminases were elevated during the first days after burn. Further research on how severe burns affect the hepatic function and outcome, especially long-term, is necessary.

Multicentre, longitudinal, observational cohort study to examine the relationship between neutrophil function and sepsis in adults and children with severe thermal injuries: a protocol for the Scientific Investigation of the Biological Pathways Following Thermal Injury-2 (SIFTI-2) study

INTRODUCTION

Burn-induced changes in the phenotype and function of neutrophils, cells which provide front-line protection against rapidly dividing bacterial infections, are emerging as potential biomarkers for the early prediction of sepsis. In a longitudinal study of adult burns patients, we recently demonstrated that a combined measurement of neutrophil phagocytic capacity, immature granulocyte (IG) count and plasma cell-free DNA (cfDNA) levels on the day of injury gave good discriminatory power for the prediction of later sepsis development. However, limited by a small sample size, single-centre design and focus on adult burns patients, these biomarkers require prospective validation in a larger patient cohort. The Scientific Investigation of the Biological Pathways Following Thermal Injury-2 study aims to prospectively validate neutrophil phagocytic activity, IG count and plasma cfDNA levels as early prognostic biomarkers of sepsis in thermally injured adult and paediatric patients.

METHODS AND ANALYSIS

This multicentre, longitudinal, observational cohort study will enrol 245 paediatric and adult patients with moderate to severe burns within 24 hours of injury. Blood samples will be obtained at 19 postinjury time points (days 1-14, day 28, months 3, 6, 12 and 24) and analysed for neutrophil phagocytic activity, IG count and cfDNA levels. Patients will be screened daily for sepsis using the 2007 American Burn Association diagnostic criteria for sepsis. In addition, daily multiple organ dysfunction syndrome and Sequential Organ Failure Assessment Scores will be recorded relationships between neutrophil phagocytic activity, IG count and plasma cfDNA levels on day 1 of injury and the development of sepsis will be examined using logistic regression models.

ETHICS AND DISSEMINATION

This study received ethics approval from the West Midlands, Coventry and Warwickshire Research Ethics Committee (REC reference:16/WM/0217). Findings will be presented at national and international conferences, and submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04693442.

Early Prediction of Multiple Organ Dysfunction in the Pediatric Intensive Care Unit

Objective: The objective of the study is to build models for early prediction of risk for developing multiple organ dysfunction (MOD) in pediatric intensive care unit (PICU) patients. Design: The design of the study is a retrospective observational cohort study. Setting: The setting of the study is at a single academic PICU at the Johns Hopkins Hospital, Baltimore, MD. Patients: The patients included in the study were <18 years of age admitted to the PICU between July 2014 and October 2015. Measurements and main results: Organ dysfunction labels were generated every minute from preceding 24-h time windows using the International Pediatric Sepsis Consensus Conference (IPSCC) and Proulx et al. MOD criteria. Early MOD prediction models were built using four machine learning methods: random forest, XGBoost, GLMBoost, and Lasso-GLM. An optimal threshold learned from training data was used to detect high-risk alert events (HRAs). The early prediction models from all methods achieved an area under the receiver operating characteristics curve ≥0.91 for both IPSCC and Proulx criteria. The best performance in terms of maximum F1-score was achieved with random forest (sensitivity: 0.72, positive predictive value: 0.70, F1-score: 0.71) and XGBoost (sensitivity: 0.8, positive predictive value: 0.81, F1-score: 0.81) for IPSCC and Proulx criteria, respectively. The median early warning time was 22.7 h for random forest and 37 h for XGBoost models for IPSCC and Proulx criteria, respectively. Applying spectral clustering on risk-score trajectories over 24 h following early warning provided a high-risk group with ≥0.93 positive predictive value. Conclusions: Early predictions from risk-based patient monitoring could provide more than 22 h of lead time for MOD onset, with ≥0.93 positive predictive value for a high-risk group identified pre-MOD.

The role of matrix metalloproteinase-9 and its inhibitor TIMP-1 in burn injury: a systematic review

Matrix metalloproteinase-9 (MMP-9) and its endogenous inhibitor, tissue inhibitor of metalloproteinase-1 (TIMP-1), are key mediators of acute inflammation and regulators of the wound healing process. The aim of this systematic review was to determine the local and systemic involvement of the MMP-9/TIMP-1 system following burn injury. Two databases (Scopus and MEDLINE) were searched for all studies reporting MMP-9 and/or TIMP-1 after burn injury. Based on our eligibility criteria, we reviewed 24 studies involving 508 burns patients in 11 clinical studies and 367 animals in 13 preclinical studies. Local, systemic, and peripheral gene expression, protein levels and activity of MMP-9 and TIMP-1 were assessed. Increased MMP-9 was reported at the site of injury early after burn trauma in all studies, and remained elevated in non-healing wounds. Increased TIMP-1 expression in burn wounds occurred later than MMP-9, and was persistent in hypertrophic burn scars. Similar to local expression, systemic MMP-9 and TIMP-1 concentrations were significantly elevated after burn injury in response to upregulation of proinflammatory cytokines. While no association was found between systemic MMP-9 concentration and extent of injury or outcome, serum or plasma TIMP-1 showed good correlation with survival and burn severity. This review also found evidence of the MMP-9/TIMP-1 system contributing to secondary tissue damage distant from the burn site, including burn-associated musculoskeletal damage and acute lung injury. In addition, increased MMP-9 synthesis and activity in the brain after peripheral burn may lead to blood-brain barrier dysfunction and cerebral edema, a significant contributor to mortality. This systematic review provides an overview of the available evidence of the role of MMP-9 and TIMP-1 in burn injury pathophysiology and finds that TIMP-1 may be a promising biomarker in outcome prognostication of burns patients. Large-scale studies of both pediatric and adult burns patients with increased female representation and repeated sampling are recommended to validate the reliability of TIMP-1 as a prognostic marker following burn injury.

Admission creatinine is associated with poor outcomes in burn patients

INTRODUCTION

Renal failure is the most common organ failure in severely burned patients. However, defining acute kidney injury and renal failure is very challenging. This study was designed to determine the relationship between a biomarker commonly measured on admission, serum creatinine, and outcomes in burn patients.

METHODS

We conducted a retrospective cohort study of adult patients (≥ 18 years) with a burn ≥ 5% total body surface area (TBSA) and a serum creatinine level measured within the first 72 h after injury. Patients were admitted over an 11-year period and divided into two groups based on creatinine levels measured within the first 72 h after injury. Patients were categorized in the high creatinine group if they had a measured creatinine ≥107 μmol/L (≥1.21 mg/dL); this value was chosen as the threshold for creatinine based on our institution's reference range. Clinical outcomes included morbidities, hospital length of stay, and mortality. Multivariable logistic regression was used to model the association between high admission creatinine and each outcome, adjusting for patient and injury characteristics.

RESULTS

We studied 923 patients, mean age 47 ± 18 years and median 13% (IQR 8-24) TBSA burned. There were 718 patients categorized with low admission creatinine and 205 patients with high admission creatinine. After adjustment for patient and injury characteristics, high admission creatinine was associated with a significantly higher rate of sepsis (OR 3.44; 95% CI 2.11-5.59), pneumonia (OR 4.56; 95% CI 1.8-11.53), and mortality (OR 3.59; 95% CI 1.91-6.75).

CONCLUSIONS

Elevated creatinine on admission is associated with an increased risk of morbidity and mortality. We suggest that admission creatinine can be used as a "red flag" to identify patients at a higher risk for poor outcomes.

The Effect of Burn Resuscitation Volumes on the Gut Microbiome in a Swine Model

INTRODUCTION

While recent reports underscore the significance of the gut microbiome (GM) in health and disease, its importance in burn outcomes remains unclear. Moreover, aggressive intravenous (IV) fluid resuscitation of patients may alter intestinal flora. Herein, we describe GM changes following a large burn in swine randomized to different volumes of IV Lactated Ringers' (LR).

METHODS

Anesthetized Yorkshire swine sustained 40% total body surface area full-thickness burns and were randomized to different volumes of IV LR: none (n = 5), 15 mL/kg/d (low; n = 6), or 80 mL/kg/d (high; n = 6). At baseline and days 1 and 2, fecal swabs were collected for 16s rDNA sequencing. Proximal jejunum was collected immediately after euthanasia (day 2) for western blot, histopathology, and cytokine analyses.

RESULTS

Burns produced significant shifts in β-diversity and non-significant reductions in α-diversity that did not recover regardless of treatment group. Burn-induced increases in Proteobacteria and decreases in Firmicutes were attenuated by IV fluids in a dose-dependent manner, and also correlated with α-diversity. IV fluids caused a dose-dependent increase in Bacteroides and prevented a transient increase in the opportunistic pathogen Haemophilus parainfluenzae. While high volumes of IV fluids increased intestinal Hsp70 levels (P = 0.0464), they reduced SGLT1 (P = 0.0213) and caspase3 (P = 0.0139) levels. IV fluids elicited a non-specific cytokine response; however, Bacteroidetes levels correlated with intestinal IL18 levels (P = 0.0166, R = 0.4201).

CONCLUSIONS

We present the first report on the gut microbiome in a porcine burn model, and present data to suggest that IV fluids may influence GM and gut functional proteins following a burn. Overall, burn-induced GM diversity shifts may expose diagnostic and/or therapeutic targets to improve outcomes.

Characteristics of Burn-Injured Children in 117 U.S. PICUs (2009-2017): A Retrospective Virtual Pediatric Systems Database Study

OBJECTIVES

To describe characteristics and outcomes of children with burn injury treated in U.S. PICUs.

DESIGN

Retrospective study of admissions in the Virtual Pediatric Systems, LLC, database from 2009 to 2017.

SETTING

One hundred and seventeen PICUs in the United States.

PATIENTS

Patients less than 18 years old admitted with an active diagnosis of burn at admission.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 2,056 patients were included. They were predominantly male (62.6%) and less than 6 years old (66.7%). Cutaneous burns were recorded in 92.1% of patients, mouth/pharynx burns in 5.8%, inhalation injury in 5.1%, and larynx/trachea/lung burns in 4.5%. Among those with an etiology recorded (n = 861), scald was most common (38.6%), particularly in children less than 2 years old (67.8%). Fire/flame burns were most common (46.6%) in children greater than or equal to 2 years. Multiple organ failure was present in 26.2% of patients. Most patients (89%) were at facilities without American Burn Association pediatric verification. PICU mortality occurred in 4.5% of patients. On multivariable analysis using Pediatric Index of Mortality 2, greater than or equal to 30% total body surface area burned was significantly associated with mortality (odds ratio, 5.40; 95% CI, 2.16-13.51; p = 0.0003). When Pediatric Risk of Mortality III was used, greater than or equal to 30% total body surface area burned (odds ratio, 5.45; 95% CI, 1.95-15.26; p = 0.001) and inhalation injury (odds ratio, 5.39; 95% CI, 1.58-18.42; p = 0.007) were significantly associated with mortality. Among 366 survivors (18.6%) with Pediatric Cerebral Performance Category or Pediatric Overall Performance Category data, 190 (51.9%) had a greater than or equal to 1 point increase in Pediatric Cerebral Performance Category or Pediatric Overall Performance Category disability category and 80 (21.9%) had a new designation of moderate or severe disability, or persistent vegetative state.

CONCLUSIONS

Burn-injured patients in U.S. PICUs have a substantial burden of organ failure, morbidity, and mortality. Coordination among specialized facilities may be particularly important in this population, especially for those with higher % total body surface area burned or inhalation injury.

Use of Fresh Scalp Allografts From Living Relatives for Extensive Deep Burns in Children: A Clinical Study Over 7 Years

Conventionally, pediatric patients with major burns need frozen cadaveric allografts to save their lives. However, these allografts are insufficient in many burn units because of cultural and local governmental laws in China. This paper reported 22 pediatric patients with major burns who received fresh scalp allografts from their parents, siblings, or relatives from January 2011 to December 2017. These 22 pediatric patients sustained deep partial-thickness to full-thickness burns involving 40% total body surface area (TBSA) on average. Wounds were covered with fresh scalp allografts alone or with postage stamp autografts and fresh scalp allografts post excision. Data were collected from medical files of the treated patients, including sex, age, etiology of burn injury, abbreviated burn severity index (ABSI), and TBSA. Postoperative variables included early survival rate of skin grafts, mean time to rejection, length of hospital stay (LHS), healing time of donor sites, and follow-up complications of donors. The 1-year survival rate of the 22 pediatric patients included into the study was 100%. The early survival rate of the scalp allografts was similar to the autografts. The mean time to rejection was 15.5 ± 3.60 days. The average LHS was 58 days. All donor sites healed within 7.6 days on average, without scar formation, alopecia areata, or folliculitis. Following up data of the donors revealed a full psychological sense of accomplishment and no regrets of donating the scalp to save the burned children. Therefore, the use of fresh scalp allografts is a feasible alternative to save pediatric patients with major burns when frozen allografts are unavailable.

Protective Effects of Melatonin against Severe Burn-Induced Distant Organ Injury: A Systematic Review and Meta-Analysis of Experimental Studies

Extensive burns result in a local wound response and distant-organ injury (DOI) caused by oxidative-stress and inflammation. Melatonin (MT) shows promise in alleviating oxidative-stress and inflammation, but its role in thermal injury is largely unexplored. The present systematic review and meta-analysis were designed to assess the effects of MT on oxidative-stress and inflammatory markers against severe burn-induced DOI. Mean difference (MD)/standard mean difference (SMD) with 95% confidence interval (CI) were estimated using fixed-effect/random-effects models. Eighteen experimental studies met the inclusion criteria. Compared with the control group, MT significantly decreased the levels of malondialdehyde (SMD, −1.03; 95% CI, −1.30, −0.76, p < 0.00001) and 4-hydroxynonenal (MD, −1.06; 95% CI, −1.57, −0.56, p < 0.0001). Additionally, MT increased the levels of glutathione (SMD, 1.94; 95% CI, 1.27, 2.61, p < 0.00001) and superoxide-dismutase (SMD, 0.76; 95% CI, 0.08, 1.45, p = 0.03). Finally, MT significantly decreased the levels of tumor necrosis factor-α (SMD, −1.34; 95% CI, −1.92 to −0.77; p < 0.00001) and C-reactive protein (MD, −12.67; 95% CI, −16.72 to −8.62; p < 0.00001). Meta-analysis indicates that severe burn followed by immediate MT (10 mg/kg) intervention shows significant beneficial effects after 24-h against DOI by regulating oxidative-stress and the inflammatory response.

Covalent modification of nephrilin peptide with valproic acid increases its efficacy as a therapeutic in burn trauma

Introduction:

Nephrilin peptide, a designed inhibitor of Rictor complex, modulates systemic responses to trauma, alleviating clinically relevant variables in a rat scald model and sepsis mortality in a mouse model. This study explores the possibility that chemical conjugation of small molecules to the aminoterminus of nephrilin can modify its biological activity in the rat scald model.

Methods:

One of four molecules (valproic acid, decanoic acid, fenofibric acid and ibuprofen) was chemically attached to the amino terminus of nephrilin during synthesis. Animals were treated with each modified nephrilin by subcutaneous bolus injection on days 1–7 post-burn.

Results:

Compared to nephrilin, valproic acid-modified nephrilin showed significantly (all p < 0.05) improved systemic effects on kidney function (creatinine 0.17 ± 0.03 vs 0.31 ± 0.09 mg/dL), glycemic control (AUC 57.5 ± 40 vs 136.4 ± 69.2 mg.dL.hr), inflammation (IL-6 24 ± 9 vs 39 ± 8 pg/ml), pathological angiogenesis (1.46 ± 0.87 vs 6.53 ± 3.16 pct pixels) and weight gain (3.74 ± 0.31 vs 2.99 ± 0.53 slope), all variables previously shown to bear upon clinically relevant burn injury outcomes.

Conclusion:

Modification of nephrilin with valproic acid increases the efficacy of nephrilin peptide in burns.

Soluble Suppression Of Tumorigenicity-2 Predicts Hospital Mortality in Burn Patients: An Observational Prospective Cohort Pilot Study

BACKGROUND

The IL33/ST2 pathway has been implicated in the pathogenesis of different inflammatory diseases. Our aim was to analyze whether plasma levels of biomarkers involved in the IL33/ST2 axis might help to predict mortality in burn patients.

METHODS

Single-center prospective observational cohort pilot study performed at the Burns Unit of the Plastic and Reconstructive Surgery Department of the Vall d'Hebron University Hospital (Barcelona). All patients aged ≥18 years old with second or third-degree burns requiring admission to the Burns Unit were considered for inclusion. Blood samples were taken to measure levels of interleukins (IL)6, IL8, IL33, and soluble suppression of tumorigenicity-2 (sST2) within 24 h of admission to the Burns Unit and at day 3. Results are expressed as medians and interquartile ranges or as frequencies and percentages.

RESULTS

Sixty-nine patients (58 [84.1%] male, mean age 52 [35-63] years, total body surface area burned 21% [13%-30%], Abbreviated Burn Severity Index 6 [4-8]) were included. Thirteen (18.8%) finally died in the Burns Unit. Plasma levels of sST2 measured at day 3 after admission demonstrated the best prediction accuracy for survival (area under the receiver-operating curve 0.85 [0.71-0.99]; P < 0.001). The best cutoff point for the area under the receiver-operating curve index was estimated to be 2,561. In the Cox proportional hazards model, after adjusting for potential confounding, a plasma sST2 level ≥2,561 measured at day 3 was significantly associated with mortality (hazard ratio 6.94 [1.73-27.74]; P = 0.006).

CONCLUSIONS

Plasma sST2 at day 3 predicts hospital mortality in burn patients.

Positive effects of ferric iron on the systemic efficacy of nephrilin peptide in burn trauma

INTRODUCTION

Nephrilin peptide is a designed inhibitor of Rictor complex (also known as mTORC2), an evolutionarily conserved assembly believed to modulate responses to cellular stress. We previously demonstrated the ability of nephrilin peptide to suppress neuroinflammation, loss of body mass, glycaemic control and kidney function in a rat scald model, as well as sepsis mortality in a mouse model. The present study explores the effect of nephrilin plus iron formulations on clinically relevant outcomes in the rat scald model.

METHODS

Animals were treated with nephrilin by subcutaneous bolus injection on post-burn days 1-7. Equimolar ferric iron in the formulation improved the positive systemic effects of nephrilin on kidney function, glycaemic control, oxidative stress, early hyperinflammation, late inflammasome activation, hyperangiogenesis and body mass, all variables previously shown to bear upon clinically relevant burn injury outcomes. The sparing effects of nephrilin-iron were demonstrated in both sexes.

DISCUSSION

Surprisingly, optimum daily treatment doses were in the range of 2-4 mg/kg, while 8 mg/kg was less effective, suggesting the possibility of marginal pro-oxidant effects from the 'free' iron fraction. Thus, although ferric iron in the nephrilin formulation is clearly helpful, care must be exercised to select an optimum treatment dose.

CONCLUSION

Iron increases the efficacy of nephrilin peptide in burns.

Reversible dilative cardiomyopathy after electrical injury: a case report

Background

Dilative cardiomyopathy is an uncommon cardiac complication of electric shock.

Case presentation

We report a case of a 12-year-old German boy with a high voltage injury who developed a four-chamber dilative cardiomyopathy, which was diagnosed on the 13th week postburn. One year after the accident, echocardiography showed a normal function of his heart with 64% ejection fraction and normal cavities’ dimensions.

Conclusions

Despite the fact that dilative cardiomyopathy is not very common in electrical injuries but can be fatal, a prolonged echocardiography follow-up for patients with electrical injury could be recommended. Until now this case is the first child with severe burns after electrocution, who developed a reversible dilative cardiomyopathy.

Emergency Care of Pediatric Burns

Although the overall incidence of and mortality rate associated with burn injury have decreased in recent decades, burns remain a significant source of morbidity and mortality in children. Children with major burns require emergent resuscitation. Resuscitation is similar to that for adults, including pain control, airway management, and administration of intravenous fluid. However, in pediatrics, fluid resuscitation is needed for burns greater than or equal to 15% of total body surface area (TBSA) compared with burns greater than or equal to 20% TBSA for adults. Unique to pediatrics is the additional assessment for non-accidental injury and accurate calculation of the percentage of total burned surface area (TBSA) in children with changing body proportions are crucial to determine resuscitation parameters, prognosis, and disposition.

Role of Elevated Fibrinogen in Burn-Induced Mitochondrial Dysfunction: Protective Effects of Glycyrrhizin

INTRODUCTION

Skeletal muscle wasting and weakness with mitochondrial dysfunction (MD) are major pathological problems in burn injury (BI) patients. Fibrinogen levels elevated in plasma is an accepted risk factor for poor prognosis in many human diseases, and is also designated one of damage-associated molecular pattern (DAMPs) proteins. The roles of upregulated fibrinogen on muscle changes of critical illness including BI are unknown. The hypothesis tested was that BI-upregulated fibrinogen plays a pivotal role in the inflammatory responses and MD in muscles, and that DAMPs inhibitor, glycyrrhizin mitigates the muscle changes.

METHODS

After third degree BI to mice, fibrinogen levels in the plasma and at skeletal muscles were compared between BI and sham-burn (SB) mice. Fibrinogen effects on inflammatory responses and mitochondrial membrane potential (MMP) loss were analyzed in C2C12 myotubes. In addition to survival, the anti-inflammatory and mitochondrial protective effects of glycyrrhizin were tested using in vivo microscopy of skeletal muscles of BI and SB mice.

RESULTS

Fibrinogen in plasma and its extravasation to muscles significantly increased in BI versus SB mice. Fibrinogen applied to myotubes evoked inflammatory responses (increased MCP-1 and TNF-α; 32.6 and 3.9-fold, respectively) and reduced MMP; these changes were ameliorated by glycyrrhizin treatment. In vivo MMP loss and superoxide production in skeletal muscles of BI mice were significantly attenuated by glycyrrhizin treatment, together with improvement of BI survival rate.

CONCLUSIONS

Inflammatory responses and MMP loss in myotubes induced by fibrinogen were reversed by glycyrrhizin. Anti-inflammatory and mitochondrial protective effect of glycyrrhizin in vivo leads to amelioration of muscle MD and improvement of BI survival rate.

Septic predictor index: A novel platform to identify thermally injured patients susceptible to sepsis

BACKGROUND

During the past decades' sepsis has become the major cause of death in severely burned patients. Despite the importance of burn sepsis, its diagnosis, let alone its prediction, is difficult if not impossible. Recently, we have demonstrated burn patients have increased NLRP3 inflammasome activation in white adipose tissue. We aimed to delineate a unique immune profile that can be used to identify septic outcomes in severely burned patients.

METHODS

Adult burn patients (n = 37) admitted to our burn center between June 2013-2015 were enrolled in this study. White adipose tissue from the site of injury and plasma were collected from severely burned patients (>20% total body surface area) within 96 hours after thermal injury, indiscriminate of sex or age.

RESULTS

We found that patients exhibiting aberrantly high levels of proinflammatory interleukin-1β and decreased macrophages at the site of injury are highly susceptible to development of sepsis. Septic patients also had increased anti-inflammatory (interleukin-10, interleukin-1RA) cytokines in plasma. The Septic Predictor Index was generated as a quotient for the site of injury macrophage proportion and interleukin-1β production. All patients who eventually develop sepsis had septic predictor index values >0.5. Septic patients with Septic Predictor Index values >1 all had sepsis onset within 12 days post-injury, whereas patients with Septic Predictor Index values between 0.5-1 all had later onset (>12 days).

CONCLUSION

The Septic Predictor Index can determine sepsis onset accurately in thermally injured patients a priori and further enables surgeons to develop clinical studies and focused therapies specifically designed for septic cohorts.

Toll-Like Receptor Signaling in Burn Wound Healing and Scarring

Significance: Damage-associated molecular patterns (DAMPs) and pathogen-associated molecular patterns (PAMPs) emanate from burn-injured tissue and enter systemic circulation. Locally and systemically, they activate pattern-recognition receptors, including toll-like receptors (TLRs), to stimulate cytokine secretion, which in the severest burns typically results in extreme systemic cytokine levels, a dysfunctioning immune system, infection, impaired healing, and excessive scarring. This system-wide disruption of homeostasis can advance to life-threatening, multiorgan dysfunction syndrome. Knowledge of DAMP- and PAMP-TLR signaling may lead to treatments that ameliorate local and systemic inflammation and reduce scarring and other burn injury sequela. Recent Advances: Many PAMPs and DAMPs, the TLRs they activate, and their downstream signaling molecules have been shown to contribute to local and systemic inflammation and tissue damage following burn injury. Critical Issues: Whether TLR-pathway-targeting treatments applied at different times postburn injury might improve scarring remains an open question. The evaluation of this question requires the use of appropriate preclinical and clinical burn models carried out until after mature scar has formed. Future Directions: After TLR-pathway-targeting treatments are evaluated in porcine burn wound models and their safety is demonstrated, they can be tested in proof-of-concept clinical burn wound models.

The P50 Research Center in Perioperative Sciences: How the investment by the National Institute of General Medical Sciences in team science has reduced postburn mortality

Since the inception of the P50 Research Center in Injury and Peri-operative Sciences (RCIPS) funding mechanism, the National Institute of General Medical Sciences has supported a team approach to science. Many advances in critical care, particularly burns, have been driven by RCIPS teams. In fact, burns that were fatal in the early 1970s, prior to the inception of the P50 RCIPS program, are now routinely survived as a result of the P50-funded research. The advances in clinical care that led to the reduction in postburn death were made by optimizing resuscitation, incorporating early excision and grafting, bolstering acute care including support for inhalation injury, modulating the hypermetabolic response, augmenting the immune response, incorporating aerobic exercise, and developing antiscarring strategies. The work of the Burn RCIPS programs advanced our understanding of the pathophysiologic response to burn injury. As a result, the effects of a large burn on all organ systems have been studied, leading to the discovery of persistent dysfunction, elucidation of the underlying molecular mechanisms, and identification of potential therapeutic targets. Survival and subsequent patient satisfaction with quality of life have increased. In this review article, we describe the contributions of the Galveston P50 RCIPS that have changed postburn care and have considerably reduced postburn mortality.

Sepsis in the burn patient: a different problem than sepsis in the general population

Sepsis has recently been defined as "life-threatening organ dysfunction caused by a dysregulated host response to infection". A great amount of effort has been made to develop early treatments for sepsis through the Surviving Sepsis Campaign. There are similar but slightly different recommendations for the treatment of sepsis in the pediatric population. These international efforts have led to earlier diagnosis and treatments for sepsis that have led to improvements in survival. Sepsis is also the leading cause of death in the burn patient but most clinical sepsis studies have excluded burns. The reason for the exclusion is that the sepsis found in burn patients is different than that of the general population. The early treatment strategies, such as those directed by the Surviving Sepsis Campaign, focus on patients presenting to hospitals with recent signs of infection. Burn patients lose their primary barrier to infection, the skin, and thus the risk of infection persists as long as that barrier is absent. Efforts have been made to define sepsis, septic shock and infection in the burn population but there is constant need for revisions. One focus of this review is to discuss the differences in burn sepsis versus sepsis of the general population. Children often have profound responses to sepsis but can also make remarkable recoveries. This review will also explore problems specific to pediatric burns. The treatment of burns requires a continuous vigilance to watch for the subtle early signs of sepsis and then expeditious initiation of aggressive therapy. Strategies covering optimal management of pediatric burn sepsis will also be summarized.

The occurrence of single and multiple organ dysfunction in pediatric electrical versus other thermal burns

BACKGROUND

Multiple organ failure (MOF) is a major contributor to morbidity and mortality in burned children. While various complications induced by electrical injuries have been described, the incidence and severity of single organ failure (SOF) and MOF associated with this type of injury are unknown. The study was undertaken to compare the incidence and severity of SOF and MOF as well as other complications between electrically and thermally burned children.

PATIENTS AND METHODS

Between 2001 and 2016, 288 pediatric patients with electrical burns (EB; n = 96) or thermal burns (CTR; n = 192) were analyzed in this study. Demographic data; length of hospitalization; and number and type of operations, amputations, and complications were statistically analyzed. Incidence of SOF and MOF was assessed using the DENVER2 classification in an additive mixed model over time. Compound scores and organ-specific scores for lung, heart, kidney, and liver were analyzed. Serum cytokine expression profiles of both groups were also compared over time. Significance was accepted at p < 0.05.

RESULTS

Both groups were comparable in age (CTR, 11 ± 5 years, vs EB, 11 ± 5 years), percent total body surface area burned (CTR, 33% ± 25%, vs EB, 32 ± 25%), and length of hospitalization (CTR, 18 ± 26 days, vs EB, 18 ± 21 days). The percentage of high-voltage injury in the EB group was 64%. The incidence of MOF was lower in the EB group (2 of 96 [2.1%]) than the CTR group (20 of 192 [10.4%]; p < 0.05). The incidence of single organ failure was comparable between groups. Incidence of pulmonary failure was comparable in both groups, but incidence of inhalation injury was significantly higher in the CTR group (p < 0.0001). Patients in the EB group had more amputations (p < 0.001), major amputations (p = 0.001), and combined major amputations (p < 0.01). Mortality was comparable between the groups. Serum cytokine expression profiles were also comparable between the groups.

CONCLUSIONS

In pediatric patients, electrical injury is associated with a lower incidence of MOF than other thermal burns. Early and radical debridement of nonviable tissue is crucial to improve outcomes in the electrical burn patient population.

LEVEL OF EVIDENCE

Retrospective chart review, level III.

Specific Etiologies Associated With the Multiple Organ Dysfunction Syndrome in Children: Part 2

OBJECTIVE

To describe a number of conditions and therapies associated with multiple organ dysfunction syndrome presented as part of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Multiple Organ Dysfunction Workshop (March 26-27, 2015). In addition, the relationship between burn injuries and multiple organ dysfunction syndrome is also included although it was not discussed at the workshop.

DATA SOURCES

Literature review, research data, and expert opinion.

STUDY SELECTION

Not applicable.

DATA EXTRACTION

Moderated by an expert from the field, issues relevant to the association of multiple organ dysfunction syndrome with a variety of conditions and therapies were presented, discussed, and debated with a focus on identifying knowledge gaps and the research priorities.

DATA SYNTHESIS

Summary of presentations and discussion supported and supplemented by relevant literature.

CONCLUSIONS

Sepsis and trauma are the two conditions most commonly associated with multiple organ dysfunction syndrome both in children and adults. However, many other pathophysiologic processes may result in multiple organ dysfunction syndrome. In this article, we discuss conditions such as liver failure and pancreatitis, pathophysiologic processes such as ischemia and hypoxia, and injuries such as trauma and burns. Additionally, therapeutic interventions such as medications, blood transfusions, transplantation may also precipitate and contribute to multiple organ dysfunction syndrome. The purpose of this article is to describe the association of multiple organ dysfunction syndrome with a variety of conditions and therapies in an attempt to identify similarities, differences, and opportunities for therapeutic intervention.

Epidemiology and Outcomes of Pediatric Multiple Organ Dysfunction Syndrome

OBJECTIVE

To summarize the epidemiology and outcomes of children with multiple organ dysfunction syndrome as part of the Eunice Kennedy Shriver National Institute of Child Health and Human Development multiple organ dysfunction syndrome workshop (March 26-27, 2015).

DATA SOURCES

Literature review, research data, and expert opinion.

STUDY SELECTION

Not applicable.

DATA EXTRACTION

Moderated by an experienced expert from the field, issues relevant to the epidemiology and outcomes of children with multiple organ dysfunction syndrome were presented, discussed, and debated with a focus on identifying knowledge gaps and research priorities.

DATA SYNTHESIS

Summary of presentations and discussion supported and supplemented by the relevant literature.

CONCLUSIONS

A full understanding the epidemiology and outcome of multiple organ dysfunction syndrome in children is limited by inconsistent definitions and populations studied. Nonetheless, pediatric multiple organ dysfunction syndrome is common among PICU patients, occurring in up to 57% depending on the population studied; sepsis remains its leading cause. Pediatric multiple organ dysfunction syndrome leads to considerable short-term morbidity and mortality. Long-term outcomes of multiple organ dysfunction syndrome in children have not been well studied; however, studies of adults and children with other critical illnesses suggest that the risk of long-term adverse sequelae is high. Characterization of the long-term outcomes of pediatric multiple organ dysfunction syndrome is crucial to identify opportunities for improved treatment and recovery strategies that will improve the quality of life of critically ill children and their families. The workshop identified important knowledge gaps and research priorities intended to promote the development of standard definitions and the identification of modifiable factors related to its occurrence and outcome.

Postburn Hypermetabolism: Past, Present, and Future

Hypermetabolism is the ubiquitous response to a severe burn injury, which was first described in the nineteenth century. Despite identification of important components of this complex response, hypermetabolism is still not well understood in its entirety. This article describes this incredibly fascinating response and the understanding we have gained over the past 100 years. Additionally, this article describes novel insights and delineates treatment options to modulate postburn hypermetabolism with the goal to improve outcomes of burn patients.

Effects of the nephrilin peptide on post-burn glycemic control, renal function, fat and lean body mass, and wound healing

The mechanisms underlying the effects of severe burn trauma are not well understood. We previously demonstrated the ability of nephrilin peptide (an iron-binding peptide believed to enter cells through iron-uptake pathways) to suppress aspects of the neuroinflammatory response in a rat scald model, as well as sepsis mortality in a mouse model. This study explores the effect of nephrilin on other clinically relevant outcomes in the rat scald model. In a rat scald model, animals were treated with nephrilin either in week 1 or week 2 post-burn. Measurements were made of serum glucose and creatinine as well as wound area by planimetry and body composition by DEXA. Given the potential role of iron, results were analyzed both for the entire cohort of animals and for the normoferremic (>100 ug/dL serum iron) subset of animals. Nephrilin improved body composition, wound healing, kidney function, and glycemic control. The first two effects were significant in normoferremic but not in hypoferremic animals suggesting an effect of iron status on burn injury outcomes. Nephrilin treatment modulates a number of relevant variables in the rat scald model.

Effects of different duration exercise programs in children with severe burns

INTRODUCTION

Burns lead to persistent and detrimental muscle breakdown and weakness. Standard treatment at our institution includes a voluntary 12-week rehabilitative exercise program to limit and reverse the effects of increased muscle catabolism. In the present work, we investigated if different durations of exercise, 6 or 12 weeks, produce comparable improvements in muscle strength, body composition, and cardiopulmonary fitness.

METHODS

We prospectively enrolled and randomized patients with ≥30% total body surface area (TBSA) burned to receive 6 or 12 weeks of exercise rehabilitation. Patients were evaluated for muscle strength, oxygen consumption capacity, and lean body mass at discharge (n=42) and after exercise. After 6 weeks (n=18) or 12 weeks (n=24) of exercise training, leg muscle strength was assessed as peak torque per body weight using a Biodex isokinetic dynamometer. Oxygen consumption capacity, measured as peak VO₂, was studied using a standard treadmill-based test, and lean body mass was determined using dual-energy X-ray absorptiometry.

RESULTS

Significant improvements in muscle strength, peak VO₂, and lean body mass were seen after 6 weeks of exercise training (p<0.001), with only significant improvements in peak VO₂ being seen after 6 weeks more of training.

CONCLUSION

These data suggest that a 6-week rehabilitative exercise program is sufficient for improving muscle strength, body composition, and cardiopulmonary fitness in pediatric burn patients. However, continuation of at- or near-home cardiopulmonary training following the 6 weeks of at-hospital rehabilitation may be useful.

The Physiologic Basis of Burn Shock and the Need for Aggressive Fluid Resuscitation

Burn trauma in the current age of medical care still portends a 3% to 8% mortality. Of patients who die from their burn injuries, 58% of deaths occur in the first 72 hours after injury, indicating death from the initial burn shock is still a major cause of burn mortality. Significant thermal injury incites an inflammatory response, which distinguishes burns from other trauma. This article focuses on the current understanding of the pathophysiology of burn shock, the inflammatory response, and the direction of research and targeted therapies to improve resuscitation, morbidity, and mortality.

Predictive Value of IL-8 for Sepsis and Severe Infections After Burn Injury: A Clinical Study

The inflammatory response induced by burn injury contributes to increased incidence of infections, sepsis, organ failure, and mortality. Thus, monitoring postburn inflammation is of paramount importance but, so far, there are no reliable biomarkers available to monitor and/or predict infectious complications after burn. As interleukin 8 (IL-8) is a major mediator for inflammatory responses, the aim of our study was to determine whether IL-8 expression can be used to predict postburn sepsis, infections, and mortality. Plasma cytokines, acute-phase proteins, constitutive proteins, and hormones were analyzed during the first 60 days after injury from 468 pediatric burn patients. Demographics and clinical outcome variables (length of stay, infection, sepsis, multiorgan failure [MOF], and mortality) were recorded. A cutoff level for IL-8 was determined using receiver operating characteristic analysis. Statistical significance is set at P < 0.05. Receiver operating characteristic analysis identified a cutoff level of 234 pg/mL for IL-8 for survival. Patients were grouped according to their average IL-8 levels relative to this cutoff and stratified into high (H) (n = 133) and low (L) (n = 335) groups. In the L group, regression analysis revealed a significant predictive value of IL-8 to percent of total body surface area burned and incidence of MOF (P < 0.001). In the H group, IL-8 levels were able to predict sepsis (P < 0.002). In the H group, elevated IL-8 was associated with increased inflammatory and acute-phase responses compared with the L group (P < 0.05). High levels of IL-8 correlated with increased MOF, sepsis, and mortality. These data suggest that serum levels of IL-8 may be a valid biomarker for monitoring sepsis, infections, and mortality in burn patients.

Pathophysiologic Response to Burns in the Elderly

Over the last decades advancements have improved survival and outcomes of severely burned patients except one population, elderly. The Lethal Dose 50 (LD50) burn size in elderly has remained the same over the past three decades, and so has morbidity and mortality, despite the increased demand for elderly burn care. The objective of this study is to gain insights on why elderly burn patients have had such a poor outcome when compared to adult burn patients. The significance of this project is that to this date, burn care providers recognize the extreme poor outcome of elderly, but the reason remains unclear. In this prospective translational trial, we have determined clinical, metabolic, inflammatory, immune, and skin healing aspects. We found that elderly have a profound increased mortality, more premorbid conditions, and stay at the hospital for longer, p < 0.05. Interestingly, we could not find a higher incidence of infection or sepsis in elderly, p > 0.05, but a significant increased incidence of multi organ failure, p < 0.05. These clinical outcomes were associated with a delayed hypermetabolic response, increased hyperglycemic and hyperlipidemic responses, inversed inflammatory response, immune-compromisation and substantial delay in wound healing predominantly due to alteration in characteristics of progenitor cells, p < 0.05. In summary, elderly have substantially different responses to burns when compared to adults associated with increased morbidity and mortality. This study indicates that these responses are complex and not linear, requiring a multi-modal approach to improve the outcome of severely burned elderly.

•

The outcome of elderly burn management is low with reasons that remain unclear.

•

Elderly have a higher mortality, more premorbid conditions and a higher incidence of multi organ failure.

•

Elderly stay at the hospital for longer time.

•

The incidence of infection or sepsis is not higher than young adult.

•

Elderly show delayed hyper-metabolic response, increased hyperglycemic and hyperlipidemic responses.

•

Elderly present inversed inflammatory response.

•

Elderly show substantial delay in wound healing, predominantly due to alteration in characteristics of progenitor cells.

Despite advancements in treatment of severely burned patients, the death rate is still high in elderly. In this project, we investigate the reason behind this poor outcome. Our report highlights some of the deficiencies that we have observed in elderly patients and compare them to the young adults. Elderly have late immune responses which are necessary to fight the disease. Their body lacks some of the essential stem cells which are essential for skin healing. By learning the major deficiencies that come with this age group, we will be able to help elderly who have been subjected to burn injury.

Integrity of airway epithelium in pediatric burn autopsies: Association with age and extent of burn injury

This study examines the structural integrity of the airway epithelium in autopsy tissues from pediatric burn subjects.

METHODS

A semi-quantitative score for the degree of airway epithelial integrity was made for seventy- two pediatric burn autopsies. Multivariate ordinal logistic regression was performed to identify relationships between epithelial integrity and conditions related to tissue fixation, time of death after injury, age, total body surface area burn (TBSA), extent of 3rd degree burn, presence of inhalation injury, ventilator days and pneumonia.

RESULTS

No significant difference in epithelial integrity scores was identified between burn only cases and those with inhalation injury. Significant correlations with bronchiolar epithelial integrity scores were identified for age, p=0.02, and percent 3rd degree burn, p=0.02. There was no significant relationship between epithelial integrity and time between death and autopsy, p>0.44.

CONCLUSIONS

Airway epithelial loss seen in autopsy tissue is not simply an artifact of tissue fixation. The degree of compromise correlates most strongly with age and degree of burn. Further studies are needed to identify physiological or critical care factors following burn injury that contribute to compromise in the structural and functional properties of the airway epithelium.

Morbidity and survival probability in burn patients in modern burn care

OBJECTIVE

Characterizing burn sizes that are associated with an increased risk of mortality and morbidity is critical because it would allow identifying patients who might derive the greatest benefit from individualized, experimental, or innovative therapies. Although scores have been established to predict mortality, few data addressing other outcomes exist. The objective of this study was to determine burn sizes that are associated with increased mortality and morbidity after burn.

DESIGN AND PATIENTS

Burn patients were prospectively enrolled as part of the multicenter prospective cohort study, Inflammation and the Host Response to Injury Glue Grant, with the following inclusion criteria: 0-99 years old, admission within 96 hours after injury, and more than 20% total body surface area burns requiring at least one surgical intervention.

SETTING

Six major burn centers in North America.

MEASUREMENTS AND MAIN RESULTS

Burn size cutoff values were determined for mortality, burn wound infection (at least two infections), sepsis (as defined by American Burn Association sepsis criteria), pneumonia, acute respiratory distress syndrome, and multiple organ failure (Denver 2 score>3) for both children (<16 yr) and adults (16-65 yr). Five hundred seventy-three patients were enrolled, of which 226 patients were children. Twenty-three patients were older than 65 years and were excluded from the cutoff analysis. In children, the cutoff burn size for mortality, sepsis, infection, and multiple organ failure was approximately 60% total body surface area burned. In adults, the cutoff for these outcomes was lower, at approximately 40% total body surface area burned.

CONCLUSIONS

In the modern burn care setting, adults with over 40% total body surface area burned and children with over 60% total body surface area burned are at high risk for morbidity and mortality, even in highly specialized centers.

Hypoglycemia is associated with increased postburn morbidity and mortality in pediatric patients

OBJECTIVE

The objective of this study was to determine the prevalence of hypoglycemia after burn injury and whether hypoglycemia is associated with increased postburn morbidity and mortality.

DESIGN

Cohort analysis.

SETTING

Academic pediatric burn hospital.

PATIENTS

This analysis included 760 pediatric burn patients, who were stratified according the number of hypoglycemic episodes (< 60 mg/dL glucose) they experienced while in the ICU. Clinical outcomes and metabolic and inflammatory biomarkers were analyzed during the first 60 days post admission. Patients with one or more hypoglycemic events were matched with patients not experiencing any event using propensity score matching, and outcomes and biomarker expression were compared between groups.

MEASUREMENTS AND MAIN RESULTS

Eighty-four patients had one episode of hypoglycemia, 108 patients had two or more episodes of hypoglycemia, and 568 patients never experienced hypoglycemia. Patients with one or more hypoglycemic episodes had longer hospitalization, as well as more frequent infections, sepsis, multiple organ failure, and death (p < 0.05). The 166 propensity score-matched patients with one or more hypoglycemic events had greater inflammatory and metabolic responses, prevalence of sepsis, multiple organ failure, and mortality than burn patients without hypoglycemic (p < 0.05).

CONCLUSIONS

Hypoglycemic episodes correlate with injury severity and inhalation injury. When adjusted for injury severity, hypoglycemia is associated with significantly higher postburn morbidity and mortality.