The impact of initial surgical management on outcome in patients with severe burns: a 9-year retrospective analysis

Purpose To investigate the prognostic value of the factors related to the initial surgical management of burn wounds in severely burned patients. Methods A total of 189 severely burned adult patients who were admitted to our institute between January 2012 and December 2020 and met the inclusion criteria were recruited. Patients were divided into survival and nonsurvival groups. The patient data included sex, age, total burn surface area (TBSA), burn index (BI), inhalation injury, mechanical ventilation, initial surgical management of the burn wound (including post-injury time before surgery, surgical duration, surgical area, intraoperative fluid replenishment, intraoperative blood loss, and intraoperative urine output), and duration in the burn intensive care unit (BICU). Independent samples t tests, Mann-Whitney U tests, and χ 2 tests were performed on these data. those of which with statistically significant differences were subjected to univariate and multivariate Cox regression analyses to identify independent risk factors affecting the prognosis of severely burned patients. Receiver operating characteristic (ROC) curves were plotted, and the area under the curve (AUC), optimal cut-off value were calculated. Patients were divided into two groups, according to the optimal cut-off value of the independent risk factors. The TBSA, surgical area and survival rates of the two groups during hospitalization were analysed. Results The survival group (146 patients) and the nonsurvival group (43 patients) differed significantly in TBSA, burn index, inhalation injury, mechanical ventilation, initial surgical area, intraoperative fluid replenishment, intraoperative blood loss, and duration in the BICU (P<0.05). Univariate Cox regression analysis showed that TBSA, burn index, mechanical ventilation, initial surgical area, intraoperative fluid replenishment, and intraoperative blood loss were risk factors for death in severely burned patients (P<0.05). Multivariate Cox regression analysis showed that the burn index and intraoperative blood loss were independent risk factors for death in severely burned patients (P<0.05). When the intraoperative blood loss during the initial surgical management of burn wounds was used to predict death in 189 severely burned patients, the AUC was 0.637 (95% confidence interval (CI): 0.545-0.730, P=0.006), and the optimal cut-off for intraoperative blood loss was 750 ml. Kaplan-Meier survival analysis showed that the prognosis of the group with intraoperative blood loss ≤750 ml was better than that of the group with intraoperative blood loss >750 ml (P=0.008). Meanwhile, the TBSA and surgical area in the group with intraoperative blood loss ≤750 ml were significantly lower than that of the group with intraoperative blood loss >750 ml (P<0.05). Conclusion The burn index and intraoperative blood loss during the initial surgical management of burn wounds are independent risk factors affecting the outcome of severely burned patients with good predictive values. During surgery, haemostatic and anaesthetic strategies should be adopted to reduce bleeding, and the bleeding volume should be controlled within 750 ml to improve the outcome.

A 3-Years Pneumonia Incidence in Burn Cases with Inhalation Injury at the Burn Center of Dr. Soetomo General Hospital Surabaya in 2015-2018

Introduction: Inhalation injury is one of burns impact. Airway burns due to inhalation injury is a non-specific term which refer to all respiratory tract injuries occurred due to irritative chemicals, including heat and smoke during inspiration. Inhalation injury increases the risk of death in burns. Pneumonia is one of burns-related inhalation injury complications.Methods: This was a descriptive retrospective study aiming to determine the incidence of pneumonia in burn patients with inhalation injury using secondary data at Burn Center Dr. Soetomo General Hospital Surabaya in the period of January 2015 - December 2018.Results: There were 5 cases of pneumonia in 14 burn cases with inhalation injury (35.71%). Respectively, 2 and 3 cases were found in 2017 and 2018. There were 2 female (40%) and 3 male (60%) patients, with age varied within 28-73 years old. The burn area of burn patients with inhalation injury and pneumonia were found by 15%, 20%, 24%, 32% and 71%, or within the classification of 11-20% burn area, and most complication found was hypoalbuminemia, as much as 3 cases (60%).\Conclusion: Most pneumonia in burn cases with inhalation injury was occurred in 2018, dominated by male patients. The age of the patient were ranging from early adulthood to elderly. Most burns were in the range of 11-20% burn area with the most complication found was hypoalbuminemia.

Colonic Oxygen Microbubbles Augment Systemic Oxygenation and CO2 Removal in a Porcine Smoke Inhalation Model of Severe Hypoxia

Inhalation injury can lead to pulmonary complications resulting in the development of respiratory distress and severe hypoxia. Respiratory distress is one of the major causes of death in critically ill patients with a reported mortality rate of up to 45%. The present study focuses on the effect of oxygen microbubble (OMB) infusion via the colon in a porcine model of smoke inhalation-induced lung injury. Juvenile female Duroc pigs (n=6 colonic OMB, n=6 no treatment) ranging from 39-51 kg in weight were exposed to smoke under general anesthesia for 2 h. Animals developed severe hypoxia 48 h after smoke inhalation as reflected by reduction in SpO2 to 66.3 % +/- 13.1% and PaO2 to 45.3 +/- 7.6 mmHg, as well as bilateral diffuse infiltrates demonstrated on chest x-ray. Colonic OMB infusion (75 - 100 mL/kg dose) resulted in significant improvements in systemic oxygenation as demonstrated by an increase in PaO2 of 13.2 +/- 4.7 mmHg and SpO2 of 15.2% +/- 10.0% out to 2.5 h, compared to no-treatment control animals that experienced a decline in PaO2 of 8.2 +/- 7.9 mmHg and SpO2 of 12.9% +/- 18.7% over the same timeframe. Likewise, colonic OMB decreased PaCO2 and PmvCO2 by 19.7 +/- 7.6 mmHg and 7.6 +/- 6.7 mmHg, respectively, compared to controls that experienced increases in PaCO2 and PmvCO2 of 17.9 +/- 11.7 mmHg and 18.3 +/- 11.2 mmHg. We conclude that colonic OMB therapy has potential to treat patients experiencing severe hypoxemic respiratory failure.

Incidence and Mortality of Acute Respiratory Distress Syndrome in Patients With Burns: A Systematic Review and Meta-Analysis

Objective: We conducted a systematic review and meta-analysis to comprehensively estimate the incidence and mortality of acute respiratory distress syndrome (ARDS) in overall and subgroups of patients with burns.Data sources: Pubmed, Embase, the Cochrane Library, CINAHL databases, and China National Knowledge Infrastructure database were searched until September 1, 2021.Study selection: Articles that report study data on incidence or mortality of ARDS in patients with burns were selected.Data extraction: Two researchers independently screened the literature, extracted data, and assessed the quality. We performed a meta-analysis of the incidence and mortality of ARDS in patients with burns using a random effects model, which made subgroup analysis according to the study type, inclusion (mechanical ventilation, minimal burn surface), definitions of ARDS, geographic location, mean age, burn severity, and inhalation injury. Primary outcomes were the incidence and mortality of burns patients with ARDS, and secondary outcomes were incidence for different subgroups.Data synthesis: Pooled weighted estimate of the incidence and mortality of ARDS in patients with burns was 0.24 [95% confidence interval (CI)0.2–0.28] and 0.31 [95% CI 0.18−0.44]. Incidences of ARDS were obviously higher in patients on mechanical ventilation (incidence = 0.37), diagnosed by Berlin definition (incidence = 0.35), and with over 50% inhalation injury proportion (incidence = 0.41) than in overall patients with burns. Patients with burns who came from western countries and with inhalation injury have a significantly higher incidence of ARDS compared with those who came from Asian/African countries (0.28 vs. 0.25) and without inhalation injury (0.41 vs. 0.24).Conclusion: This systematic review and meta-analysis revealed that the incidence of ARDS in patients with burns is 24% and that mortality is as high as 31%. The incidence rates are related to mechanical ventilation, location, and inhalation injury. The patients with burns from western countries and with inhalation injury have a significantly higher incidence than patients from Asian/African countries and without inhalation injury.Systematic Review Registration: identifier: CRD42021144888.

A review of the most impactful published pharmacotherapy-pertinent literature of 2019 and 2020 for clinicians caring for patients with thermal or inhalation injury

Keeping abreast with current literature can be challenging, especially for practitioners caring for patients sustaining thermal or inhalation injury. Practitioners caring for patients with thermal injuries publish in a wide variety of journals, which further increases the complexity for those with resource limitations. Pharmacotherapy research continues to be a minority focus in primary literature. This review is a renewal of previous years’ work to facilitate extraction and review of the most recent pharmacotherapy-centric studies in patients with thermal and inhalation injury. Sixteen geographically dispersed, board-certified pharmacists participated in the review. A MeSH-based, filtered search returned 1,536 manuscripts over the previous 2-year period. After manual review and exclusions, only 98 (6.4%) manuscripts were determined to have a potential impact on current pharmacotherapy practices and included in the review. A summary of the 10 articles that scored highest are included in the review. Nearly half of the reviewed manuscripts were assessed to lack a significant impact on current practice. Despite an increase in published literature over the previous 2-year review, the focus and quality remain unchanged. There remains a need for investment in well-designed, high impact, pharmacotherapy-pertinent research for patients sustaining thermal or inhalation injuries.