710 Use of Airway Pressure Relief Ventilation (APRV) in Burn Patients with and Without Inhalation Injury

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S186-S187
Author(s):  
Kevin N Foster ◽  
Dylon Buchanan ◽  
Timothy Durr ◽  
Karen J Richey
Keyword(s):  
Airway Pressure ◽  
Burn Injury ◽  
Demographic Data ◽  
Inhalation Injury ◽  
Hospital Length Of Stay ◽  
Burn Patients ◽  
Pressure Relief ◽  
Arterial Blood ◽  
Ventilator Mode ◽  
Ventilator Settings

Abstract Introduction Burn patients often require ventilator management because of large % TBSA injury, the presence of inhalation injury, and/or other factors. Airway pressure relief ventilation (APRV) offers several advantages over conventional ventilation modes including improved alveolar recruitment, better oxygenation and hemodynamics, preservation of spontaneous breathing, and possibly less ventilator-induced lung injury. This study reviews the use of APRV as the primary ventilator mode in burn patients with and without inhalation injury. Methods A retrospective chart review of patients admitted to the burn center and requiring APRV ventilation over a ten year period was performed. Data collected included demographic data, burn injury data, ventilator settings, arterial blood gas data, and development of ventilator-associated pneumonia (VAP). Results There were 411 patients identified over the ten year period. Mean age was 46 years, and mean % TBSA burned was 33. Seventy-three percent were male. One-half (51%) of patients had an inhalation injury. Mean hospital length of stay was 32 days with 22 mean ventilator days. Average number of surgeries was 4.4 per patient. Mean high pressure (P high) was 23 mm Hg. Mean FiO2 was 88% on post-injury day (PID) 1, 65% on day PID 2, and 45% thereafter. Mean P/F ratio was 333. Mean pH was 7.40, mean pCO2 was 40 mmHg, and mean HCO3 was 25 mm Hg. Forty-six percent of patients met criteria for diagnosis of VAP. Conclusions These data demonstrate that burn patients requiring mechanical ventilation can be safely and effectively managed with APRV. Oxygenation, carbon dioxide removal, normal acid-base status, and excellent P/F ratios were maintained with relatively low ventilator settings such as peak airway pressure and FiO2. Patients were able to breathe spontaneously when able and were easily liberated form the ventilator at the appropriate time. Applicability of Research to Practice This study defines an unconventional and potentially improved ventilator mode use in burn patients.

14 Use of Airway Pressure Relief Ventilation (APRV) in Burn Patients With and Without Inhalation Injury

2021 ◽  
Vol 42 (Supplement_1) ◽  
pp. S15-S16
Author(s):  
Kevin N Foster ◽  
Dylon Buchanan ◽  
Timothy Durr ◽  
Karen J Richey
Keyword(s):  
Airway Pressure ◽  
Burn Injury ◽  
Demographic Data ◽  
Inhalation Injury ◽  
Hospital Length Of Stay ◽  
Burn Patients ◽  
Post Injury ◽  
Pressure Relief ◽  
Arterial Blood ◽  
Ventilator Settings

Abstract Introduction Burn patients often require ventilator management because of large % TBSA injury, the presence of inhalation injury, and/or other factors. Airway pressure relief ventilation (APRV) offers several advantages over conventional ventilation modes including improved alveolar recruitment, better oxygenation and hemodynamics, preservation of spontaneous breathing, and possibly less ventilator-induced lung injury. This study reviews the use of APRV as the primary ventilator mode in burn patients with and without inhalation injury. Methods A retrospective chart review of patients admitted to the burn center and requiring APRV ventilation over a ten-year period was performed. Data collected included demographic data, burn injury data, ventilator settings, arterial blood gas data, and development of ventilator-associated pneumonia (VAP). Results There were 411 patients identified over the ten-year period. Mean age was 46 years, and mean % TBSA burned was 33. Seventy-three percent were male. One-half (51%) of patients had an inhalation injury. Mean hospital length of stay was 32 days with 22 mean ventilator days. Average number of surgeries was 4.4 per patient. Mean high pressure (P high) was 23 mm Hg. Mean FiO2 was 88% on post-injury day (PID) 1, 65% on day PID 2, and 45% thereafter. Mean P/F ratio was 333. Mean pH was 7.40, mean pCO2 was 40 mmHg, and mean HCO3 was 25 mm Hg. Forty-six percent of patients met criteria for diagnosis of VAP. Conclusions These data demonstrate that burn patients requiring mechanical ventilation can be safely and effectively managed with APRV. Oxygenation, carbon dioxide removal, normal acid-base status, and excellent P/F ratios were maintained with relatively low ventilator settings such as peak airway pressure and FiO2. Patients were able to breathe spontaneously when able and were easily liberated form the ventilator at the appropriate time.

11 Vitamin D Deficiency on Admission and the Association with Length of Stay in Patients with Thermal Injury: A Multi-center Analysis

2021 ◽  
Vol 42 (Supplement_1) ◽  
pp. S13-S14
Author(s):  
Sarah Zavala ◽  
Kate Pape ◽  
Todd A Walroth ◽  
Melissa A Reger ◽  
Katelyn Garner ◽  
...  
Keyword(s):  
Vitamin D ◽  
Length Of Stay ◽  
Vitamin D Deficiency ◽  
Burn Injury ◽  
Total Body Surface Area ◽  
Inhalation Injury ◽  
Hospital Length Of Stay ◽  
Burn Patients ◽  
Comfort Care ◽  
The Impact

Abstract Introduction In burn patients, vitamin D deficiency has been associated with increased incidence of sepsis. The objective of this study was to assess the impact of vitamin D deficiency in adult burn patients on hospital length of stay (LOS). Methods This was a multi-center retrospective study of adult patients at 7 burn centers admitted between January 1, 2016 and July 25, 2019 who had a 25-hydroxyvitamin D (25OHD) concentration drawn within the first 7 days of injury. Patients were excluded if admitted for a non-burn injury, total body surface area (TBSA) burn less than 5%, pregnant, incarcerated, or made comfort care or expired within 48 hours of admission. The primary endpoint was to compare hospital LOS between burn patients with vitamin D deficiency (defined as 25OHD < 20 ng/mL) and sufficiency (25OHD ≥ 20 ng/mL). Secondary endpoints include in-hospital mortality, ventilator-free days of the first 28, renal replacement therapy (RRT), length of ICU stay, and days requiring vasopressors. Additional data collected included demographics, Charlson Comorbidity Index, injury characteristics, form of vitamin D received (ergocalciferol or cholecalciferol) and dosing during admission, timing of vitamin D initiation, and form of nutrition provided. Dichotomous variables were compared via Chi-square test. Continuous data were compared via student t-test or Mann-Whitney U test. Univariable linear regression was utilized to identify variables associated with LOS (p < 0.05) to analyze further. Cox Proportional Hazard Model was utilized to analyze association with LOS, while censoring for death, and controlling for TBSA, age, presence of inhalation injury, and potential for a center effect. Results Of 1,147 patients screened, 412 were included. Fifty-seven percent were vitamin D deficient. Patients with vitamin D deficiency had longer LOS (18.0 vs 12.0 days, p < 0.001), acute kidney injury (AKI) requiring RRT (7.3 vs 1.7%, p = 0.009), more days requiring vasopressors (mean 1.24 vs 0.58 days, p = 0.008), and fewer ventilator free days of the first 28 days (mean 22.9 vs 25.1, p < 0.001). Univariable analysis identified burn center, AKI, TBSA, inhalation injury, admission concentration, days until concentration drawn, days until initiating supplementation, and dose as significantly associated with LOS. After controlling for center, TBSA, age, and inhalation injury, the best fit model included only deficiency and days until vitamin D initiation. Conclusions Patients with thermal injuries and vitamin D deficiency on admission have increased length of stay and worsened clinical outcomes as compared to patients with sufficient vitamin D concentrations.

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

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S57-S58
Author(s):  
John W Keyloun ◽  
Saira Nisar ◽  
Kathleen Brummel-Ziedins ◽  
Maria Bravo ◽  
Matthew Gissell ◽  
...  
Keyword(s):  
Tissue Factor ◽  
Tissue Factor Pathway Inhibitor ◽  
Burn Injury ◽  
Endothelial Damage ◽  
Inhalation Injury ◽  
Burn Patients ◽  
Mixed Effect ◽  
Significant Difference ◽  
Tissue Factor Pathway ◽  
Injured Patients

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 < 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.

508 Fungal Infections in Burn Patients from 2014–2019: A 5-year Retrospective Review

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S90-S91
Author(s):  
Kaitlin A Pruskowski ◽  
Julie A Rizzo ◽  
Leopoldo C Cancio
Keyword(s):  
Mortality Rate ◽  
High Mortality ◽  
Bacterial Infections ◽  
Burn Injury ◽  
Fungal Infections ◽  
Early Recognition ◽  
Hospital Length Of Stay ◽  
Burn Patients ◽  
Average Hospital ◽  
Time From Injury

Abstract Introduction Topical and systemic antibiotic agents used to treat burn wounds allow for fungal growth. Fungal infections often occur later in the hospital course and carry a higher mortality rate than bacterial infections in critically ill burn patients. The primary objective of this study was to describe the incidence and characteristics of fungal infections in our burn center. Methods This was a retrospective chart review. Subjects who were admitted between January 2014 and February 2019 after sustaining a burn injury and received a systemic antifungal agent were included. All cultures and histopathology results that were positive for fungus were recorded. Results Ninety one subjects were included in this analysis. The average age was 42.3±16.9 years and 74 (81.3%) subjects were male. Seventy four (81.3%) subjects were admitted after flame burn. The average burn size was 40.1±24.2% TBSA. The average hospital length of stay was 57.2±44.8 days. Thirty eight (41.7%) subjects died during their hospital stay. The 91 subjects had 220 cultures positive for fungi: 29 blood cultures, 19 BAL cultures, 23 sputum cultures, 118 tissue cultures, and 31 urine cultures. The most common fungal genera isolated were: Candida (n=146), Aspergillus (n=55), and Fusarium (n=44). Twenty six (28.6%) subjects had histopathology results that showed fungus in non-viable tissue, with an average time from injury to fungus of 20.4±11.8 days. Twenty six (28.6%) subjects had histopathology results that showed fungus in viable tissue, with an average time from injury to fungus of 22.7±16.7 days. Of note, these were not the group that had fungus in non-viable tissue. Twelve (13.2%) subjects had angioinvasion, with an average time to angioinvasion of 26.6±22 days. The 91 subjects received 133 courses of antifungals. The average course of antifungal therapy was 7.8±8.9 days. The most common antifungals used were: micafungin (n=54), fluconazole (n=53), and liposomal amphotericin B (n=44). Conclusions Patients who were started on a systemic antifungal had a high mortality rate. Common fungi isolated included Candida and Aspergillus, which is consistent with previous literature. Further research is needed on the early recognition, accurate diagnosis, and timely management of fungal infections in this patient population. Applicability of Research to Practice Fungal infections after burn injury carry a high mortality rate. Early recognition and timely management of these infections is paramount.

122 Prevalence and Associated Predictors for Patients Developing Chronic, Neuropathic Pain Following Burns

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S81-S82
Author(s):  
Kevin M Klifto ◽  
C Scott Hultman
Keyword(s):  
Mechanical Ventilation ◽  
Neuropathic Pain ◽  
Burn Injury ◽  
Hospital Length Of Stay ◽  
Direct Result ◽  
Medical Illness ◽  
Burn Patients ◽  
Chronic Neuropathic Pain ◽  
Burn Center ◽  
Burn Unit

Abstract Introduction Chronic pain, unrelated to the burn itself, can manifest as a long-term complication in patients sustaining burn injuries. The purpose of this study was to determine the prevalence and compare burn characteristics between burn patients who developed chronic neuropathic pain (CNP) and burn patients without CNP treated at a Burn Center. Methods A single-center, retrospective analysis of 1880 patients admitted to the adult Burn Center was performed from January 1, 2014 through January 1, 2019. Patients included were over the age of fifteen years, sustained a burn injury and were admitted to the Burn Unit. CNP was diagnosed clinically following burn injury. Patients were excluded from the definition of CNP if their pain was due to an underlying medical illness or medication. Comparisons between patients admitted to the Burn Unit with no pain and patients admitted to the Burn Unit who developed CNP were performed. Results One hundred thirteen (n=113) of the 1880 burn patients developed CNP as a direct result of burn injury over five years with a prevalence of 6%. Patients who developed CNP were a significantly older median age [54 vs. 46, p=0.002], abused alcohol [29% vs. 8.5%, p< 0.001], abused substances [31% vs. 9%, p< 0.001], were current everyday smokers [73% vs. 34%, p< 0.001], suffered more full-thickness burns [58% vs. 43%, p< 0.001], greater median %TBSA burns [6 vs. 3.5, p< 0.001], were more often intubated on mechanical ventilation [33% vs. 14%, p< 0.001], greater median number of surgeries [2 vs. 0, p< 0.001] and longer median hospital length of stay (LOS) [10 vs. 3 days, p< 0.001], compared to those who did not develop CNP, respectively. Median patient follow-up was 27 months. Conclusions The prevalence of CNP over five years was 6% in the Burn Center. Older ages, alcohol abuse, substance abuse, current everyday smoking, greater %TBSA burns, third degree burns, being intubated on mechanical ventilation, having more surgeries and longer hospital LOS were associated with developing CNP following burn injury. Applicability of Research to Practice The largest study to date assessing the prevalence of chronic nerve pain following burns. Identified new independent predictors for chronic neuropathic pain following burn injury, not previously assessed in the literature.

scholarly journals The development and impact of heterotopic ossification in burns: a review of four decades of research

2017 ◽  
Vol 3 ◽  
pp. 205951311769565 ◽  
Author(s):  
Rachel Kornhaber ◽  
Nichola Foster ◽  
Dale Edgar ◽  
Denis Visentin ◽  
Elad Ofir ◽  
...  
Keyword(s):  
Heterotopic Ossification ◽  
Daily Living ◽  
Burn Injury ◽  
Rare Complication ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Burn Patients ◽  
Recommended Treatment ◽  
Joint Range Of Motion ◽  
Joint Range

[Formula: see text] Introduction: Heterotopic ossification (HO) is the formation of lamellar bone within connective and other tissue where bone should not form and is a rare complication after burn injury. However, it leads to severe pain and distress, marked reduction in joint range of motion (ROM), impaired function and increased hospital length of stay. The pathophysiology, incidence and risk factors of HO remain poorly understood in burns and other traumas and the management, controversial. The aim of this comprehensive review, therefore, was to synthesise the available evidence on the development and treatment of HO after acute burn injury. Methods: The review was based on a systematic search of five electronic databases PubMed, EMBASE, CINAHL, LILACS and Scopus. Results: Synthesis and analysis of the data highlighted that, despite the passage of time, little translatable evidence is available to guide any prevention, screening, diagnostic or pharmacological or physical management protocols. Discussion: Causes of HO remain confounded, therefore prevention is difficult. Although spontaneous resolution is possible, surgical resection remains the recommended treatment when ROM and activities of daily living are severely affected. Conclusion: The findings from this review indicate that multicentre data pooling is needed to understand the optimum pathway to prevention, identification and treatment of HO in acute burn patients.

593 Mortality of Burn patients over two decades: Improving outcomes in the elderly

2021 ◽  
Vol 42 (Supplement_1) ◽  
pp. S148-S148
Author(s):  
Melissa J Grigsby ◽  
Kathleen S Romanowski ◽  
Soman Sen ◽  
Tina L Palmieri ◽  
Matthew D Ponzini ◽  
...  
Keyword(s):  
Burn Injury ◽  
Lethal Dose ◽  
The Elderly ◽  
Continuous Model ◽  
Inhalation Injury ◽  
Burn Patients ◽  
Full Thickness ◽  
The Past ◽  
Average Patient ◽  
The Relationship

Abstract Introduction Shifting paradigms in the care of burn patients over the past two decades have led to the improved survival of adult and pediatric patients, but the same trend has not been manifested in the elderly population. We aimed to review our patient population, particularly the elderly, for the last twenty years and examine the relationship of age to the TBSA (total burn surface area) LD50 (lethal dose, 50%). Methods This IRB approved study retrospectively analyzed acute burn patients admitted at two academic regional burn centers from January 1, 1999 to August 1, 2019. Data collected included age, gender, TBSA, mortality, mechanism of burn, inhalation injury, and presence of full-thickness burn. The relationship between mortality and TBSA and age was assessed using logistic regression. The TBSA LD50 was calculated conditional on age and confidence intervals were constructed based on 1000 bootstrap samples. Results A total of 9,721 patients were admitted for treatment of acute burn injury between the two institutions. In our population, flame was the most common cause of burn injury (51%), full-thickness burns were present 47% of the time, and mean TBSA was 13%. The average patient age was 28, although there were 789 patients over the age of 65. The TBSA LD50 relationship to age best fit a cubic regression model with a peak of 81% TBSA LD50 at 17 years of age, rapid decrease early in the 5th decade and a general leveling out at the nadir of 27% TBSA (Figure). The LD50 did not reach 30% until 78 years of age. Conclusions Over the past two decades, elderly patients treated at our hospitals appear to have improved survival in comparison to the outcomes reported nationally. Due the ongoing rapid aging of the population, it is important that we continue to focus on both improving survival and delivering the best care to this vulnerable part of the population. Moreover, this continuous model could be used to track improvements in care within our institution and serve as a template for a national model.

Burns

2019 ◽  
Author(s):  
Edward A. Bittner ◽  
Connie W. Chaudhary
Keyword(s):  
Pain Management ◽  
Burn Injury ◽  
Anesthetic Management ◽  
Injured Patient ◽  
Inhalation Injury ◽  
The Body ◽  
Temperature Management ◽  
Burn Patients ◽  
Optimal Care ◽  
Injured Patients

Anesthetic management of burn-injured patients can be particularly challenging. Burn-injured patients exhibit pathophysiologic changes that can affect nearly all the organs in the body. Challenges the anesthesiologist may encounter when caring for burn patients include difficult airway management, impaired lung function, vascular access issues, hypothermia, pharmacokinetic and pharmacodynamic alterations, and pain management. Other important considerations that could affect the condition of burn patients include blood loss, hypermetabolism, pain control, and temperature management.  Anticipating appropriate precautions can change the clinical outcome of these patients.  Optimal care requires a full understanding of the unique preoperative, intraoperative, and postoperative issues of the burn-injured patient. This review contains 2 figures, 3 tables, and 77 references. Key Words: anesthetic management of acute burns, burn injury, electrical injury, fluid resuscitation, inhalation injury, Parkland formula, pain management

scholarly journals Nonmedical Factors Influencing Early Deaths in Burns: A Study of the National Burn Repository

2019 ◽  
Author(s):  
Rachel M Nygaard ◽  
Frederick W Endorf
Keyword(s):  
Socioeconomic Factors ◽  
Burn Injury ◽  
Total Body Surface Area ◽  
Early Period ◽  
Inhalation Injury ◽  
Burn Patients ◽  
Commercial Insurance ◽  
Severe Burns ◽  
Hispanic Patients ◽  
Major Factors

Abstract It is well-established that survival in burn injury is primarily dependent on three factors: age, percent total-body surface area burned (%TBSA), and inhalation injury. However, it is clear that in other (nonburn) conditions, nonmedical factors may influence mortality. Even in severe burns, patients undergoing resuscitation may survive for a period of time before succumbing to infection or other complications. In some cases, though, families in conjunction with caregivers may choose to withdraw care and not resuscitate patients with large burns. We wanted to investigate whether any nonmedical socioeconomic factors influenced the rate of early deaths in burn patients. The National Burn Repository (NBR) was used to identify patients that died in the first 72 hours after injury and those that survived more than 72 hours. Both univariate and multivariate regression analyses were used to examine factors including age, gender, race, comorbidities, burn size, inhalation injury, and insurance type, and determine their influence on deaths within 72 hours. A total of 133,889 burn patients were identified, 1362 of which died in the first 72 hours. As expected, the Baux score (age plus burn size), and inhalation injury predicted early deaths. Interestingly, on multivariate analysis, patients with Medicare (p = .002), self-pay patients (p < .001), and those covered by automobile policies (p = .045) were significantly more likely to die early than those with commercial insurance. Medicaid patients were more likely to die early, but not significantly (p = .188). Worker’s compensation patients were more likely to survive the first 72 hours compared with patients with commercial insurance (p < .001). Men were more likely to survive the early period than women (p = .043). On analysis by race, only Hispanic patients significantly differed from white patients, and Hispanics were more likely to survive the first 72 hours (p = .028). Traditional medical factors are major factors in early burn deaths. However, these results show that nonmedical socioeconomic factors including race, gender, and especially insurance status influence early burn deaths as well.

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