Faculty Opinions recommendation of Transfusion requirement in burn care evaluation (TRIBE): A multicenter randomized prospective trial of blood transfusion in major burn injury.

Abstract Patients with major burn injuries typically require numerous blood transfusions. It is not known if an inhalation injury (INHI) directly influences the need for blood transfusion. The purpose of this study was to determine whether INHI increases the amount of blood transfused to major burn patients. A secondary analysis from the Transfusion Requirement in Burn Care Evaluation (TRIBE) study was conducted. Patients with INHI were compared with patients without INHI. The number of red blood cell (RBC) transfusions per day (RBC per day) between INHI and No INHI was analyzed with a multivariable regression. Patients with INHI (n = 78) had significantly larger burns (P = .0004), larger full-thickness burns (P = .0007), greater admission APACHE score (P < .0001), higher admission multiple organ dysfunction scores (P < .0001), and were transfused more RBC per day (P = .009) than No INHI patients (n = 267). In the multivariable regression analysis, RBC per day was significantly associated with the %TBSA burn (P < .0001), age of the patient (P = .004), the need for more than 1 day of mechanical ventilation (P < .0001), the occurrence of at least one blood stream infection (BSI; P = .044), and being assigned to the liberal transfusion arm of TRIBE (P < .001) but not the presence of INHI (P = .056). The null hypothesis that INHI exerts no influence on the amount of blood transfused could not be rejected. Larger burn size, advanced patient age, mechanical ventilation, and BSIs are important determinants of the blood transfusion rate in major burn patients.

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97 Major Psychiatric Illness and Substance Use Disorder Influence Mortality in Major Burn Injury: A Secondary Analysis of the Transfusion Requirement in Burn Care Evaluation (TRIBE) Study

Journal of Burn Care & Research ◽

10.1093/jbcr/irab032.101 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

pp. S66-S67

Author(s):

John A Andre ◽

Soman Sen ◽

David G Greenhalgh ◽

Tina L Palmieri ◽

Kathleen S Romanowski

Keyword(s):

Psychiatric Illness ◽

Transfusion Requirement ◽

Total Body Surface Area ◽

Secondary Analysis ◽

Inhalation Injury ◽

Burn Injuries ◽

Burn Care ◽

Major Burn ◽

Total Body ◽

Care Evaluation

Abstract Introduction Prior studies of burn patients with < 20% total body surface area (TBSA) burns have found that 15.4% of patients have major psychiatric illness (MPI) and 27.6% have Substance Use Disorder (SUD). In patients with small burns, SUD is associated with larger burn size and secondarily with longer length of stay while MPI is associated with longer lengths of stay while not increasing burn size. The purpose of this study was to determine whether MPI or SUD dependence affects outcomes such as mortality in patients with major burn injuries (≥20% TBSA). Methods A secondary analysis from the prospective, randomized, multicenter Transfusion Requirement in Burn Care Evaluation (TRIBE) study was conducted. Patients with MPI and SUD were compared with patients without these disorders. Statistical analysis with chi-square for categorical variables and student’s t-test for continuous variables was conducted. Mortality between those with and without MPI and SUD were analyzed with a multivariable regression analysis. Results A total of 347 patients with a mean age of 43±17 years, 274 men and 73 women, were analyzed. The mean total body surface area burn (TBSA) was 38±18%, and 23% had inhalation injury. In this study population, 29.1% had SUD, 7.5% had MPI, and 2.3% had both. There was no difference with respect to age, gender, TBSA, frailty, or assignment to the liberal or restrictive transfusion strategy based on the presence of MPI, SUD, or both. Inhalation injury was more common in patients with MPI (27%) or SUD (35%) when compared with patients without these comorbidities (18%) or those who have both (11%) (p=0.006). Patients with MPI were more likely to die of their burn injuries (27%) when compared with those with SUD (17%), both (11%), or neither (8%) (p=0.014). On multivariate analysis for mortality controlling for TBSA and inhalation injury, MPI was found to be an independent predictor of death with an odds ratio of 5 (95% confidence interval 1.7–15, p=0.003). Conclusions In burns >20% TBSA, both MPI and SUD influence patient’s likelihood of sustaining inhalation injury. MPI is also independently associated with mortality in the study. Further work must be done to mitigate the effects of mental illness on burn outcomes.

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Treatment of Anaemia in Patients with Acute Burn Injury: A Study of Blood Transfusion Practices

Journal of Clinical Medicine ◽

10.3390/jcm10030476 ◽

2021 ◽

Vol 10 (3) ◽

pp. 476

Author(s):

Ioana Tichil ◽

Samara Rosenblum ◽

Eldho Paul ◽

Heather Cleland

Keyword(s):

Blood Transfusion ◽

Surgical Management ◽

Burn Injury ◽

Total Body Surface Area ◽

Perioperative Period ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Burn Care ◽

Transfusion Requirements ◽

Total Body

Objective: To determine blood transfusion practices, risk factors, and outcomes associated with the use of blood products in the setting of the acute management of burn patients at the Victorian Adult Burn Service. Background: Patients with burn injuries have variable transfusion requirements, based on a multitude of factors. We reviewed all acute admissions to the Victorian Adult Burns Service (VABS) between 2011 and 2017: 1636 patients in total, of whom 948 had surgery and were the focus of our analysis. Method and results: Patient demographics, surgical management, transfusion details, and outcome parameters were collected and analyzed. A total of 175 patients out of the 948 who had surgery also had a blood transfusion, while 52% of transfusions occurred in the perioperative period. The median trigger haemoglobin in perioperative was 80mg/dL (IQR = 76–84.9 mg/dL), and in the non-perioperative setting was 77 mg/dL (IQR = 71.61–80.84 mg/dL). Age, gender, % total body surface area (TBSA) burn, number of surgeries, and intensive care unit and hospital length of stay were associated with transfusion. Conclusions: The use of blood transfusions is an essential component of the surgical management of major burns. As observed in our study, half of these transfusions are related to surgical procedures and may be influenced by the employment of blood conserving strategies. Furthermore, transfusion trigger levels in stable patients may be amenable to review and reduction. Risk adjusted analysis can support the implementation of blood transfusion as a useful quality indicator in burn care.

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A Review of Burn Patients Requiring Extracorporeal Membrane Oxygenation at a Burns Facility

European Journal of Burn Care ◽

10.3390/ebj2040021 ◽

2021 ◽

Vol 2 (4) ◽

pp. 293-300

Author(s):

Stephen Frost ◽

Liz Davies ◽

Claire Porter ◽

Avinash Deodhar ◽

Reena Agarwal

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Burn Injury ◽

Burn Injuries ◽

Burn Patients ◽

Review Of The Literature ◽

Respiratory Compromise ◽

Burn Care ◽

Membrane Oxygenation ◽

Regular Time ◽

Major Burn

Respiratory compromise is a recognised sequelae of major burn injuries, and in rare instances requires extracorporeal membrane oxygenation (ECMO). Over a ten-year period, our hospital trust, an ECMO centre and burns facility, had five major burn patients requiring ECMO, whose burn injuries would normally be managed at trusts with higher levels of burn care. Three patients (60%) survived to hospital discharge, one (20%) died at our trust, and one patient died after repatriation. All patients required regular, time-intensive dressing changes from our specialist nursing team, beyond their regular duties. This review presents these patients, as well as a review of the literature on the use of ECMO in burn injury patients. A formal review of the overlap between the networks that cater to ECMO and burn patients is recommended.

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Effect of blood transfusion on outcome after major burn injury: A multicenter study

Yearbook of Critical Care Medicine ◽

10.1016/s0734-3299(08)70274-0 ◽

2007 ◽

Vol 2007 ◽

pp. 89-90

Author(s):

B.A. Latenser

Keyword(s):

Blood Transfusion ◽

Multicenter Study ◽

Burn Injury ◽

Major Burn

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Life After Burn Injury: Striving for Regained Freedom

Qualitative Health Research ◽

10.1177/1049732308326652 ◽

2008 ◽

Vol 18 (12) ◽

pp. 1621-1630 ◽

Cited By ~ 39

Author(s):

Asgjerd Litleré Moi ◽

Eva Gjengedal

Keyword(s):

Life Stories ◽

Burn Injury ◽

Personal Goals ◽

Extreme Situation ◽

Meaningful Life ◽

Burn Care ◽

Major Burn ◽

Significant Effort ◽

Optimal Quality

Focusing beyond survival, the priority of modern burn care is optimal quality of life. Our aim with this study, which was informed by phenomenology, was to describe and identify invariant meanings in the experience of life after major burn injury. Fourteen adults having sustained a major burn were interviewed, on average, 14 months postinjury, and asked about their experience of important aspects of life. The accident meant facing an extreme situation that demanded vigilance, appropriate action, and the need for assistance. The aftermath of the burn injury and treatment included having to put significant effort into creating coherence in their disrupted personal life stories. Continuing life meant accepting the unchangeable, including going through recurrent processes of enduring, grief, fatalism, comparisons with others, and new feelings of gratefulness. Furthermore, a continuous struggle to change what was changeable, to achieve personal goals, independence, relationships with others, and a meaningful life, were all efforts to regain freedom, aiming for a life as it was before—and sometimes even better.

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Urinary Cortisol and Catecholamine Excretion after Burn Injury in Children

The Journal of Clinical Endocrinology & Metabolism ◽

10.1210/jc.2006-2158 ◽

2008 ◽

Vol 93 (4) ◽

pp. 1270-1275 ◽

Cited By ~ 34

Author(s):

William B. Norbury ◽

David N. Herndon ◽

Ludwik K. Branski ◽

David L. Chinkes ◽

Marc G. Jeschke

Keyword(s):

Burn Injury ◽

Prospective Trial ◽

Total Body Surface Area ◽

Severe Infection ◽

Reference Ranges ◽

Infection Rates ◽

Urinary Cortisol ◽

Urinary Catecholamines ◽

Major Burn ◽

Urine Cortisol

Abstract Introduction: A severe burn causes increased levels of urine cortisol and catecholamines. However, little is known about the magnitude of this increase or how and when the levels return to normal. The purpose of this study was to determine in a large clinical prospective trial the acute and long-term pattern of urine cortisol and catecholamine expression in severely burned children. Methods: Pediatric patients with burns greater than 40% total body surface area (TBSA), admitted to our unit over a 6-yr period, were included into the study. Clinical data including length of stay, number of operations, and duration and number of infections were determined. Patients had regular 24-h urine collections during their acute admission and reconstructive periods. Urine collections were analyzed for cortisol, epinephrine, and norepinephrine. Each urine cortisol was compared with age-adjusted reference ranges. Ninety-five percent confidence intervals and ANOVA analysis were used where appropriate. Results: Two hundred twelve patients were included in the study (75 females and 137 males), with a mean ± sem TBSA of 58 ± 1% (third-degree 45 ± 2%) and mean age of 9 ± 0.4 yr. Urinary cortisol levels were significantly increased (3- to 5-fold) up to 100 d after the burn and then approached normal levels (P < 0.05). The rise in urine cortisol was significantly higher in male than female patients (P < 0.05). Early hypercortisolemia was associated with increased duration of severe infection (P < 0.05). Persistent hypercortisolemia was associated with increases in both infection rates and duration of severe infection (P < 0.05). Urinary catecholamines showed a significant increase at 11–20 d after the burn (P < 0.05). Urinary norepinephrine levels were significantly increased up to 20 d and then returned to normal (P < 0.05). Conclusions: Urinary levels of cortisol, epinephrine, and norepinephrine are significantly increased after a major burn. Early hypercortisolemia is associated with increased duration of severe infection. Persistent hypercortisolemia is associated with increases in both infection rates and duration of severe infection.

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Transfusion Requirement in Burn Care Evaluation (TRIBE)

Annals of Surgery ◽

10.1097/sla.0000000000002408 ◽

2017 ◽

Vol 266 (4) ◽

pp. 595-602 ◽

Cited By ~ 33

Author(s):

Tina L. Palmieri ◽

James H. Holmes ◽

Brett Arnoldo ◽

Michael Peck ◽

Bruce Potenza ◽

...

Keyword(s):

Transfusion Requirement ◽

Burn Care ◽

Care Evaluation

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Advantages of immediate excision of burn eschar

Anaesthesia and Intensive Care ◽

10.1177/0310057x19895523 ◽

2020 ◽

Vol 48 (2) ◽

pp. 89-92

Author(s):

John E Greenwood

Keyword(s):

Gold Standard ◽

Burn Injury ◽

Smoke Inhalation ◽

Survival Outcomes ◽

Post Injury ◽

Burn Care ◽

Major Burn ◽

The Hours

Early excision of deep burn eschar and the expeditious closure of the resultant wounds have become established as gold standard burn care. However, early burn excision has been accepted as up to four days post injury based on a series of misconceptions, not least that the patient is too unwell to undergo surgery and tolerate anaesthesia too soon after injury. There are several reasons why immediate burn excision yields superior survival outcomes, and these are expounded in this article. The systemic pathophysiology following major burn injury, especially when complicated by the respiratory pathophysiology accompanying smoke inhalation, evolves. The hours immediately after burn injury offer several windows of surgical opportunity, windows closed by the pathophysiological events that peak 24 hours later and make surgery and anaesthesia at that time both dangerous and ill-advised.

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