Concomitant Inhalation Injury Research Articles

Hydroxocobalamin is not associated with methemoglobinemia in patients with inhalation injury and suspected cyanide toxicity and a proposed algorithm for hydroxocobalamin administration

BackgroundCyanide poisoning poses a significant threat to burn patients exposed to smoke in residential or workplace fires, leading to central nervous system dysfunction, hemodynamic instability, cardiovascular collapse, and death. Prompt administration of an effective antidote is critical. Hydroxocobalamin, a form of vitamin B12, is the gold standard treatment for cyanide toxicity, by binding to cyanide molecules and converting them into non-toxic cyanocobalamin that is eliminated by the kidneys. This mechanism is distinct from previous cyanide antidotes, which induce the formation of methemoglobin to bind to cyanide. Recent case studies have reported elevated methemoglobin levels after hydroxocobalamin administration, raising concerns regarding its safety. The current study investigates smoke inhalation patients treated with hydroxocobalamin at a single institution Burn Unit in hopes of enhancing our understanding of the complexities surrounding cyanide antidote therapy. MethodsAfter Institutional Board Approval, a retrospective cohort study was conducted. Our sample comprised burn patients with inhalation injury admitted to a single institution from 2013 to 2023 and treated with hydroxocobalamin for suspected cyanide toxicity. We also analyzed a matched control cohort of similar patients with inhalation injury not treated with hydroxocobalamin. We analyzed changes and peaks in methemoglobin levels, lactate levels, blood urea nitrogen (BUN) and creatinine, ventilator days, % total body surface area (TBSA), various types of medications and dressings, and mortality. Statistical analyses included t-tests, chi-square, linear and logistic regressions, and correlation analysis. ResultsIn the study, 36 patients with suspected inhalation injury were treated with hydroxocobalamin at the Los Angeles General (LAG) Burn Unit from 2013 to 2023, who were matched to 32 control patients with inhalation injury who were not treated with hydroxocobalamin. Demographic and baseline characteristics showed no statistically significant differences between the groups, including age, gender, BMI, and %TBSA. No significant differences were found in initial, final, peak, or change in methemoglobin levels. The study also revealed no significant disparities in initial lactate levels, mortality, kidney function tests, ventilator days, surgeries, or use of medications/treatments (e.g., Silvadene dressings, Vitamin C) between the two groups. When controlling for covariates, multiple linear regression analysis (age, gender, and %TBSA) indicated that hydroxocobalamin administration was not significantly associated with changes in methemoglobin or mortality. Increased %TBSA, however, was linked to elevated lactate levels. ConclusionsOur investigation sought to assess the potential risks associated with hydroxocobalamin administration in burn patients with concomitant inhalation injury. Contrary to our initial hypothesis, we found no statistically significant differences in methemoglobinemia, lactate levels, mortality, or kidney function. The influence of other factors, such as methemoglobinemia-inducing drugs or hydroxocobalamin's interference with co-oximetry, adds complexity. Although elevated methemoglobin levels were observed in some cases, their clinical significance was limited. However, this study's limitations, particularly the rarity of inhalation injury cases with concern for cyanide toxicity, warrant consideration. Further research is required to comprehensively elucidate the impact of hydroxocobalamin administration on burn patients' outcomes.

Associated predictors of prolonged length of stay in patients surviving extensive burns: A large multicenter retrospective study

BackgroundPatients with extensive burns are critically ill and have long treatment periods. Length of stay (LOS) is a good measure for assessing treatment. This study sought to identify predictors of prolonged LOS in patients with extensive burns (≥50% TBSA). MethodsThis retrospective multicenter cohort study included adults aged ≥ 18 years who survived extensive burns in three burn centers in Eastern China between January 2016 and June 2022. Epidemiological, demographic and clinical outcomes data were extracted from electronic medical records and compared between patients with/without prolonged LOS, which was defined as LOS greater than the median. Logistic regression analysis was used to identify predictors of prolonged LOS. ResultsThe study sample included 321 patients, of whom 156 (48.6%) had an LOS of 58 days (IQR 41.0–77.0). Univariate regression analysis showed that increased total burn area and increased full-thickness burn area; electrical, chemical and other burns; increased erythrocytes, leukocytes, platelets or serum creatinine within 24 h of admission; concomitant inhalation injury, pulmonary edema, sepsis, bloodstream infection, wound infection, pulmonary infection, urinary tract infection, or HB < 70 g/L during hospitalization were associated with prolonged LOS in patients with extensive burns. Increased number of surgical operations, mechanical ventilation and renal replacement therapy were also associated with prolonged LOS (P < 0.05 or P < 0.001). Multivariate regression analysis revealed that increased total burn area (ratio 1.032, 95%CI 1.01–1.055; P = 0.004), electrical and chemical or other burns (3.282, 1.335–8.073; P = 0.01), development of wound infection (2.653 1.285–5.481; P = 0.008) and increased number of operative procedures (1.714, 1.388–2.116, P < 0.001) were significant predictors. ConclusionsIncreased area of full-thickness burn,occurrence of electrical and chemical or other burns,occurrence of wound infection and increased number of surgeries are the best predictors of prolonged LOS in patients with extensive burns. Clarifying relevant predictors of burn patients’ LOS provides a reliable reference for clinical treatment.

Improvement of the Dilatational Tracheostomy Technique

Objective: To describe an improved technique for dilatational tracheostomy. Clinical case: We report a case of severe community-acquired polysegmental viral pneumonia, grade 2 respiratory failure. After the start of antiviral therapy and staged respiratory support, the female patient was placed on mechanical ventilation 12 hours following hospital admission due to an increasing systemic inflammatory response and cytokine storm. In 20 hours, a dilatational tracheostomy using a modified technique was performed. Advantages of the modified technique are low trauma, short duration (5-10 minutes), significantly rarer wound infection (important benefit due to the COVID-19 features), significantly rarer postoperative scarring and cicatricial stenosis of the trachea. Technical improvement of dilatational tracheostomy allows for optimal management of critically ill patients (multiple organ failure, severe sepsis, considerable total body surface area burns with concomitant inhalation injury), which will significantly increase treatment efficiency, reduce the number of complications, and speed up the hospital discharge.

99 Retrospective Review of Pediatric Fluid Resuscitation at a Large Burn Center

Abstract Introduction Foundational approaches to burn fluid resuscitation were largely developed with the adult patient in mind. Experience has shown, however, that physiologic nuances between adults and children necessitate an adjusted approach to resuscitation for pediatric patients. As practice has advanced to account for these differences, our burn center sought to evaluate efficacy of resuscitation for our pediatric patient population. The purpose of this study was to examine pediatric fluid resuscitation including trends and complications, and to establish a baseline for future quality improvement initiatives. Methods This was a retrospective review of pediatric patients &amp;lt;14 years of age treated with resuscitation in a burn center between 2017 and 2021. Descriptive statistics were calculated. Results Over a five-year period, 42 pediatric patients were admitted with a burn total body surface area (TBSA) &amp;gt;20%, of which 23 met inclusion/exclusion criteria. Average admission weight was 31.8 kg and average TBSA of 39%. Contributing mechanisms of injury were flame (61%), scald (35%) and chemical (4%). Concomitant inhalation injury was diagnosed in 17% of patients. Average hourly fluid resuscitation volume was 6.9 mL/kg/TBSA with a mean resuscitation duration of 25.7 hours. Total volume administered throughout resuscitation exceeded recommendations per the Parkland formula for 83% of the sample. Continuous albumin was administered for 74% of patients and was initiated on average at 10 hours post-injury. Boluses of lactated ringer’s and albumin were administered for 30% and 9% of patients, respectively. Urine output for the pediatric patients averaged 60 mL/hr with a mean low optimal urine output of 15.9mL/hr and high optimal output of 25.5 mL/hr. Adverse events occurring during fluid resuscitation included temperature &amp;lt; 36◦C (35%), vasopressor administration (9%), intra-abdominal pressure &amp;gt;12 (13%) and/or &amp;gt;19 (9%), and peripheral vascular pulses &amp;lt; +1 (61%). Prophylactic escharotomy was performed for 35%. Of note, none of the patients were diagnosed with compartment syndrome nor abdominal compartment syndrome and none required abdominal laparotomy. One patient (4%) was diagnosed with acute respiratory distress syndrome. Continuous renal replacement therapy (CRRT) was not utilized for any pediatric patients during or post-resuscitation, compared to 34% of adults resuscitated at the same center. No patients expired in the initial 48 hours post-burn. The overall survival rate for this population was 91.3%, with 87% discharged direct to home. Conclusions Resuscitation volumes for pediatric patients in a large burn center have exceeded historically accepted rates for resuscitation. Despite the divergence from traditional practice, associated complications remain low, and outcomes have been favorable. Applicability of Research to Practice Further research is needed to establish benchmarks for pediatric fluid resuscitation.

550 Retrospective Review of Fluid Resuscitation and Associated Complications for Adults in a Large Burn Center

Abstract Introduction The foundation for burn fluid resuscitation is well established, however an opportunity exists to improve outcomes for patients requiring such intervention. Resuscitation is influenced by a variety of factors, including associated complications. The purpose of this study was to establish a baseline at our center using historical performance and outcomes to drive quality improvement initiatives. Methods This was a retrospective chart review of patients admitted over a five-year period requiring resuscitation. Due to factors, such as early enactment of comfort care, patients who expired &amp;lt; 48 hours of injury were excluded. Results Charts were reviewed for 346 patients with a total body surface area (TBSA) &amp;gt;20%, 297 were adults. Of these, 32 died &amp;lt; 48-hours post-injury and 127 did not undergo fluid resuscitation or complete records were not available. Thus 138 were evaluable. Averages at admission were age 44.9, weight 86.4 kg and TBSA 39%. Most patients were male (71%). Mechanism was predominantly flame (86%), followed by 7% scald, 3% contact, 2% electrical, and 1% chemical. Concomitant inhalation injury was diagnosed for 34%. Average hourly fluid resuscitation volume was 6.5mL/kg/TBSA with a duration of 31.8 hours. Total volume exceeded Parkland formula calculations for 80%. Continuous albumin was administered for 97%, initiated on average at 8 hours post-injury. Boluses of lactated ringer’s and albumin were administered for 43% and 36% of patients, respectively. Urine output averaged 91 mL/hr and we identified a mean low optimal urine output of 43.2 mL/hr and mean high optimal output of 69.1 mL/hr. Associated complications during fluid resuscitation included temperature &amp;lt; 36◦C (58%), vasopressor administration (12%), intra-abdominal pressure &amp;gt;12 (59%) and/or &amp;gt;19 (14%), and peripheral vascular pulses &amp;lt; +1 (70%). Escharotomy was performed for 42%; 32% preventative, 2% required subsequent fasciotomy. Laparotomy/open abdomen was performed for 7.9%. Diagnosed complications were low for compartment syndrome (9.5%), abdominal compartment syndrome (6.5%), and acute respiratory distress syndrome (1.4%). Continuous renal replacement therapy was initiated for 11.5% of patients &amp;lt; 48 hours post-burn and for 22.4% &amp;gt;48 hours; 25% requiring CRRT had a dialysis or renal history. The overall survival rate for this population was 76.1%. Patients were discharged most often to rehab (37%), home (19%), or skilled nursing facility (12%). Conclusions A baseline for resuscitation in our center revealed a rate double historically accepted rates. Despite nonconformity with tradition, complications remain low. Outcomes have been favorable, yet opportunity for improvement endures. Applicability of Research to Practice Further research is needed to evaluate the predictive value of assessment measures to forecast associated complications.

Massive Burn Injuries: Characteristics and Outcomes From a Single Institution.

Massive burn injuries are a unique patient population with unique treatment paradigms. Data from 155 adult patients, admitted from 2009 to 2019, with >50% total body surface area burns (TBSA) were collected and analyzed. Average burn size was 70% TBSA and 63% had a concomitant inhalation injury. Approximately 30% of patients (46/155) transitioned to comfort care-only measures within 24 hours of admission. Standard treatment patients were younger (37 ± 13 vs 60 ± 19 years; p < .00001), male (94% vs 28%; p = .001) and had smaller TBSA (66 ± 13 vs 80 ± 16; p < .00001). Of the standard treatment group, 72 (66%) survived to discharge. Survivors had smaller TBSA (64 ± 13 vs 71 ± 13; p = .003), less third-degree TBSA (48 ± 25 vs 71 ± 13; p = .003) and lower incidence of renal failure requiring dialysis (22% vs 73%, p < .00001). Multivariate regression analysis showed that age (OR 1.05; p = .025), total TBSA (OR 1.07; p = .005), and renal failure (OR 10.2; p = .00005) were independently associated with mortality. Inhalation injury was not significantly associated with mortality. About 23% (35/155) of patients had a psychiatric condition on admission and 19% (30/155) of patients were burned attempting suicide. Patients with psychiatric conditions spent more time in the hospital (62 vs 30 days; p = .004), more time on ventilator (31 vs 12 days; p = .046), underwent more surgery (4 vs 2 operations, p = .03), and were less likely to die (34% vs 59%; p = .02). In summary, age, burn size, and renal failure were independently associated with mortality, with renal failure being the strongest factor. Psychiatric conditions are prevalent pre-injury and tend to require more inpatient care.

Multiplexed Human Gene Expression Analysis Reveals a Central Role of the TLR/mTOR/PPARγ and NFkB Axes in Burn and Inhalation Injury-Induced Changes in Systemic Immunometabolism and Long-Term Patient Outcomes.

Burn patients are subject to significant acute immune and metabolic dysfunction. Concomitant inhalation injury increases mortality by 20%. In order to identify specific immune and metabolic signaling pathways in burn (B), inhalation (I), and combined burn-inhalation (BI) injury, unbiased nanoString multiplex technology was used to investigate gene expression within peripheral blood mononuclear cells (PBMCs) from burn patients, with and without inhalation injury. PBMCs were collected from 36 injured patients and 12 healthy, non-burned controls within 72 h of injury. mRNA was isolated and hybridized with probes for 1342 genes related to general immunology and cellular metabolism. From these specific gene patterns, specific cellular perturbations and signaling pathways were inferred using robust bioinformatic tools. In both B and BI injuries, elements of mTOR, PPARγ, TLR, and NF-kB signaling pathways were significantly altered within PBMC after injury compared to PBMC from the healthy control group. Using linear regression modeling, (1) DEPTOR, LAMTOR5, PPARγ, and RPTOR significantly correlated with patient BMI; (2) RPTOR significantly correlated with patient length of stay, and (3) MRC1 significantly correlated with the eventual risk of patient mortality. Identification of mediators of this immunometabolic response that can act as biomarkers and/or therapeutic targets could ultimately aid the management of burn patients.

528 Evaluation of phosphate replacement practices in burn patients

IntroductionBurn injury causes acute shifts in phosphorus leading to hypophosphatemia and negative sequelae, such as motor neuropathy, muscle weakness, cardiac failure, and respiratory failure. These patients require frequent phosphorus level monitoring and repletion beyond the needs of a general critical care patient. Data suggests patients with normal phosphorus levels have lower incidence of ventilator wean failure and positive clinical outcomes. There is limited data evaluating phosphate replacement practices in burn patients for their intensive care unit (ICU) length of stay while also evaluating those who concomitantly receive continuous renal replacement therapy (CRRT) as it is the primary mode of renal replacement therapy in this population and further depletes phosphorus levels.MethodsThis was a single-center, retrospective, observational study of patients with a burn injury admitted and discharged from a burn intensive care unit (BICU) from January 1, 2016 to June 30, 2020 who received phosphate. Patients less than 18 years of age and those admitted to the BICU for non-burn injuries were excluded. Burn injury type, number of phosphorus doses per day, and phosphorus levels were collected. Normal phosphorus was defined as 2.5-4.9 mg/dL and hypophosphatemia as < 2.5mg/dL. Patient data was evaluated in 24-hour time intervals as defined as midnight to midnight. Phosphorus lab values were included in data analysis if there was corresponding phosphate administration in that 24-hour interval. The primary objective was to assess the temporal dose-response to phosphate replacement in burn patients.ResultsThere were 291 patients who met criteria, 116 were selected in chronological order by admission date and were included in data analysis. The mean age was 51.51 years and the mean total body surface area burned was 21.48%. Flame burn accounted for 83.6 % (n=97) of patients and 37.06% (n=43) of patients had concomitant inhalation injury. The mean amount of phosphate given to a patient per day was 28.38 mmol and patients on CRRT received a mean amount of phosphate of 33.34 mmol per day. In response to phosphate administration, the mean change in phosphorus was 0.334 ± 1.08 mg/dL. In patients on CRRT, the mean change in phosphorus was 1.4 ± 1.89 mg/dL. Patients experienced hypophosphatemia 69.63% of the days that they received phosphate repletion and patients on CRRT had hypophosphatemia 87.39% of the days they received phosphate repletion.ConclusionsHypophosphatemia is common in the burn injury population and current phosphate replacement practices are insufficient to replete phosphorus in burn injury patients.

702 Outcomes of COPD Patients with Burn Injuries at a Single Institution

IntroductionChronic obstructive pulmonary disease (COPD) is a condition with significant morbidity and mortality. In 2018, about 16 million adults in the United States reported a diagnosis of COPD based on data from the American Lung Association. Home oxygen is often used in more severe cases of COPD, and despite warnings against smoking while using home oxygen, many patients continue to sustain burn injuries. An existing diagnosis of COPD can further complicate management of a burn patient, especially if there is concomitant inhalation injury present. The objective of this study was to explore the outcomes of COPD patients admitted to our Burn Center.MethodsThis was a single-site, retrospective review using our institutional Burn Center registry. All adult patients with flame burns (18 years or older) admitted to our Burn Center between July 1, 2011 and June 30, 2020 who had a history of COPD with and without home oxygen use were included in this study. All adult patients with flame burns, who did not have a history of COPD, were included for comparative purposes. Variables of interest included demographics, burn mechanism, length of stay (LOS), ICU and ventilator days, and mortality.ResultsThere were a total of 4,397 patients with flame burns included in this study, and 515 of those patients were identified to have an existing diagnosis of COPD. The mean age of the COPD group was 45.1 years +/- 13.0 years, and the patient population was predominantly male (60.4%). The mean total body surface area (TBSA) involvement was 5.12% +/- 10.38%. Inhalation injury was present in 10.1% of patients with COPD and in 7.8% of those without COPD. The mean LOS for the COPD group was 11.9 days +/- 19.4 days and 13.4 days +/- 31.0 days for the non-COPD group. The mean ICU LOS for the COPD group was 11.2 days +/- 19.9 days and 18.0 days +/- 37.0 days for the non-COPD group. The mean number of ventilator days was 16.5 days +/- 35.4 days for the COPD group and 26.3 days +/- 42.0 days for the non-COPD group. The overall hospital mortality was 10.3% for the COPD group and 4.3% for the non-COPD group.ConclusionsThis study demonstrates that the overall hospital mortality was highest in the COPD group. Although hospital and ICU length of stay, as well as the number of ventilator days were higher in the non-COPD group, it remains clear that an existing diagnosis of COPD can negatively impact the outcomes of burn patients.

Inhalation Injury Is Associated With Endotheliopathy and Abnormal Fibrinolytic Phenotypes in Burn Patients: A Cohort Study.

Burn injury is associated with endothelial dysfunction and coagulopathy and concomitant inhalation injury (IHI) increases morbidity and mortality. The aim of this work is to identify associations between IHI, coagulation homeostasis, vascular endothelium, and clinical outcomes in burn patients. One hundred and twelve patients presenting to a regional burn center were included in this retrospective cohort study. Whole blood was collected at set intervals from admission through 24 hours and underwent viscoelastic assay with rapid thromboelastography (rTEG). Syndecan-1 (SDC-1) on admission was quantified by ELISA. Patients were grouped by the presence (n = 28) or absence (n = 84) of concomitant IHI and rTEG parameters, fibrinolytic phenotypes, SDC-1, and clinical outcomes were compared. Of the 112 thermally injured patients, 28 (25%) had IHI. Most patients were male (68.8%) with a median age of 40 (interquartile range, 29–57) years. Patients with IHI had higher overall mortality (42.68% vs 8.3%; P < .0001). rTEG LY30 was lower in patients with IHI at hours 4 and 12 (P < .05). There was a pattern of increased abnormal fibrinolytic phenotypes among IHI patients. There was a greater proportion of IHI patients with endotheliopathy (SDC-1 > 34 ng/ml) (64.7% vs 26.4%; P = .008). There was a pattern of increased mortality among patients with IHI and endotheliopathy (0% vs 72.7%; P = .004). Significant differences between patients with and without IHI were found in measures assessing fibrinolytic potential and endotheliopathy. Mortality was associated with abnormal fibrinolysis, endotheliopathy, and IHI. However, the extent to which IHI-associated dysfunction is independent of TBSA burn size remains to be elucidated.

87 Evaluating Endothelial Dysfunction in Thermally-injured Patients with syndecan-1, Tissue Factor Pathway Inhibitor, and Thrombomodulin as Predictors of Mortality

Abstract Introduction Endotheliopathy in burn patients is largely uncharacterized. Syndecan-1 (SDC-1), thrombomodulin (TM), and tissue factor pathway inhibitor (TFPI) are components of the vascular endothelial glycocalyx. Proteolytic cleavage of these moieties may yield biomarkers for endothelial damage. The aim of this study is to evaluate endotheliopathy after burn injury by monitoring plasma levels of these biomarkers over time to investigate potential relationship to mortality. Methods Burn injured patients presenting to a regional burn center from 2012 to 2017 were prospectively enrolled. Blood samples were collected at 0, 2, 4, 8, 12, 24, 36, 48, 60, and 72 hours from admission. Plasma SDC-1, TM, and TFPI levels were quantified by ELISA. Demographic data and injury characteristics were obtained from the medical chart. Patients with concomitant inhalation injury, trauma, or &amp;lt; 10% total body surface area (TBSA) burns were excluded. Statistical analysis was performed using mixed-effect models with Sidak’s correction for multiple comparisons. Significance was set at p =0.05. Data are presented as mean ± standard deviation. Results A cohort of 22 patients was identified with an average age of 45±14 years, TBSA of 30±15%, with 6 patients who died from their injuries. The deceased group was older (59±13 vs. 40±10 years, p = 0.01), and there was no significant difference in burn size. Mean SDC-1 levels were higher in the deceased group at all time points (p=0.0004) and this difference was significant at hour 12 (106±11 vs. 41±31 ng/mL, p = 0.0002), hour 24 (160±39 vs. 35±20 ng/mL, p = 0.04) and hour 72 (100±3 vs. 35±38 ng/mL, p = 0.01). Mean soluble TM levels were higher in the deceased group after hour 12 (p = 0.04) and there was a trend towards higher TFPI levels after hour 12 in the deceased group. Conclusions Biomarkers are elevated in patients following burn injury who die, when inhalation injury and trauma are excluded. Given equivalent TBSA, older patients appear more sensitive to thermally induced glycocalyx degradation. SDC-1 shows the greatest promise as a prognostic indicator as levels tend to be higher among deceased patients on admission and are significantly higher as early as hour 12. Applicability of Research to Practice Reliable assessment of the patient’s endothelial damage may hold predictive value for clinicians and could assist in clinical decision making. Further research must investigate endotheliopathy in burn patients.

88 A Retrospective Review of the Use of Airway Pressure Release Ventilation (APRV) in the Burn Operating Room

Airway Pressure Release Ventilation (APRV) is the preferred mode of mechanical ventilation for the initial treatment of inhalation injury at our burn center. APRV improves alveolar recruitment, thus improving oxygenation. However, general anesthesia cannot be administered when patients are on APRV, resulting in frequent interruptions in the circuit and subsequent alveolar derecruitment with prolonged periods of sub-optimal ventilation post-operatively. Total IV anesthesia (TIVA) allows for the continued use of APRV perioperatively. The purpose of this study was to assess the safety and efficacy of APRV during surgery. This was a retrospective chart review of patients that remained on APRV during surgery over a 3-year period. Demographic, injury, ventilator, and outcome data were collected. Pre (PRE) and post-operative (POST) FIO2, Rate (set & spontaneous), Tidal Volume (TV), Minute Volume (MV), P High/Low, T High/Low, and Mean Airway Pressures (MAP) were compared for each surgery. The charts of 55 patients were reviewed, mean age was 45 years, the majority were male (75%) and 9% had pre-existing pulmonary disease. The most common mechanism was flame/flash (67%) with total body surface area (TBSA) burned ranging from 0 - 92% (M 42%). Concomitant inhalation injury was present for 58% of patients. Total ventilator days (M 42.2, ±35.7), total APRV days (M 16, ±12.9). Total number of surgeries (M 9.4, ±7.94), total number of surgeries on APRV (M 3.4, ±2.65). There were 38 patients with complete PRE and POST ventilator data. Surgery 1 on APRV; there were no significant differences for FIO2, Rate, TV, MV, P High/Low, T High, MAP; POST T Low was lower (M 0.8) when compared to PRE (M 0.9), (p=0.0005). Surgery 2 (n=35), POST mean FIO2 requirements were higher; PRE (0.47) vs POST (0.57), (p=.0358). Surgery 3 (n=25) average TV was lower POST-OP; PRE-OP (630) vs POST (523), (p=.005). There were no significant differences between PRE and POST requirements for patients on APRV during surgeries 4 (n=16) and 5 (=13). No patients suffered complications pre, peri or post-operatively when on APRV. Overall inpatient mortality was 35%. Of survivors, 92% required transfer to a post-acute care facility. APRV can be continued intra-operatively with the use of TIVA. This retrospective study demonstrates that TIVA and intra-operative APRV are safe and effective. TIVA allows the continued use of APRV intra-operatively in burn patients requiring aggressive ventilator support.

Microskin autografting in the treatment of burns over 70% of total body surface area: 14 years of clinical experience

Despite the fact that early excision and grafting have significantly improved burn outcomes, the management of severely burned patients whose burn size exceeds 70% total body surface area (TBSA) still represents a big challenge for burn surgeons all over the world. During the period of 1997–2010 at our centre, aggressive excision and microskin autografting were performed in 63 severely burned patients. Their burn sizes ranged from 70% to 98% TBSA with a mean of 84.9%. The average full-thickness burn was 66.3% (range, 29–94%). Thirty patients had concomitant inhalation injury. Two to 7 days after burn, these patients underwent aggressive excisions ranging from 25% to 60% TBSA and transplantation of microskin autograft overlaid with allograft. The ratios of donor-site to recipient-site surface area were between 1:6 and 1:18. Signs of epithelialization were shown within 35–55 days. The wound healing rate was 74.9% (176/235), with 51.1% of cases (120/235) healing completely and 23.8% (56/235) improving. Microskin autografting yielded an overall survival rate of 63.5%; only 23 patients died. Our clinical experience in using the microskin autografting for burn coverage suggests that the technique is very effective in covering extensive burns, and that it is particularly useful when graft donor sites are very limited due to its high utilization rate of donor site. The factors affecting the outcome of microskin autografting are discussed herein.

UPPER AIRWAY MUCUS DEPOSITION IN LUNG TISSUE OF BURN TRAUMA VICTIMS

Previous study in an ovine model of smoke inhalation and burn (S + B) injury has shown distal migration of upper airway mucus. This study examines the localization of an upper airway gland specific mucus, mucin 5B (MUC5B) in lung autopsy tissues of burn-only injury and in victims of S + B injury. We hypothesize that victims with S + B injury would exhibit increased distal migration of MUC5B than that seen in victims of burn-only injury. Autopsy lung tissue from victims of burn injury alone (n = 38) and combined S + B injury (n = 22) were immunostained for MUC5B. No normal lung tissues were included in the study. Semiquantitative analysis of the extent of MUC5B in bronchioles and parenchyma was performed on masked slides. Irrespective of injury conditions, all victims showed MUC5B in bronchioles. Mucin 5B was seen in the parenchyma except in two burn victims. No statistically significant difference was seen in the mean bronchiolar and parenchyma MUC5B scores between S + B and burn-only victims (P > 0.05). No strong statistical correlation of MUC5B scores with days postinjury or to the number of ventilatory days was evident. The percentage of pneumonia, identified histologically, was also similar between study groups. This study did not confirm our results in an ovine model of S + B injury. In contrast, virtually all pediatric burn victims, regardless of concomitant inhalation injury, showed MUC5B in their bronchioles and parenchyma. Increased mucus synthesis and/or impaired mucociliary function may contribute to the pulmonary pathophysiology associated with burn injury.

Are serum cytokines early predictors for the outcome of burn patients with inhalation injuries who do not survive?

IntroductionSeverely burned patients suffering from inhalation injury have a significantly increased risk for mortality compared with burned patients without inhalation injury. Severe burn is associated with a distinct serum cytokine profile and alterations in cytokines that contribute to morbidity and mortality. The aim of the present study was therefore to determine whether severely burned pediatric patients with concomitant inhalation injury who had a fatal outcome exhibited a different serum cytokine profile compared with burn patients with inhalation injury who survived. Early identification followed by appropriate management of these high-risk patients may lead to improved clinical outcome.MethodsThirteen severely burned children with inhalation injury who did not survive and 15 severely burned pediatric patients with inhalation injury who survived were enrolled in the study. Blood was collected within 24 hours of admission and 5 to 7 days later. Cytokine levels were profiled using multiplex antibody coated beads. Inhalation injury was diagnosed by bronchoscopy during the initial surgery. The number of days on the ventilator, peak inspiratory pressure rates, arterial oxygen tension (PaO2)/fraction of inspired oxygen (FiO2) ratio and incidence of acute respiratory distress syndrome were recorded for those patients.ResultsSignificantly altered levels of IL-4, IL-6, IL-7, IL-10, and IL-13 were detected within the first 7 days after admission in serum from burn pediatric patients with concomitant inhalation injury who did not survive when compared with similar patients who did (P < 0.05). Alterations in these cytokines were associated with increased incidence of acute respiratory distress syndrome, number of days under ventilation, increased peak inspiratory pressure, and lower PaO2/FiO2 ratio in this patient population. Multiple logistic regression analysis revealed that patients with increased IL-6 and IL-10 as well as decreased IL-7 serum levels had a significantly greater risk for mortality (P < 0.05).ConclusionEarly alterations in serum levels of IL-6, IL-7 and IL-10 may constitute useful predictive markers for identifying patients those who have sustained a burn with concomitant inhalation injury and who have high mortality.

Circulating cytokines and outcome prediction of burned children with concomitant inhalation injury

Being able to accurately predict probability of death is important for the intensivist. Serum cytokine levels parallel physiological derangements observed in critically ill patients and are used in commonly applied scoring systems and prediction models. Thus, serum cytokine based prediction models of outcome seem to be reasonable and of great interest. In this issue of Critical Care, Gauglitz and colleagues present their prediction equation for paediatric burn patients with concomitant inhalation injury. They found that IL-10 on admission, or IL-6 and IL-7 five to seven days later, may predict outcome in an excellent way. Increased mortality is observed as serum IL-6 and IL-10 levels increase and serum IL-7 levels decrease. However, the complexity of cytokine kinetics in critically ill patients and the variety of factors capable to affect circulating cytokines even in a subgroup of critically ill patients may affect the valitidy of the results. Also, serum cytokine based prediction models need to be compared to commonly applied prediction models based on clinical parameters. This will enable identification of the most suitable, accurate, cheapest, and easiest to use model to predict outcome.

Blood transfusions are associated with increased risk for development of sepsis in severely burned pediatric patients*

To determine the risk of developing sepsis following transfusion of blood products in severely burned pediatric patients. Retrospective, cohort study. Shriners Hospital for Children and University Hospital. Severely burned pediatric patients with >30% total body surface area (TBSA) burn. None. Two hundred seventy-seven pediatric burn patients over a period of 7 yrs (1997-2004) were included in the study, with 25 patients being septic at admission and therefore excluded. Patients were stratified according to TBSA burn and presence or absence of inhalation injury. The amounts of packed red blood cells (RBCs) and fresh frozen plasma (FFP) were recorded during hospital stay before the development of sepsis. Blood product administration was normalized for the number of surgeries and divided into two groups: high (RBCs>20/FFP>5) or low (RBCs<20/FFP<5) amount of blood products. Sepsis was diagnosed based on the criteria set by the Society of Critical Care Medicine in conjunction with positive blood culture or presence of organisms in the organs at autopsy. By stratifying the groups into low and high blood transfusion, we found that patients with >60% TBSA burn with inhalation injury have an 8% risk of developing sepsis in the low RBC group, which increases to 58% in the high RBC group (p<.05). Similar results were found for RBCs per operation, FFP, and FFP per operation (p<.05). There were no differences in age and gender between groups. Pediatric burn suffering from a 60% TBSA burn with concomitant inhalation injury are more likely to develop sepsis if they are given high amounts of blood products, indicating an immunocompromised state following blood transfusion.

Influence of demographics and inhalation injury on burn mortality in children

Background: Pulmonary failure has emerged as one of the leading causes of mortality in burned children due, in part, to the success in reducing the incidence of sepsis, early surgery and fluid resuscitation, and new advances in nutritional support. To evaluate the effect of pulmonary injury, age, gender, race, and burn size on mortality, the records of 3179 burned children admitted to our burn center from 1985 to 2001 were reviewed. In this population, 1246 were admitted within 14 days of injury with burns greater than 20% of their total body surface area (TBSA). Methods: Lethal burn areas (LAs) for a thermal injury only or burn plus inhalation injury were estimated from best fit probit curve within 95% confidence limits. Data analysis was by χ 2-test, t-test, or Fisher’s exact test where appropriate. Results: The lethal burn area for a 10% mortality rate with and without concomitant inhalation injury was a 50 and 73% TBSA burn, respectively. Children up to the age of 3 with ≥20% TBSA burns had a higher rate of mortality (9.9%) compared to those 3–12 years of age (4.9%) and 13–18 years of age (4.2%). Children with 21–80% TBSA burns showed a significant difference in mortality ( P<0.05) between those with burn plus inhalation injury (13.9%) and burn only (2.9%), while those with 81–100% TBSA burns showed no significant difference between burn only and burn plus inhalation injury. Conclusion: Inhalation injury remains one of the primary contributors to burn mortality. Children under the age of 3 years, however, are at a higher risk both with and without inhalation injury.

Current Management of Burns

Major burns are relatively frequent injuries that carry a high risk for morbidity and mortality. Patients at the extremes of age or with concomitant inhalation injury are at increased risk for complications and death from their thermal injuries. The initial management of thermal injuries continues to prioritize maintenance of the airway, breathing, and circulation with prompt consideration for transfer to a specialized burn care center. Early fluid resuscitation is best accomplished with an isotonic crystalloid solution to maintain tissue perfusion, hemodynamic stability and prevent remote organ failure. The necessary fluid volume is estimated from the patient's weight and percentage of body surface area burned and adjusted as determined by the patient's clinical response. Patients who have sustained an inhalation injury are at increased risk for pneumonia and require additional fluid resuscitation, meticulous pulmonary toilet and, occasionally, mechanical ventilation. Wound care following fluid resuscitation is based on topical antimicrobial therapy followed by early surgical excision and grafting to achieve wound closure and control infection. Adequate enterai nutrition is required to minimize the loss of lean body mass. Progressive improvements in the understanding of burn shock, early wound excision and closure, the control of infection, nutritional requirements and the treatment of inhalation injuries have significantly improved the survival of burn patients in recent years.

Early cardiorespiratory patterns in severely burned patients with concomitant inhalation injury

Hemodynamic and oxygenation parameters were determined during the first 24 h in 13 burned patients with concomitant inhalation injury (burn surface area 40–60 percent). In all patients right ventricular function was severely compromised evidenced as a significant increase in end-diastolic volumes, decrease in ejection fractions, low stroke work indices and increased pulmonary vascular resistances. Inotropic support with dobutamine and careful titration of volume infusion according to end-diastolic volume indices improved the hemodynamics as demonstrated by significant increases in right ventricular ejection fractions in all patients without any changes in mean arterial pressures, urine output and oxygenation. Assessment of ventricular performance by a specially designed pulmonary artery catheter is helpful in the management of severely burned patients with concomitant inhalation injury.