Sodium variability is associated with increased mortality in severe burn injury

Abstract Background Dysnatremias are associated with increased mortality in critically ill patients. Hypernatremia in burn patients is also associated with poor survival. Based on these findings, we hypothesized that high plasma sodium variability is a marker for increased mortality in severely burn-injured patients. Methods We performed a retrospective review of adult burn patients with a burn injury of 15% total body surface area (TBSA) or greater from 2010 to 2014. All patients included in the study had at least three serum sodium levels checked during admission. We used multivariate logistic regression analysis to determine if hypernatremia, hyponatremia, or sodium variability independently increased the odds ratio (OR) for death. Results Two hundred twelve patients met entry criteria. Mean age and %TBSA for the study was 45 ± 18 years and 32 ± 19%. Twenty-nine patients died for a mortality rate of 14%. Serum sodium was measured 10,310 times overall. The median number of serum sodium measurements per patient was 22. Non-survivors were older (59 ± 19 vs. 42 ± 16 years) and suffered from a more severe burn injury (50 ± 25% vs. 29 ± 16%TBSA). While mean sodium was significantly higher for non-survivors (138 ± 3 milliequivalents/liter (meq/l)) than for survivors (135 ± 2 meq/l), mean sodium levels remained within the laboratory reference range (135 to 145 meq/l) for both groups. Non-survivors had a significantly higher median number of hypernatremic (> 145 meq/l) measurements (2 vs. 0). Coefficient of variation (CV) was significantly higher in non-survivors (2.85 ± 1.1) than survivors (2.0 ± 0.7). Adjusting for TBSA, age, ventilator days, and intensive care unit (ICU) stay, a higher CV of sodium measurements was associated with mortality (OR 5.8 (95% confidence interval (CI) 1.5 to 22)). Additionally, large variation in sodium ranges in the first 10 days of admission may be associated with increased mortality (OR 1.35 (95% CI 1.06 to1.7)). Conclusions Increased variability in plasma sodium may be associated with death in severely burned patients.

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Тhe use of corticosteroids in patients with severe burn injuries

Actual problems of modern medicine ◽

10.26565/2617-409x-2020-5-07 ◽

2020 ◽

Keyword(s):

Burn Injury ◽

Burn Shock ◽

Burn Patients ◽

Severe Burn ◽

Septic Complications ◽

Results Of Treatment ◽

Adults And Children ◽

Severe Burn Injuries ◽

Burn Disease ◽

Severe Burn Injury

Modern treatment of burns has led to a significant reduction in mortality in patients with burns whose injuries were fatal several years ago. However, along with improved survival, new problems arose in the treatment of burn patients. Systemic inflammatory response, capillary leak, sepsis top the list of the most common problems in both adults and children with severe thermal injury. Currently, new strategies are being developed and studied in the treatment of this category of patients. One of the ways to improve the results of treatment of patients with severe burn injury is to prescribe corticosteroids, both in the stage of burn shock and in the development of septic complications. Do corticosteroids reduce mortality and improve recovery in burn patients? The discussion about this has been going on for many years, but the opinion about their effectiveness remains controversial. An analysis of the literature shows that corticosteroids can play a significant role in the treatment of patients with severe burn injury and can be successfully used at any stage of a burn disease. The effect of reducing capillary leakage, increasing myocardial contractility, antiemetic, membrane-stabilizing effect of corticosteroids will be useful in the stage of burn shock. The anti-inflammatory, immunomodulatory effect of corticosteroids will play a role in any stage of a burn disease. With the aim of preventing and treating sepsis, corticosteroids may be useful in the stage of toxemia, septicotoxemia. It is also necessary to remember about adrenal insufficiency, which develops in burn patients. The article analyzes the literature, substantiates the use of corticosteroids in patients with severe burn injury in different periods of a burn disease.

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A prospective observation on nutrition support in adult patients with severe burns

British Journal Of Nutrition ◽

10.1017/s0007114519000217 ◽

2019 ◽

Vol 121 (09) ◽

pp. 974-981 ◽

Cited By ~ 1

Author(s):

Fengmei Guo ◽

Hua Zhou ◽

Jian Wu ◽

Yingzi Huang ◽

Guozhong Lv ◽

...

Keyword(s):

Hospital Mortality ◽

Burn Injury ◽

Early Stage ◽

Energy Requirement ◽

Total Body Surface Area ◽

Nutrition Therapy ◽

Nutrition Support ◽

Burn Patients ◽

Severe Burn ◽

Severe Burns

AbstractNutrition therapy is considered an important treatment of burn patients. The aim of the study was to delineate the nutritional support in severe burn patients and to investigate association between nutritional practice and clinical outcomes. Severe burn patients were enrolled (n 100). In 90 % of the cases, the burn injury covered above 70 % of the total body surface area. Mean interval from injury to nutrition start was 2·4 (sd 1·1) d. Sixty-seven patients were initiated with enteral nutrition (EN) with a median time of 1 d from injury to first feed. Twenty-two patients began with parenteral nutrition (PN). During the study, thirty-two patients developed EN intolerance. Patients received an average of about 70 % of prescribed energy and protein. Patients with EN providing <30 % energy had significantly higher 28- d and in-hospital mortality than patients with EN providing more than 30 % of energy. Mortality at 28 d was 11 % and in-hospital mortality was 45 %. Multiple regression analysis demonstrated that EN providing <30 % energy and septic shock were independent risk factors for 28- d prognosis. EN could be initiated early in severe burn patients. Majority patients needed PN supplementation for energy requirement and EN feeding intolerance. Post-pyloric feeding is more efficient than gastric feeding in EN tolerance and energy supplement. It is difficult for severe burn patients to obtain enough feeding, especially in the early stage of the disease. More than 2 weeks of underfeeding is harmful to recovery.

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Severe burn injury in late pregnancy: a case report and literature review

Burns & Trauma ◽

10.1186/s41038-015-0002-z ◽

2015 ◽

Vol 3 ◽

pp. 1-4 ◽

Cited By ~ 9

Author(s):

Yan Shi ◽

Xiong Zhang ◽

Bo-Gao Huang ◽

Wen-Kui Wang ◽

Yan Liu

Keyword(s):

Burn Injury ◽

Late Pregnancy ◽

Clinical Problem ◽

Burn Injuries ◽

Burn Patients ◽

Severe Burn ◽

Burn Center ◽

Maternal Survival ◽

Low Incidence ◽

Severe Burn Injury

Abstract The management of serious burn injuries during pregnancy is an unsolved clinical problem because of the low incidence of this disease. Although it has been documented that the effect of burns on fetal and maternal survival is detrimental, there have been conflicting reports among the different burn centers regarding the mortality of burned pregnant women and the management of burn patients during pregnancy. We report a case of severe burn in late pregnancy treated at our burn center. Additionally, we searched and summarized the literature concerning the management of pregnant patients to provide useful information for their treatment.

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Acute kidney injury in patients with severe burn injury

10.1093/med/9780199592548.003.0253_update_001 ◽

2018 ◽

Author(s):

Nele Brusselaers ◽

Eric A. J. Hoste

Keyword(s):

Acute Kidney Injury ◽

Burn Injury ◽

Negative Impact ◽

Kidney Injury ◽

Severe Form ◽

Burn Shock ◽

Burn Patients ◽

Severe Burn ◽

Abdominal Hypertension ◽

Severe Burn Injury

Acute kidney injury (AKI) occurs in approximately one-quarter of all patients with severe burn injury (as defined by the RIFLE consensus classification), and approximately 3% of paediatric burn patients. Overall, a three- to six-fold higher mortality for burn patients with AKI is observed, depending on the applied definition. When AKI is defined by the sensitive RIFLE classification, median mortality of AKI is approximately 35%. This chapter describes the general pathophysiology of AKI in burns, particularly the severe form of burn shock, and discusses in addition the roles of intra-abdominal hypertension, rhabdomyolysis, and the potentially negative impact of povidone-iodine burn dressing. Finally the definitions used in burn pathology, the prevention of AKI with a discussion of the fluid therapy in burned patients, and the role of renal replacement therapy in these patients is discussed.

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126 Early Transcriptomic Response to Burn injury: Prolonged Inflammatory Response is Associated with Mortality

Journal of Burn Care & Research ◽

10.1093/jbcr/irab032.130 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

pp. S85-S86

Author(s):

John W Keyloun ◽

Ross Campbell ◽

Leanne Detwiler ◽

Stacy-Ann Miller ◽

Aarti Guatam ◽

...

Keyword(s):

Pathway Analysis ◽

Cellular Response ◽

Burn Injury ◽

High Morbidity ◽

Burn Patients ◽

Severe Burn ◽

Transcriptomic Response ◽

Burn Care ◽

Inflammatory Pathways ◽

Severe Burn Injury

Abstract Introduction Burn injuries are associated with high morbidity and mortality. Burn care has improved significantly in the last few decades with emphasis on early surgical management, improvements in local wound care, and specialized critical care. While survival rates are improving, mortality remains high in certain patient populations, including those with larger burns. Burn injury induces a systemic hyperinflammatory response with detrimental side effects. Prior studies have offered early insights into the biochemical changes that occur after severe burn injury. The underlying cellular response is still largely unknown. The goal of this work is to characterize the blood transcriptome of severe burn injury and compare this response between patients who live or subsequently die of their injuries. Methods Burn patients presenting to a regional center between 2012–2017 were prospectively enrolled. Blood was collected on admission and at predetermined timepoints (Hours 2, 4, 8, 12, 24) over the first 24 hours. mRNA was isolated and a transcriptomic microarray was used to measure global transcript levels over time. To identify differentially regulated genes (FDR≤0.1) by injury severity, patients were grouped by burn size (TBSA >20%) and mortality. Microarray data was analyzed using bioinformatics software and pathway analysis. Descriptive statistics were generated with Mann-Whitney, Chi-Square, and Fisher’s exact test as appropriate. Results Sixty-eight patients were included in this analysis, most patients were male with a median age of 41 (IQR, 30.5–58.5) years, and TBSA of 20% (IQR, 11–34%). Thirty-five patients suffered %TBSA injury >20%, and this group experienced greater mortality (26% vs. 3%, p=0.008). There were no significant differences in age, race, or gender. Comparative analysis of genes from patients with < />20% TBSA revealed 1250, 444, 209, 20, 865, and 557 differentially regulated genes at hours 0, 2, 4, 8, 12 and 24 respectively. Pathway analysis reveals an initial upregulation in several immune/inflammatory pathways within the >20% TBSA groups between hours 0–2 followed by shutdown between hours 12–24. Immune pathways include Th17 activation pathway and natural killer cell signaling, inflammatory pathways include EIF2 signaling. These pathways remain upregulated in the group of patients with >20% TBSA who died. Conclusions Severe burn injury is associated with an early proinflammatory immune response followed by shutdown of these pathways. Burn patients who die show continued upregulation in the first 24 hours after injury in several proinflammatory pathways compared to those who live.

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Serum Level of Musclin Is Elevated Following Severe Burn

Journal of Burn Care & Research ◽

10.1093/jbcr/irz101 ◽

2019 ◽

Vol 40 (5) ◽

pp. 535-540 ◽

Cited By ~ 1

Author(s):

Audra Clark ◽

Ryan M Huebinger ◽

Deborah L Carlson ◽

Steven E Wolf ◽

Juquan Song

Keyword(s):

Serum Level ◽

Burn Injury ◽

Total Body Surface Area ◽

Cytokine Profile ◽

C2c12 Myoblast ◽

Burn Patients ◽

Severe Burn ◽

Rat Serum ◽

Serum Stimulation

Abstract Muscle wasting induced by severe burn worsens clinical outcomes is associated with hyperglycemia. A novel muscle-specific secretory factor, musclin, was reported to regulate glucose metabolism with a homologous sequence of natriuretic peptides. The purpose of the study was to investigate musclin expression in response to burn injury in both human and animal models. Serum was collected from 13 adult burn patients and circulating levels of musclin protein were measured via elisa. The cytokine profile was measured by Bio-Plex multiple immunoassay. Following the clinical study, we used a burn rat model with 40% TBSA to study the time course of musclin expression till day 14. Rat serum and muscle tissue sample were harvested. Finally, an in vitro study was applied to investigate whether the muscle cell C2C12 myoblast expressed musclin under 10% burn serum stimulation. Pearson analysis showed that there was a significant positive correlation of musclin expression to total body surface area of burn in patients (P &= .038). Musclin expression was significantly positively correlated with IL-4, IL-7, IL-12, and IL-13 in burn patients’ serum (P < .05). In the animal study, we found that the musclin level evaluated at 6 hours and 1 day in burn rat serum (P < .05). In vitro, musclin mRNA expression significantly increased with burn serum stimulation at 24 hours (P < .05). In conclusion, serum level of musclin elevated both in human patients and burn animals; musclin was correlated with the severity of burn injury as well as with an elevated cytokine profile in patients; burn serum-stimulated musclin expression in vitro further identified the resource of musclin expression after burn.

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Increased oxidative phosphorylation in lymphocytes does not atone for decreased cell numbers after burn injury

Innate Immunity ◽

10.1177/1753425918805544 ◽

2020 ◽

Vol 26 (5) ◽

pp. 403-412

Author(s):

Tony Chao ◽

Belinda I. Gomez ◽

Tiffany C. Heard ◽

Michael A. Dubick ◽

David M. Burmeister

Keyword(s):

High Resolution ◽

Burn Injury ◽

Total Body Surface Area ◽

Mitochondrial Activity ◽

Swine Model ◽

Compensatory Mechanism ◽

Severe Burn ◽

Post Injury ◽

Cytokine Analysis ◽

Severe Burn Injury

The acute systemic inflammatory response syndrome (SIRS) and multiorgan dysfunction (MOD) that occur in large burn injuries may be attributed, in part, to immunosuppressive responses such as decreased lymphocytes. However, the mitochondrial bioenergetics of lymphocytes after severe burn injury are poorly understood. The purpose of this study was to examine mitochondrial function of lymphocytes following severe burns in a swine model. Anesthetized Yorkshire swine ( n = 17) sustained 40% total body surface area full-thickness contact burns. Blood was collected at pre-injury (Baseline; BL) and at 24 and 48 h after injury for complete blood cell analysis, flow cytometry, cytokine analysis, and ficoll separation of intact lymphocytes for high-resolution mitochondrial respirometry analysis. While neutrophil numbers increased, a concomitant decrease was found in lymphocytes ( P < 0.001) after burn injury, which was not specific to CD4+ or CD8+ lymphocytes. No changes in immune cell population were observed from 24 h to 48 h post-injury. IL 12-23 decreased while a transient increase in IL 4 was found from BL to 24h ( P < 0.05). CRP progressively increased from BL to 24h ( P < 0.05) and 48h ( P < 0.001) post-injury. Routine and maximal mitochondrial respiration progressively increased from BL to 24h ( P < 0.05) and 48 h post-injury ( P < 0.001). No changes were found in leak respiration or residual oxygen consumption. When considering the reduction in lymphocyte number, the total peripheral lymphocyte bioenergetics per volume of blood significantly decreased from BL to 24h and 48h (P < 0.05). For the first time, we were able to measure mitochondrial activity in intact lymphocyte mitochondria through high-resolution respirometry in a severely burned swine model. Our data showed that the non-specific reduction in peripheral T cells after injury was larger than the increased mitochondrial activity in those cells, which may be a compensatory mechanism for the total reduction in lymphocytes. Additional studies in the metabolic activation of T cell subpopulations may provide diagnostic or therapeutic targets after severe burn injury.

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Revival of old antibiotics: pharmacokinetic study of multiple-dose intravenous polymyxin B in patients with severe burn injury undergoing continuous renal replacement therapy

10.26226/morressier.56d6be79d462b80296c97bd7 ◽

2016 ◽

Author(s):

Linlin Hu

Keyword(s):

Renal Replacement Therapy ◽

Continuous Renal Replacement Therapy ◽

Replacement Therapy ◽

Pharmacokinetic Study ◽

Multiple Dose ◽

Burn Injury ◽

Polymyxin B ◽

Severe Burn ◽

Severe Burn Injury

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

Journal of Burn Care & Research ◽

10.1093/jbcr/irab032.016 ◽

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.

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