Sodium variability is associated with increased mortality in severe burn injury

Antibiotics in patients with severe burn injury-A modifiable variable in hypernatremia etiology

INTRODUCTION

Hypernatremia is a common problem among patients with severe burn injuries and seems to be associated with an unfavorable clinical outcome. The current study was designed to evaluate the impact of antibiotics with a high proportion of sodium on this phenomenon.

METHODS

All admissions to our burn center from 01/2017 till 06/2023 were retrospectively screened. All patients aged >18 years which suffered from at least 20 % total body surface burned area (TBSA) 2nd degree burn injuries or more than 10 % TBSA when including areas of 3rd degree burn injuries were included. The course of the serum Na-level was analyzed from two days before till two days after the start of the antibiotic treatment. Ampicillin/sulbactam, cefazoline and piperacillin/tazobactam were classified as high-dose sodium antibiotics (HPS), meropenem and vancomycin as low-dose sodium antibiotics (LPS).

RESULTS

120 patients met the inclusion criteria. A significant increase of the serum Na was detectable in the HPS group on day 1 and 2 after initiating the antibiotic treatment (n = 64, day 1: 2,1 (SD 4,18) mmol/l, p < 0,001; day 2: 2,44 (SD 5,26) mmol/l, p < 0,001) while no significant changes were detectable in the LPS group (n = 21, day 1: 0,18 (SD 7,45) mmol/l, p = 0,91; day 2: -0,27 (SD 7,44) mmol/l, p = 0,87). This effect was further aggravated when analyzing only the HPS patients with a TBSA ≥30 % (n = 33; day 1: 2,93 (SD 4,68) mmol/l, p = 0,002; day 2: 3,41 (SD 5,9) mmol/l, p = 0,003).

CONCLUSION

The amount of sodium in antibiotics seems to have a relevant impact on the serum Na during the early stages of severe burn injury. Therefore, this aspect should be taken into account when searching for the most appropriate antibiotic treatment for patients with severe burn injury, especially when being at acute risk for a clinical relevant hypernatremia.

Effect of high sodium ion level on the interaction of AmB with a cholesterol-rich phospholipid monolayer

Invasive fungal infections are a primary reason for high mortality in immunocompromised people, especially in critically ill patients, such as intensive care unit (ICU) patients, advanced cancer patients, or severe burn patients. Hypernatremia also can increase mortality in severely ill patients. Amphotericin B (AmB) is the gold standard for treating infections, but in severely ill patients, AmB can cause hematotoxicity when administered intravenously due to its interaction with cholesterol on red blood cell membranes. This results in limited doses of AmB and affects the treatment of infections. The proportion of cholesterol molecules in membrane lipids in red blood cells is as high as 50 mol%, and the sodium ions can influence the interaction between AmB and lipids on the membrane. Therefore, in the complex clinical situation of a severely ill patient with a fungal infection and hypernatremia, the interaction between amphotericin B and the red blood cell membranes is worth studying in depth. In this work, the interaction between AmB and the dipalmitoyl phosphatidylcholine (DPPC)/cholesterol mixed monolayer in the presence of high sodium ion levels was studied when the proportion of cholesterol was 50%. The results show that the effect of AmB on reducing the monolayer's area at a high level of sodium ions is slightly stronger at 30 mN/m. The effect of AmB on reducing the elastic modulus of the DPPC/Chol monolayer is significantly weakened by a high sodium ion level, compared with the level of sodium ions at normal physiological concentration. The higher the sodium ion concentration, the weaker the intermolecular force of the DPPC/Chol/AmB mixed monolayers. The scanning electron microscope (SEM) and atomic force microscopy (AFM) observations suggest that at a high sodium ion level, the presence of AmB significantly reduces the surface roughness of the DPPC/Chol monolayer. AmB may bind to cholesterol molecules, and it isolates cholesterol from the monolayer, resulting in a reduced height of the cholesterol-rich monolayer and an increasingly dispersed monolayer region. The results are beneficial to understanding the mechanism of impact of a high sodium ion level on the relationship between AmB and red blood cell membranes rich in cholesterol and are valuable for understanding the hemolytic toxicity of AmB to red blood cells at a high sodium ion level.

Hyponatremia after COVID-19 is frequent in the first year and increases re-admissions

Hyponatremia on admission has been related to worse outcomes in patients with COVID-19 infection. However, little is known about the frequency and the associated risk factors of hyponatremia after COVID-19 discharge. We performed an observational 24-month follow-up study of patients admitted during the first COVID-19 wave. Kaplan-Meier curves and Cox proportional hazard models were used to assess the main variables in predicting hyponatremia on follow-up (HYPO-FU). A total of 161 out of 683 (24.4%) developed HYPO-FU. The group with HYPO-FU comprised of more men [(62.3%) vs. (49.2%); p < 0.01], older [65.6 ± 18.2 vs. 60.3 ± 17.0; p < 0.01] and more frequently re-admitted [(16.2%) vs. (3.8%); p < 0.01). The rate of HYPO-FU was higher in the first year 23.6 per 100 individuals per year. After Cox regression analysis, the independent risk factors of HYPO-FU were diabetes [OR 2.12, IC 95% (1.48-3.04)], hypertension [OR 2.18, IC 95% (1.53-3.12)], heart failure [OR 3.34, IC 95% (1.72-6.48)] and invasive ventilation support requirement [OR: 2.38, IC 95% (1.63-3.50)]. To conclude, HYPO-FU was frequent in the first year after COVID-19 infection, and the risk was higher in older men with comorbidities, increasing rehospitalisation. Further studies aimed at evaluating the beneficial effects of correcting hyponatremia in these patients are warranted.

The Extent of Burn Injury Significantly Affects Serum Micro- and Macroelement Concentrations in Patients on the First Day of Hospitalisation

Burns exceeding 30% of total body surface area (TBSA) result in considerable hypovolemia coupled with the formation and release of inflammatory mediators, leading to subsequent systemic effects known as burn shock. Because of plasma exudation and the associated losses of large quantities of minerals, severe burns can lead to nutritional deficiencies and consequently disrupt homeostasis and metabolism of the entire body. The study group comprised 62 patients, who were divided into 3 groups according to the severity of burns. Serum samples were tested for concentrations of Ca, Mg, Mn, P, K, Zn, Cu, Fe, Se, Na, Cr, Ni, and Al. The mineral concentrations in serum of patients with burn injuries differ significantly from reference values, but this is not affected by the extent of the body burn. There are statistically significant decreases in serum concentrations of elements important for antioxidant protection (Zn, Cu, Se), and significant increases in the concentrations of toxic elements (Al and Ni), which may aggravate the effects associated with the state of burn shock. The Spearman rank correlation analysis did not reveal any statistically significant relationships between the serum concentrations of Mn, Ni, Al, K, Na, P, Mg, Zn, Se, Cr and the affected body surface area and severity of the burn—the values were at the lower end of the reference range. The obtained results indicate that proper nutrition, including elements replenishment, is extremely important in the recovery process of burn patients and time to nutrition is an important factor affecting patient survival after severe burn.

Sodium Balance Analysis In The Burn Resuscitation Period

The different formulae for resuscitation therapy after thermal damage recommend 0.5-0.6 mmol sodium for each % TBSA burned, suggesting fluid requirements from 2-4 ml/kg/% burn because of sodium loss in burned and unburned tissues. There is a gap especially in the recommendations regarding dysnatremia in the burn population. Many studies have focused on calculating amount of resuscitation fluids, avoiding the situation of "fluid creep", and not on calculating sodium remaining in the body after resuscitation. The goal of this observational study was to provide data for sodium disturbances in the shock period after burns. Our study underscores the challenge of understanding whether there is a relationship between amount of crystalloid fluids given during resuscitation and meeting sodium needs. We set out to examine sodium balance (sodium deficit, received, excreted, and retained) after burns. The area under the ROC curve was performed by analyzing fluid and sodium load. Moreover, we conducted linear regression to analyze if there was a correlation between sodium retained and sodium excreted. Sodium deficit persisted until the second 24h despite resuscitation. Resuscitation was performed using Parkland formula, but urine output (UO) values were higher than expected. The threshold for fluid administration (ml/kg/%) or fluid load in the first 24h and sodium load (mmol/kg/%) for positive state (sodium received >0.5-0.6 mmol/kg/%) was 3.7 ml/kg/%. With linear regression, it was evident that sodium excreted was responsible for sodium retained, indicating a moderate correlation in the first 24h and a strong correlation in the second 24h. Resuscitation with LR did not correct hypoosmolality hyponatremia, which persisted even after the first 24h, especially in patients with burns >60%. If more than 3.7 ml/kg/% of LR is given, a sodium load higher than the normal level will be introduced, leading to increased urinary output, elevated sodium excretion, and non-correction of plasma sodium at the end of resuscitation. What is important for colleagues in clinical practice is that the focus of burn resuscitation should be expanded with data regarding sodium balance and the impact of dysnatremias in morbidity and mortality.

The relationships between routine admission blood tests and burn size, and length of stay in intensive care unit

BACKGROUND

Although blood test is a routine in major burns, its relationship with burn size and intensive care unit length of stay (ICULOS) remains undetermined. We investigated the feasibility of using these tests as a reference for definite diagnosis of major burn size, burn size >20% of the total body surface area (TBSA), and their relationships with ICULOS.

METHODS

Data of routine laboratory blood tests within 24 h after burns (n = 73) were collected retrospectively. Correlation tests and regression analyses were performed.

RESULTS

Burns ≥20 TBSA had higher incidences of leucocytosis, hypoalbuminaemia, elevated haemoglobin (Hb), and elevated haematocrit (Hct). Burn size was correlated negatively with albumin but positively with Hb, Hct, and white blood cell (WBC) count. For each unit increase in blood urea nitrogen (BUN)/creatinine (Cr), there was an increase of 1.2 days of ICULOS in females, while in males, there was a 6.7 day increase for every unit increase in Hb and a 3.1 day increase for each unit increase in BUN. A female model including Hb and WBC was derived, discriminating burns ≥20 TBSA with sensitivity and specificity 0.94 and 1.0 respectively, and area under the receiver operating characteristic curve (AUROC) 0.96 (95% CI 0.91-1.00). The male model had sensitivity 0.96, specificity 1.0, and AUROC 0.96 (95% CI 0.89-1.00).

CONCLUSION

Admission Hb and WBC could be used as a reference for definite diagnosis of major burn size, especially in borderline cases. BUN/Cr in females, and Hb and BUN in males, were related to ICULOS.

Increased short-term and long-term mortality in community- and hospital-acquired hypernatraemia and in patients with delayed serum sodium correction

BACKGROUND

This study examined the short-term and long-term mortality of community- and hospital-acquired hypernatraemia in a large cohort of general hospitalised patients, and the impact of delayed serum sodium correction in hypernatraemic patients.

METHODS

Adult patients admitted to Mayo Clinic Rochester from 2011 to 2013 were examined. The patients with admission serum sodium ≥138 mEq/L and at least 2 serum sodium measurements during hospitalisation were included. Hypernatraemia was defined as serum sodium ≥143 mEq/L. The patients were categorised into three groups based on serum sodium at admission and during hospitalisation: (a) normal serum sodium, (b) community-acquired hypernatraemia and (c) hospital-acquired hypernatraemia. Outcomes included hospital mortality and 1-year mortality after hospital discharge amongst hospital survivors.

RESULTS

Of 25 781 eligible patients, 45% had normal serum sodium, 20% had community-acquired hypernatraemia and 35% had hospital-acquired hypernatraemia. In adjusted analysis, odds ratios (ORs) of community- and hospital-acquired hypernatraemia for hospital mortality were 4.91 (95% CI 3.47-6.94) and 4.11 (95% CI 2.94-5.73), whereas hazard ratio (HR) for 1-year mortality was 1.76 (95% CI 1.56-1.98) and 1.61 (95% CI 1.45-1.79), respectively. Hospital-acquired hypernatraemia had a higher hospital mortality but not 1-year mortality than community-acquired hypernatraemia. In patients with community-acquired hypernatraemia, 36% remained hypernatraemic by hospital day 3. Hospital mortality (OR 3.01; 95% CI 2.71-5.83) and 1-year mortality (HR 1.51; 95% CI 1.26-1.81) were significantly increased in patients with persistent hypernatraemia, compared with those with serum sodium correction into optimal range of 138-142 mEq/L.

CONCLUSION

Hypernatraemia, regardless of acquisition origin, is associated with elevated short-term and long-term mortality. Hospital-acquired hypernatraemia was more common and had a higher short-term mortality than community-acquired hypernatraemia. Failure to correct hypernatraemia by hospital day 3 is associated with increased mortality.

Hypernatremia Risk Factors And Prognostic Impact In Burn Patients: A Case Control Study

Hypernatremia is associated with poor outcomes in critically ill patients. Hypernatremia risk factors in burned patients are not well studied. We aimed to identify hypernatremia risk factors and to evaluate outcomes in burned patients admitted to our burns intensive care unit. A case control study was conducted in adult burned patients hospitalized between January 1st 2017 and December 31st 2019. Cases who developed hypernatremia (>145 meq/L) during hospitalization were matched 1:1 with controls based on age and total burn surface area. There were 57 cases and 57 controls with a mean age of 41 ± 18 years. The majority of patients had major burns (n=99, 86.8%). The time onset of hypernatremia was seven days post burn. Compared to controls, the case group mostly consisted of transferred patients with longer time from injury to intensive care unit admission. Inhalation injury, mechanical ventilation, intravenous fosfomycin and colistin were associated with hypernatremia. Admission to the intensive care unit after six hours post-burn was the independent risk factor (OR=4.5). Hypernatremia was associated with longer length of stay and with higher mortality. We conclude that delayed management, inhalation injury, mechanical ventilation, fosfomycin and colistin administration are the main hypernatremia risk factors in burned patients.

Increased mortality risk associated with serum sodium variations and borderline hypo- and hypernatremia in hospitalized adults

Background

This study aimed to evaluate short-term and long-term mortalities in a cohort of unselected hospitalized patients with serum sodium concentration ([Na⁺]) variations within and outside of reference range.

Methods

All adult patients admitted to the Mayo Clinic, Rochester, MN, USA from January 2011 to December 2013 (n = 147358) were retrospectively screened. Unique patients admitted during the study period were examined. The main exposure was serum [Na⁺] variation. Outcome measures were hospital and 1-year all-cause mortalities.

Results

A total of 60944 patients, mean age 63 ± 17 years, were studied. On admission, 17% (n = 10066) and 1.4% (n = 852) had hypo- and hypernatremia, respectively. During the hospital stay, 11044 and 4128 developed hypo- and hypernatremia, respectively, accounting for 52.3 and 82.9% of the total hypo- and hypernatremic patients. Serum [Na⁺] variations of ≥6 mEq/L occurred in 40.6% (n = 24 740) of the 60 944 patients and were significantly associated with hospital and 1-year mortalities after adjusting potential confounders (including demographics, comorbidities, estimated glomerular filtration rate, admission serum [Na⁺], number of [Na⁺] measurements and length of hospital stay). Adjusted odds ratios for hospital and 1-year mortalities increased with increasing [Na⁺] variations in a dose-dependent manner, from 1.47 to 5.48 (all 95% confidence intervals >1.0). Moreover, in fully adjusted models, [Na⁺] variations (≥6 mEq/L) within the reference range (135–145 mEq/L) or borderline hypo- or hypernatremia (133–137 and 143–147 mEq/L, respectively) compared with 138–142 mEq/L were associated with increased hospital and 1-year mortalities.

Conclusion

In hospitalized adults, [Na⁺] fluctuation (≥6 mEq/L) irrespective of admission [Na⁺] and borderline hypo- or hypernatremia are independent predictors of progressively increasing short- and long-term mortality burdens.

Variability in Serum Sodium Concentration and Prognostic Significance in Severe Traumatic Brain Injury: A Multicenter Observational Study

BACKGROUND/OBJECTIVE

Dysnatremia is common in severe traumatic brain injury (TBI) patients and may contribute to mortality. However, serum sodium variability has not been studied in TBI patients. We hypothesized that such variability would be independently associated with mortality.

METHODS

We collected 6-hourly serum sodium levels for the first 7 days of ICU admission from 240 severe TBI patients in 14 neurotrauma ICUs in Europe and Australia. We evaluated the association between daily serum sodium standard deviation (dNa_SD), an index of variability, and 28-day mortality.

RESULTS

Patients were 46 ± 19 years of age with a median initial GCS of 6 [4-8]. Overall hospital mortality was 28%. Hypernatremia and hyponatremia occurred in 64% and 24% of patients, respectively. Over the first 7 days in ICU, serum sodium standard deviation was 2.8 [2.0-3.9] mmol/L. Maximum daily serum sodium standard deviation (dNa_SD) occurred at a median of 2 [1-4] days after admission. There was a significant progressive decrease in dNa_SD over the first 7 days (coefficient - 0.15 95% CI [- 0.18 to - 0.12], p < 0.001). After adjusting for baseline TBI severity, diabetes insipidus, the use of osmotherapy, the occurrence of hypernatremia, and hyponatremia and center, dNa_SD was significantly independently associated with 28-day mortality (HR 1.27 95% CI (1.01-1.61), p = 0.048).

CONCLUSIONS

Our study demonstrates that daily serum sodium variability is an independent predictor of 28-day mortality in severe TBI patients. Further prospective investigations are necessary to confirm the significance of sodium variability in larger cohorts of TBI patients and test whether attenuating such variability confers outcome benefits to such patients.

Novel application of an automated-machine learning development tool for predicting burn sepsis: proof of concept

Sepsis is the primary cause of burn-related mortality and morbidity. Traditional indicators of sepsis exhibit poor performance when used in this unique population due to their underlying hypermetabolic and inflammatory response following burn injury. To address this challenge, we developed the Machine Intelligence Learning Optimizer (MILO), an automated machine learning (ML) platform, to automatically produce ML models for predicting burn sepsis. We conducted a retrospective analysis of 211 adult patients (age ≥ 18 years) with severe burn injury (≥ 20% total body surface area) to generate training and test datasets for ML applications. The MILO approach was compared against an exhaustive “non-automated” ML approach as well as standard statistical methods. For this study, traditional multivariate logistic regression (LR) identified seven predictors of burn sepsis when controlled for age and burn size (OR 2.8, 95% CI 1.99–4.04, P = 0.032). The area under the ROC (ROC-AUC) when using these seven predictors was 0.88. Next, the non-automated ML approach produced an optimal model based on LR using 16 out of the 23 features from the study dataset. Model accuracy was 86% with ROC-AUC of 0.96. In contrast, MILO identified a k-nearest neighbor-based model using only five features to be the best performer with an accuracy of 90% and a ROC-AUC of 0.96. Machine learning augments burn sepsis prediction. MILO identified models more quickly, with less required features, and found to be analytically superior to traditional ML approaches. Future studies are needed to clinically validate the performance of MILO-derived ML models for sepsis prediction.

Mortality following combined burn and traumatic brain injuries: An analysis of the national trauma data bank of the American College of Surgeons

BACKGROUND

Severe burn and traumatic brain injuries (TBI) lead to significant mortality, and combined burn-TBI injuries may predispose towards even worse outcomes. The purpose of this study was to investigate the mortality of patients with burn, burn with non-TBI trauma, and combined burn/TBI to determine if combined injury portends a worse outcome.

METHODS

We obtained the National Trauma Data Bank from 2007 to 2012, identifying 32,334 patients with burn related injuries, dividing this cohort into three injury types: BURN ONLY, BURN with TRAUMA/NO TBI, and BURN with TBI. For each patient, demographic data was obtained, including age, gender, presence of trauma, TBI, or inhalation injury, burn total body surface area (TBSA), Glasgow Coma Scale, Injury Severity Score, and mortality. Multivariable logistic regression was performed.

RESULTS

Age, gender, and TBSA were similar across the three injury groups, but the incidence of inhalation injury was doubled in the BURN with TRAUMA/NO TBI (15.4 %) and BURN with TBI (15.3 %) groups when compared to the BURN ONLY (7.2 %) group. Mortality differed across injury categories after adjusting for age, TBSA, and inhalation injury. Increased mortality was seen in BURN with TRAUMA/NO TBI versus BURN ONLY (OR = 1.27 [1.06, 1.53]) and was higher when comparing BURN with TBI versus BURN ONLY (OR = 4.22 [2.85, 6.18]). BURN with TBI also had higher mortality when compared to BURN with TRAUMA/NO TBI (OR = 3.33 [2.30, 4.82]). The logs odds of mortality also increased with increasing age, TBSA and presence of inhalation injury.

DISCUSSION

This analysis of the NTDB suggests that mortality following burn-related injuries may be higher when burn injury is combined with TBI when compared to burns with other trauma, even after correcting for age, TBSA, and inhalation injury. Further clinical and laboratory research is needed to validate these findings and better understand how to optimize combined TBI and burn injury treatment.

Trajectories of Serum Sodium on In-Hospital and 1-Year Survival among Hospitalized Patients

BACKGROUND AND OBJECTIVES

This study aimed to investigate the association between in-hospital trajectories of serum sodium and risk of in-hospital and 1-year mortality in patients in hospital.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This is a single-center cohort study. All adult patients who were hospitalized from years 2011 through 2013 who had available admission serum sodium and at least three serum sodium measurements during hospitalization were included. The trend of serum sodium during hospitalization was analyzed using group-based trajectory modeling; the five main trajectories were grouped as follows: (1) stable normonatremia, (2) uncorrected hyponatremia, (3) borderline high serum sodium, (4) corrected hyponatremia, and (5) fluctuating serum sodium. The outcome of interest was in-hospital mortality and 1-year mortality. Stable normonatremia was used as the reference group for outcome comparison.

RESULTS

A total of 43,539 patients were analyzed. Of these, 47% had stable normonatremia, 15% had uncorrected hyponatremia, 31% had borderline high serum sodium, 3% had corrected hyponatremia, and 5% had fluctuating serum sodium trajectory. In adjusted analysis, there was a higher in-hospital mortality among those with uncorrected hyponatremia (odds ratio [OR], 1.33; 95% CI, 1.06 to 1.67), borderline high serum sodium (OR, 1.66; 95% CI, 1.38 to 2.00), corrected hyponatremia (OR, 1.50; 95% CI, 1.02 to 2.20), and fluctuating serum sodium (OR, 4.61; 95% CI, 3.61 to 5.88), compared with those with the normonatremia trajectory. One-year mortality was higher among those with uncorrected hyponatremia (hazard ratio [HR], 1.28; 95% CI, 1.19 to 1.38), borderline high serum sodium (HR, 1.18; 95% CI, 1.11 to 1.26), corrected hyponatremia (HR, 1.24; 95% CI, 1.08 to 1.42), and fluctuating serum sodium (HR, 2.10; 95% CI, 1.89 to 2.33) compared with those with the normonatremia trajectory.

CONCLUSIONS

More than half of patients who had been hospitalized had an abnormal serum sodium trajectory during hospitalization. This study demonstrated that not only the absolute serum sodium levels but also their in-hospital trajectories were significantly associated with in-hospital and 1-year mortality. The highest in-hospital and 1-year mortality risk was associated with the fluctuating serum sodium trajectory.

PODCAST

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The Link between Hypermetabolism and Hypernatremia in Severely Burned Patients

Hypernatremia is common in critical care, especially in severely burned patients. Its occurrence has been linked to increased mortality. Causes of hypernatremia involve a net gain of sodium or a loss of free water. Renal loss of electrolyte-free water due to urea-induced osmotic diuresis has been described as causative in up to 10% of hypernatremic critical ill patients. In this context, excessive urea production due to protein catabolism acts as major contributor. In severe burn injury, muscle wasting occurs as result of hypermetabolism triggered by ongoing systemic inflammation. In this retrospective study, severely burned patients were analysed for the occurrence of hypernatremia and subsequent signs of hypermetabolism. The urea: creatinine ratio—as a surrogate for hypermetabolism—sufficiently discriminated between two groups. Four of nine hypernatremic burn patients (44%) had a highly elevated urea: creatinine ratio, which was clearly associated with an increased urea production and catabolic index. This hypermetabolism was linked to hypernatremia via an elevated urea- and reduced electrolyte-fraction in renal osmole excretion, which resulted in an increased renal loss of electrolyte-free water. In hypermetabolic severely burned patients, the electrolyte-free water clearance is a major contributor to hypernatremia. A positive correlation to serum sodium concentration was shown.

Where there is sodium there may be sepsis

Hypernatremia affects up to 9% of critically ill patients upon hospital admission, especially in elderly patients with thirst impairment. However, hypernatremia is not entirely explained by fluid imbalance. Recent studies suggest that sodium is an important enhancer of the immune system, raising the question of whether inflammatory states such as sepsis may contribute to hypernatremia. Although sepsis patients with hypernatremia face a greater mortality rate, there is a lack of studies examining a potential association between hypernatremia and sepsis. Motivated by the frequent concurrence of hypernatremia and sepsis observed at an eastern Pennsylvanian community hospital, the current study was conducted to evaluate whether hypernatremia on admission may serve as a potential surrogate marker for sepsis. The medical records of 153 patients with hypernatremia on admission (serum sodium > 145mEq/L) were retrospectively analyzed. The mean age of patients was 81.1. Sepsis was observed in 77.1% of patients, of which 86.2% had dementia. This study demonstrated a positive correlation between hypernatremia on admission and the presence of sepsis. We suggest that the existence of hypernatremia should prompt clinicians to further investigate for sources of infection, especially in the elderly and patients with dementia.

The Dynamics of the Skin's Immune System

The skin is a complex organ that has devised numerous strategies, such as physical, chemical, and microbiological barriers, to protect the host from external insults. In addition, the skin contains an intricate network of immune cells resident to the tissue, crucial for host defense as well as tissue homeostasis. In the event of an insult, the skin-resident immune cells are crucial not only for prevention of infection but also for tissue reconstruction. Deregulation of immune responses often leads to impaired healing and poor tissue restoration and function. In this review, we will discuss the defensive components of the skin and focus on the function of skin-resident immune cells in homeostasis and their role in wound healing.

Risk factors and outcome of Hypernatremia amongst severe adult burn patients

A descriptive study was conducted on 135 adult severe burn patients treated at the Burn ICU, National Institute of Burns from 1/2017 to 12/2017. Hypernatremia was defined as increased plasma sodium ≥ 146 mmol/l. It was recorded in 24.4% of total patients with onset time of 8.3 ± 4.8 days, ranging from the 5th to 21st day postburn. Moderate and severe hypernatremia was recorded in 16 (54.5%) patients. Multivariate logistic analysis indicated that increased age, burn extent, mechanical ventilation and ventilation duration were independent predictive factors for the development of hypernatremia. Significantly higher mortality rate (59.5% vs. 40.5% respectively; p = .001) and longer duration of stay in the ICU (23.2 ± 15.4 days vs. 16.2 ± 11.6; p = .01) and in the hospital (74.4 ± 43.7 days vs. 37.9 ± 22.9; p = .002) were seen in the hypernatremia group compared to normonatremic patients. It is necessary to find further effective interventions for the prevention and treatment of this fatal complication among severe burn patients.