Mortality and causes of death of Dutch burn patients during the period 2006–2011

Components, Models of Integration, and Outcomes Associated with Palliative/ end-of-Life Care Interventions in the Burn Unit: A Scoping Review

Objective: To scope the literature to ascertain the components of palliative care (PC) interventions for burn patients, models of integration, and outcomes. Methods: Arksey and O'Malley scoping review design with narrative synthesis was employed and reported following the PRISMA-ScR guidelines. Primary studies reporting PC interventions in the burn unit were considered for inclusion. CINAHL via EBSCO, PubMed, EMBASE via OVID, Web of Science, and gray literature sources were searched from inception to June 2021. Results: Fifteen studies emerging from high-income settings were retained. Data were organized around three concepts: components of palliative/ end of life care in the burn unit; models of integration; and outcomes. The components of interventions based on the Robert Wood Johnson Foundation Critical Care End-of Life Group domains include decision-making, communication, symptom management and comfort care, spiritual support, and emotional and practical support for families. Consultative and integrative models were noted to be the strategies for integrating PC in the burn unit. The outcomes were varied with only few studies reporting healthcare staff related outcomes. Conclusion: PC may have the potential of improving end-of-life care in the burn unit albeit the limited studies and lack of standardized outcomes makes it difficult to draw stronger conclusions regarding what is likely to work best in the burn unit.

Characteristics of patients resuscitated after burn related out-of-hospital cardiac arrest

AIM

This study's objective was to describe the characteristics of burn injury patients who were resuscitated after burn related out-of-hospital cardiac arrest (OHCA).

METHOD

We conducted a retrospective cohort study and examined characteristics of burn related OHCA using data from a Japanese nationwide burn registry that was collected between April 1, 2011 and March 31, 2020. First, we compared the characteristics of burn patients with and without OHCA. Second, among burn patients with OHCA, we compared the characteristics of survivors with non-survivors.

RESULTS

In the database, there were 16,995 hospitalised burn patients and 256 burn related OHCA. Thirty-two of the 256 burn patients (13%) survived after admission. Among patients with burns who also had OHCA, flames were the most common injury mechanism (74%); in comparison to all other injury mechanisms, the rate of flame burn was significantly higher in burn patients with OHCA than in burn patients without OHCA. The most common cause of death for burn related OHCA is carbon-monoxide poisoning (46%). Compared with survivors, non-survivors had a larger burn area, greater age and more complications. such as inhalation injuries and perineal burn injuries. Compared to other mechanisms of burn injury, electrical burn injuries were more common among survivors. In twelve patients with electrical burns, eight patients survived (67%) OHCA; of those eight patients, six (50%) could be discharged home.

CONCLUSION

Patients with burn related OHCA have a poor prognosis; however, patients who sustain electrical shock injuries may do better.

Variation of the SOFA score and mortality in patients with severe burns: A cohort study

Multiple organ failure (MOF) is the leading cause of death in patients with burns requiring ICU admission. Quantifying the evolution of MOF, with the SOFA score, over the first few days after a severe burn may provide useful prognostic information. This retrospective cohort study aimed at evaluating the association between the evolution of the SOFA score between day 0 and day 3 and in-hospital mortality. All patients admitted for severe burns at the burn ICU of the Tours University Hospital between 2017 and 2020 and who stayed 3 days or more were included. Severe burns included: total body surface area burned (TBSA) ≥ 20 % or burns of any surface associated with one or more of the following items: (1) organ failure, (2) clinically significant smoke inhalation and/or cyanide poisoning, (3) severe preexisting comorbidities, (4) complex and specialized burn wound care. DeltaSOFA was defined as day 3 minus day 0 SOFA. One hundred and thirty-six patients were included. Median age was 52 years (38-70), median TBSA burned was 24 % (20-38), median day 0 SOFA was 2 (0-4) and median day 3 SOFA was 1 (0-5). In-hospital mortality was 10 %. There was a significant association between deltaSOFA and mortality that persisted after adjustment for age and TBSA (HR 1.37, 95 %CI 1.09-1.72, p < 0.01). Area under the receiver operating characteristics curve for the prediction of mortality by day 0 SOFA and deltaSOFA were 0.79 (95 %CI 0.69-0.89) and 0.83 (95 %CI 0.70-0.95) respectively. After exclusion of patients with TBSA burned< 15 %, deltaSOFA remained independently associated with mortality (HR 1.42 95 %CI 1.09-1.85, p < 0.01). In addition, SOFA variations allowed the identification of subgroups of patients with either very low or very high mortality. In patients with severe burns, SOFA score evolution between day 0 and day 3 may be useful for individualized medical and ethical decisions. Further multicenter studies are required to corroborate the present results.

Emergency Care for Burn Patients-A Single-Center Report

Burns, one of the main public health problems, lead to significant mortality and morbidity. Epidemiological studies regarding burn patients in Romania are scarce. The aim of this study is to identify the burn etiology, demographics, clinical characteristics, and outcomes in patients requiring treatment in a regional burn unit.

DESIGN

We performed a retrospective observational study of 2021.

PATIENTS

All patients admitted to our six-bed intensive care unit (ICU) were included.

INTERVENTIONS

The following data were collected for further analysis: demographics, burn pattern (etiology, size, depth, affected body region), type of ventilation, ABSI (Abbreviated Burn Severity Index) score, comorbidities, bioumoral parameters, and hospitalization days.

RESULTS

There were 93 burned patients included in our study that were divided into two groups: alive patients' group (63.4%) and deceased patients' group (36.6%). The mean age was 55.80 ± 17.16 (SD). There were 65.6% male patients, and 39.8% of the patients were admitted by transfer from another hospital. Further, 59 patients presented third-degree burns, from which 32.3% died. Burns affecting >37% of the total body surface area (TBSA) were noticed in 30 patients. The most vulnerable regions of the body were the trunk (p = 0.003), the legs (p = 0.004), the neck (p = 0.011), and the arms (p = 0.020). Inhalation injury was found in 60.2% of the patients. The risk of death in a patient with an ABSI score > 9 points was 72 times higher. Comorbidities were present in 44.1% of the patients. We observed a median LOS (length of stay) of 23 days and an ICU-LOS of 11 days. Logistic regression analysis showed that admission protein, creatinkinase, and leukocytes were independent risk factors for mortality. The general mortality rate was 36.6%.

CONCLUSION

A thermal factor was responsible for the vast majority of burns, 94.6% of cases being accidents. Extensive and full-thickness burns, burns affecting the arms, inhalation injuries, the need for mechanical ventilation, and a high ABSI score represent important risk factors for mortality. Considering the results, it appears that prompt correction of protein, creatinkinase, and leukocytes levels may contribute to improvement in severe burn patients' outcomes.

The Complexity of the Post-Burn Immune Response: An Overview of the Associated Local and Systemic Complications

Burn injury induces a complex inflammatory response, both locally and systemically, and is not yet completely unravelled and understood. In order to enable the development of accurate treatment options, it is of paramount importance to fully understand post-burn immunology. Research in the last decades describes insights into the prolonged and excessive inflammatory response that could exist after both severe and milder burn trauma and that this response differs from that of none-burn acute trauma. Persistent activity of complement, acute phase proteins and pro- and anti-inflammatory mediators, changes in lymphocyte activity, activation of the stress response and infiltration of immune cells have all been related to post-burn local and systemic pathology. This "narrative" review explores the current state of knowledge, focusing on both the local and systemic immunology post-burn, and further questions how it is linked to the clinical outcome. Moreover, it illustrates the complexity of post-burn immunology and the existing gaps in knowledge on underlying mechanisms of burn pathology.

Outcome of burn injury and associated factor among patient visited at Addis Ababa burn, emergency and trauma hospital: a two years hospital-based cross-sectional study

BACKGROUND

Burn is one of the critical health problems worldwide. Developing countries with sub-Saharan and Asian populations are affected more. Its mortality and non-fatal complications depend on several factors including age, sex, residency, cause, the extent of the burn, and time and level of care given.

OBJECTIVE

The purpose of this study was to assess the outcome of burn injury and its associated factor among patients who visited Addis Ababa burn emergency and trauma hospital.

METHODS

The institutional-based, retrospective cross-sectional study design was conducted from April 1, 2019, to March 30, 2021. After checking the data for its consistency the data were entered and analyzed by using SPSS version 25. A total of 241 patients who had visited Addis Ababa burn, emergency and trauma Hospitals after sustained burn injury were recruited through convenience sampling method for final analysis. Model goodness-of-fit was checked by Hosmer and Lemeshow test (0.272). After checking multi-collinearity both the bi-variable and multivariable logistic regression model was fitted and variables having a p-value less than or equal to 0.05 at 95% CI in the multivariable analysis were considered statistically significant.

RESULT

Adults (age 15 to 60 years) are the most affected groups accounting for 55.2% followed by pediatric age groups (age <15 years) (43.6%) and the elderly (age > 60 years) (1.2%). Scald burn was the major cause accounting for 39 % followed by Flame burn (33.6%), Electrical burn (26.6%), and chemical burn (0.8%). The mean TBSA% was 15.49%, ranging from1% to 64%. Adult males are more affected by electrical burns while adult females and the elderly encounter flame burn. 78.4% of patients were discharged without complications, 14.9% were discharged with complications and 6.6% died. The commonest long-term complication is the amputation of the extremity (19, 7.9%). Age greater than 60 years and TBSA% greater than 30% is a strong predictors of mortality with odds of 2.2 at 95% CI of [1.32, 3.69] and 8.7 at 95% CI of [1.33, 57.32] respectively.

CONCLUSION AND RECOMMENDATION

The mortality rate show decrement from previous studies. Overall scald burn is common in all age groups but electrical burns and flame burns affected more adult and elderly age groups. Extremities were by far, the commonest affected body parts. The extent of burn injury and the age of the patient independently predict mortality. Early intervention will reduce mortality and complications.

Pediatric First-Degree Burn Management With Honey and 1% Silver Sulfadiazine (Ag-SD): Comparison and Contrast

Background The cardinal area of managing fire wounds is guided by adequately evaluating the burn-induced lesion's profundity and size. Superficial second-degree burns are often treated through daily reinstating with fresh sterile bandaging with appropriate topical antimicrobials to allow rapid spontaneous epithelialization. Around the world, a wide variety of substances are used to treat these wounds, from honey to synthetic biological dressings. Objective This study intended to determine honey's therapeutic potential compared with 1% silver sulfadiazine (Ag-SD) in arsenal-caused contusion medicament fulfillment. Methods A total of 70 cases were evaluated in this research work after fulfilling the required selection criteria during the study period of January 2014 to December 2014 and January 2017 to December 2017. Purposive selection criteria were adopted in the study to select research patients. The patients in Group-1 (n = 35) relied on honey as medication, while patients in Group-2 (n = 35) relied on 1% Ag-SD. Results In Group-1, exudation (68.4%) and sloughing (82.9%) were substantially reduced by Days 3 and 5 of therapeutic intervention, respectively. However, in Group-2, a reduction of exudation (17.1%) and sloughing (22.9%) occurred after Days 3 and 5 of treatment, respectively. Completion of the epithelialization process was observed among Group-1 and Group-2 cases. It was detected after Days 7 and 10 of treatment at 36.3% and 77% (Group-1) and 27% and 67% (Group-2), respectively. Around 3 ml of 1% honey was required per body surface area per dressing in Group-1. On the other hand, in Group-2, 2 gm Ag-SD was needed per body surface area per dressing. Conclusion Patients treated with honey found better clinical outcomes in managing superficial partial-thickness burns.

What do we know about experiencing end-of-life in burn intensive care units? A scoping review

OBJECTIVES

The aim of this article is to review and synthesize the evidence on end-of-life in burn intensive care units.

METHODS

Systematic scoping review: Preferred Reporting Items for Systemic Reviews extension for Scoping Reviews was used as a reporting guideline. Searches were performed in 3 databases, with no time restriction and up to September 2021.

RESULTS

A total of 16,287 documents were identified; 18 were selected for analysis and synthesis. Three key themes emerged: (i) characteristics of the end-of-life in burn intensive care units, including end-of-life decisions, decision-making processes, causes, and trajectories of death; (ii) symptom control at the end-of-life in burn intensive care units focusing on patients' comfort; and (iii) concepts, models, and designs of the care provided to burned patients at the end-of-life, mainly care approaches, provision of care, and palliative care.

SIGNIFICANCE OF RESULTS

End-of-life care is a major step in the care provided to critically ill burned patients. Dying and death in burn intensive care units are often preceded by end-of-life decisions, namely forgoing treatment and do-not-attempt to resuscitate. Different dying trajectories were described, suggesting the possibility to develop further studies to identify triggers for palliative care referral. Symptom control was not described in detail. Palliative care was rarely involved in end-of-life care for these patients. This review highlights the need for early and high-quality palliative and end-of-life care in the trajectories of critically ill burned patients, leading to an improved perception of end-of-life in burn intensive care units. Further research is needed to study the best way to provide optimal end-of-life care and foster integrated palliative care in burn intensive care units.

Relation Between Gender and Concomitant Medications With Erythropoietin-Treatment on Wound Healing in Burn Patients. Post Hoc Subgroup-Analysis of the Randomized, Placebo-Controlled Clinical Trial “EPO in Burns”

Burns are leading causes of mortality and morbidity, including prolonged hospitalization, disfigurement, and disability. Erythropoietin (EPO) is a well-known hormone causing erythropoiesis. However, EPO may play a role in healing acute and chronic wounds due to its anti-inflammatory and pro-regenerative effects. Therefore, the large, prospective, placebo-controlled, randomized, double-blind, multi-center clinical trial “EPO in Burns” was initiated to investigate the effects of EPO versus placebo treatment in severely burned patients. The primary endpoint of “EPO in Burns” was defined as the time elapsed until complete re-epithelialization of a defined split skin graft donor site. Additional analyses of post hoc defined subgroups were performed in view of the primary endpoint. The verum (n 45) and control (n 39) groups were compared with regard to the time it took for study wounds (a predefined split skin graft donor site) to reach the three stages of wound healing (re-epithelialization levels). In addition, the effects of gender (females n 18) and concomitant medications insulin (n 36), non-steroidal anti-inflammatory drugs (NSAIDs) (n 41), and vasopressor agents (n 43) were tested. Life tables were used to compare study groups (EPO vs. placebo) within subgroups. The Cox regression model was applied to evaluate interactions between the study drug (EPO) and concomitant medications for each re-epithelialization level. Using our post hoc defined subgroups, we observed a lower chance of wound healing for women compared to men (in terms of hazard ratio: hr^100%: 5.984 [95%-CI: (0.805–44.490), p = 0.080]) in our study population, regardless of the study medication. In addition, results indicated an earlier onset of re-epithelialization in the first days of EPO treatment (EPO: 10% vs. Placebo: 3%). Moreover, the interpretation of the hazard ratio suggested EPO might have a positive, synergistic effect on early stages of re-epithelialization when combined with insulin [hr^50%: 1.307 (p = 0.568); hr^75%: 1,199 (p = 0.715)], as well as a stabilizing effect on critically ill patients [reduced need for vasopressors in the EPO group (EPO: 44% vs. Placebo 59%)]. However, additional high-quality data from clinical trials designed to address these endpoints are required to gain further insight into these effects.

Burn Registries State of Affairs: A Scoping review

Registry science allows for the interpretation of disease-specific patient data from secondary databases. It can be utilized to understand disease and injury, answer research questions, and engender benchmarking of quality-of-care indicators. Numerous burn registries exist globally, however, their contributions to burn care have not been summarized. The objective of this study is to characterize the available literature on burn registries. The authors conducted a scoping review, having registered the protocol a priori. A thorough search of the English literature, including grey literature, was carried out. Publications of all study designs were eligible for inclusion provided they utilized, analyzed, and/or critiqued data from a burn registry. Three hundred twenty studies were included, encompassing 16 existing burn registries. The most frequently used registries for peer-reviewed publications were the American Burn Association Burn Registry, Burn Model System National Database, and the Burns Registry of Australia and New Zealand. The main limitations of existing registries are the inclusion of patients admitted to burn centers only, deficient capture of outpatient and long-term outcome data, lack of data standardization across registries, and the paucity of studies on burn prevention and quality improvement methodology. Registries are an invaluable source of information for research, delivery of care planning, and benchmarking of processes and outcomes. Efforts should be made to stimulate other jurisdictions to build burn registries and for existing registries to be improved through data linkage with administrative databases, and by standardizing one international minimum dataset, in order to maximize the potential of registry science in burn care.

The impact of social isolation by COVID-19 on the epidemiological and clinical profiles of the burn patients. A retrospective study

BACKGROUND

Social isolation, imposed by the COVID-19 pandemic, may imply changes in the clinical-demographic and epidemiological profiles of burn trauma victims.

OBJECTIVE

Evaluate the changes in the epidemiological profile of patients with burns that resulted in hospitalization during the social isolation period due to the COVID-19 pandemic, comparing with the same period in the previous year.

METHODS

The medical records of burn patients who were hospitalized in our Burn Center during the local confinement period (March 18th to August 31st, 2020) and during the same period in 2019 were analyzed. Data on demographic, clinical and hospitalization aspects were studied.

RESULTS

470 patients were evaluated. In the pediatric population, a significant increase in the number of cases up to 2 years old (P = 0.0003), median of %TBSA (P = 0.037), full-thickness burns (P < 0.0001), involvement of hands (P = 0.024), debridement (P = 0.046) and grafting (P = 0.032) procedures, and higher scores of severity (P < 0.0001) were noted. In the adult population, it was only observed an increase in the burn-hospitalization interval (P = 0.029).

CONCLUSION

The pediatric population was heavily impacted by the imposed period of social isolation, presenting a greater severity of burns. In contrast, the epidemiology of burns for the adult population was slightly altered during the pandemic period.

Treatment Decisions in Patients with Potentially Non-Survivable Burn Injury in Australia and New Zealand: A Registry-based Study

Whilst burn-related mortality is rare in high-income countries, there are unique features related to prognostication that make examination of decision-making practices important to explore. Compared to other kinds of trauma, burn patients (even those with non-survivable injuries) may be relatively stable after injury initially. Complications or patient comorbidity may make it clear later in the clinical trajectory that ongoing treatment is futile. Burn care clinicians are therefore required to make decisions regarding the withholding or withdrawal of treatment in patients with potentially non-survivable burn injury. There is yet to be a comprehensive investigation of treatment decision practices following burn injury in Australia and New Zealand. Data for patients admitted to specialist burn services between July 2009 and June 2020 were obtained from the Burns Registry of Australia and New Zealand. Patients were grouped according to treatment decision: palliative management, active treatment withdrawn, and active treatment until death. Predictors of treatment initiation and withholding or withdrawing treatment within 24 hours were assessed using multilevel mixed-effects logistic regression. Descriptive comparisons between treatment groups were made. Of the 32,186 patients meeting study inclusion criteria, 327 (1.0%) died prior to discharge. Fifty-six patients were treated initially with palliative intent and 227 patients had active treatment initiated and later withdrawn. Increasing age and burn size reduced the odds of having active treatment initiated. We demonstrate differences in demographic and injury severity characteristics as well as end of life decision-making timing between different treatment pathways pursued for patients who die in-hospital. Our next step into the decision-making process is to gain a greater understanding of the clinician's perspective (e.g., through surveys and/or interviews).

Thermo-mechanical combination injuries - A rare but life-threatening entity

Thermo-mechanical-combination-injuries (TMCI) are feared for their demanding preclinical and clinical management and bear the risk of high mortality compared to the single injury of a severe burn or multiple traumata. There remains a significant lack of standardized algorithms for diagnostics, and therapy of this rare entity. The aim of the present study was to profile TMCI aiming at standardized procedures. In this study, TMCI were extracted from our burn database of a level 1 burn and trauma centre. From 2004 to 2017, all patients with TMCI were retrospectively analyzed. Further inclusion criteria were multiple trauma accompanied by burn with ≥10% TBSA. Patient and injury characteristics including ISS and outcome parameter were analyzed. A total of 45 patients matched the selective inclusion criteria of TMCI comprising of 4% of all burn injuries during the period. Average age was 38 years (range: 14-86), with a mean TBSA of 43% (range: 10-97%). The mean recorded temperature at admission was 34.8°C (range: 29.6 - 37.1) with 2215 ml volume (range: 500 - 8000) administered preclinically in total. The mean ISS was 16. The overall mortality rate was 22%. TMCI are rare and life-threatening events which require highly qualified management in combined level 1 trauma and burn centres to adress both burn and trauma treatment. The multiple injury pattern is diverse, complicating standardized management in view of burn care specific measures, as normothermia and restrictive volume management. The present study reveals further profiles and underlines the need for addressing TMCI in ABLS®; ATLS® and PHTLS® programs.

Early Palliative Care Consultation in the Burn Unit: A Quality Improvement Initiative to Increase Utilization

Despite significant morbidity and mortality for major burns, palliative care consultation (PCC) is underutilized in this population. The purpose of this study is to examine the impact of a protocol using recommended "triggers" for PCC at a single academic burn center. This is a retrospective review of patient deaths over a four-year period. Use of life-sustaining treatments, comfort care (de-escalation of one or more life-sustaining treatments) and do not attempt resuscitation (DNAR) orders were determined. Use of PCC was compared during periods before and after a protocol establishing recommended triggers for early (<72 hrs of admission) PCC was instituted in 2019. A total of 33 patient deaths were reviewed. Most patients were male (n=28, 85%) and median age was 62 years [IQR 42-72]. Median revised Baux score was 112 [IQR 81-133]. Many patients had life-sustaining interventions such as intubation, dialysis, or cardiopulmonary resuscitation, often prior to admission. Amongst patients who survived >24 hrs, 67% (n=14/21) had PCC. Frequency of PCC increased after protocol development, with 100% vs. 36% of these patients having PCC before death (p=0.004). However, even during the later period, less than half of patients had early PCC despite meeting criteria at admission. In conclusion, initiation of life-sustaining measures in severely injured burn patients occurs prior to or early during hospitalization. Thus, value-based early goals of care discussions are valuable to prevent interventions that do not align with patient values and assist with de-escalation of life-sustaining treatment. In this small sample, we found that while there was increasing use of PCC overall after developing a protocol of recommended triggers for consultation, many patients who met criteria at admission did not receive early PCC. Further research is needed to elucidate reasons why providers may be resistant to PCC.

Efficacy and safety of platelet-rich plasma in the treatment of severe burns: A protocol for systematic review and meta analysis

BACKGROUND

In recent years, platelet-rich plasma (PRP) has been used in burn wound repair, plastic surgery, bone and tendon ligament injury repair and other treatment at home and abroad. Clinical studies indicate that PRP has a good curative effect on repairing burn wounds. The residual wounds formed after large area severe burns are difficult to cure and have recurrent attacks. Because the action mechanism of PRP is unclear, its clinical efficacy of PRP in repairing severe burn wounds is controversial. And there is no relevant systematic evaluation of PRP in repairing severe burn wounds now.

OBJECTIVE

Meta analysis was used to evaluate the efficacy and safety of PRP in repairing severe burn wounds.

METHODS

Randomized controlled clinical trial of using PRP to repair severe burn wounds were retrieved by computer WanFang, China National Knowledge Infrastructure, China Science and Technology Journal Database, China Biology Medicine disc, Embase, PubMed, Web of Science and Cochrane Library from the establishment of the database to September 2020. Two researchers independently extract data and assess the quality of the included literature, and Meta analysis of the included literature is carried out by using RevMan5.3 software.

RESULTS

In this study, the efficacy and safety of PRP in repairing severe burn wounds are evaluated from the aspects of wound healing rate, wound healing time, scar index, visual simulation score, the number of layers of dressing, the number of times of changing gauze, frequency of dressing change, the positive rate of wound bacterial culture and the incidence of inflammatory reaction.

CONCLUSIONS

PRP has a good curative effect on the repair of severe burn wounds. This study provides reliable evidence for the clinical use of PRP in the clinical repair of severe burn wounds.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/FG682.

Evaluating the Saliva of Burn ICU Patients for Resistant Infections Harbor Metallo-β-Lactamase Genes

Pseudomonas aeruginosa and Acinetobacter baumannii are the bacteria which increasingly account for nosocomial infections. Due to high virulence, the rate of Multi-Drug Resistance (MDR) and limited availability of new agents, these infections create significant clinical burdens, making it important to identify the possible sources of their occurrence. The aim of this study was to assess non-lactose fermenting bacteria and their metallo-β-lactamase (MBLs) genes expression in the Burn Intensive Care Unit (BICU) patients' saliva samples. This cross-sectional study was conducted from 2017 to 2018 on 124 saliva samples of BICU patients. Identified isolates were evaluated for drug susceptibility by disc diffusion method. MBLs production isolates were detected by Modified Hodge test and Imipenem-EDTA Combined disk. MBLs related genes were evaluated by polymerase chain reaction (PCR). A total of 86 Gram negative non-lactose fermenting bacteria (38; A. baumannii) and (48; P. aeruginosa), were detected. All of the A. baumannii isolates were resistant to Carbapenems, while more than 90% of them were sensitive to Colistin. However, the highest sensitivity in P. aeruginosa isolates was related to Carbapenems and Colistin. More than 95% of A. baumannii and 32% of P. aeruginosa were detected MDR. MBLs production was confirmed in 9 (33.33%) P. aeruginosa and 18 (66.67%) A. baumannii isolates. The blaVIM was the most prevalent gene, while this gene was detected in all of MBLs positive strains. This study confirmed the prevalence of carbapenemase producer Gram-negative bacilli in the saliva of BICU patients. The results of the present study provide a new data set about saliva infection source that could lead to the proper antibiotic regimen and better control of drug resistance.

The Role of Palliative Care in Burns: A Scoping Review

CONTEXT

Patients with severe burns may face distressing symptoms with a high risk of mortality as a result of their injury. The role of palliative care in burns management remains unclear.

OBJECTIVE

To appraise the literature on the role of palliative care in burns management.

METHODS

We used scoping review with searches in 12 databases from their inception to August 2019. The citation retrieval and retention are reported in a PRISMA statement.

FINDINGS

39 papers comprising of 30 primary studies (26 from high-income and four from middle-income countries), four reviews, two editorials, two guidelines, and one expert board review document were retained in the review. Palliative care is used synonymously with comfort and end-of-life care in burns literature. Comfort care is mostly initiated when active treatment is withheld (early deaths) or withdrawn (late deaths), limiting its overall benefits to burn patients, their families, and health care professionals. Futility decisions are usually complex and challenging, particularly for patients in the late death category, and it is unclear if these decisions result in timely commencement of comfort care measures. Three comfort care pathways were identified, but it remained unclear how these pathways evaluated "good death" or supported the family which creates the need for the development of other evidence-based guidelines.

CONCLUSION

Palliative care is applicable in burns management, but its current role is mostly confined to the end-of-life period, suggesting that it is not been fully integrated in the management process. Evidence-based guidelines are needed to support the integration and delivery of palliative care in the burn patient population.

Do patients, families, and healthcare teams benefit from the integration of palliative care in burn intensive care units? Results from a systematic review with narrative synthesis

BACKGROUND

Burn units are intensive care facilities specialized in the treatment of patients with severe burns. As burn injuries have a major impact in physical, psychosocial, and spiritual health, palliative care can be a strengthening component of integrated care.

AIM

To review and appraise the existing evidence about the integration of palliative care in burn intensive care units with respect to (1) the concept, model and design and (2) the benefits and outcomes of this integration.

DESIGN

A systematic review was conducted following PRISMA guidelines. Protocol registered with PROSPERO (CRD42018111676).

DATA SOURCES

Five electronic databases were searched (PubMed/NLM, Web of Science, MEDLINE/TR, Ovid, and CINAHL/EBSCO) until May 2019. A narrative synthesis of the findings was constructed. Hawker et al.'s tool was used for quality appraisal.

RESULTS

A total of 299 articles were identified, of which five were included for analysis involving a total of 7353 individuals. Findings suggest that there may be benefits from integrating palliative care in burn units, specifically in terms of patients' comfort, decision-making processes, and family care. Multidisciplinary teams may experience lower levels of burden as result of integrating palliative care in burn units.

CONCLUSION

This review reflects the challenging setting of burn intensive care units. Evidence from these articles suggests that the integration of palliative care in burn intensive care units improves patients' comfort, decision-making process, and family care. Further research is needed to better understand how the integration of palliative care in burn intensive care units may be fostered and to identify the outcomes of this integration.

Mortality in paediatric burns at the Women's and Children's Hospital (WCH), Adelaide, South Australia: 1960-2017

BACKGROUND

Burn injuries are the third leading cause of preventable death in children worldwide, resulting in over 100 000 annual hospitalisations. In the paediatric population, scalds are the commonest mechanism and burn injuries of greater than 40% total burn surface area (TBSA) are associated with a high mortality and morbidity rate.

AIMS

The aim of this study was to review mortality in paediatric burns in a tertiary burns centre over a 60-year period, providing an understanding of local causes of mortality and directing future clinical research.

METHODS

We reviewed data collected prospectively from patients treated for burn injuries at the WCH from 1960 to 2017. Data of age, gender, mechanism of injury and TBSA were collected. TBSA of 40% and greater were included in the study.

RESULTS

All patients with total burn surface area (TBSA) less than 40% survived. There were a total of 75 patients who sustained burns of or greater than 40% TBSA. Overall mortality was 34% (26 of 75) of which 24 occurred in the 1960s. Of the 21 patients who died of flame burn injuries, 12 of them were described as clothes catching alight from being in close proximity to the source of flame. Average length of stay for patients who did not survive was 7 days (1-26).

CONCLUSION

Mortality has since declined and the prognosis for survival good, even in TBSA of greater than 90%. The investigations in fabric flammability led by Dr Thomas Pressley and Mr Murray Clarke prompted the rewriting of Australian standards for production of children's clothing. This, in combination with advances in paediatric resuscitation, surgical techniques as well as wound care has improved survival rates and outcomes in extensive burn injuries. Future studies focus to see not only better survival rates, but also better aesthetic and functional outcomes in burn survivors.

Clinical Epidemiology of Acute Burn Injuries at Nepal Cleft and Burn Centre, Kathmandu, Nepal

BACKGROUND

Burn injury is a global health problem mainly occurring in developing countries. The Nepal Cleft and Burn Centre at Kirtipur Hospital, Kathmandu, has been providing the acute burn care since 2013 with 7 intensive care unit beds, 30 general beds, and 2 dedicated operating rooms. A similar descriptive study was performed in this center in 2014. These studies will be helpful for developing prevention strategies and monitoring the progress in the standard of care of acute burn patients.

METHOD

This is a descriptive retrospective study of the clinical data of acute burn patients admitted from January 1, 2015 to December 31, 2016.

RESULTS

There were a total of 567 patients who came from 63 of 75 total districts of Nepal. Two hundred ninety-six (52.2%) patients were females and 271 (47.8%) were males. Two thirds of the patients were young adults. Most of the injuries occurred inside the house (72.1%). Flame burn was the most common mode of injury (66%) followed by scald (21.6%). Only 64 (11.3%) patients arrived on the same day of the injury. The longest time elapsed was 60 days with a median of 4.3 days. Range of total body surface area (TBSA) involved was 1% to 95%. The mean and median TBSAs were 25% and 15%, respectively. Range of hospital stay was 1 to 105 days with a median of 13.3 days.A total of 448 surgical procedures were performed in 384 patients (67.7%). A total of 110 (19.4%) patients died at the hospital. Only 13 patients (3%) survived deep burn injury involving 40% or more TBSA with either cadaveric skin allograft or with skin allograft from the live relatives.

CONCLUSIONS

The outcome of burn injuries in Nepal is very poor. Children and females are at high risk. There is a lack of knowledge about burn prevention, proper first aid, and skin donation among the Nepalese population. Delay in presentation and extensive burns are poor prognostic factors. Awareness programs about the proper first aid and the need of a skin bank has to be done to improve the burn scenario in Nepal. Availability of allograft can increase the chances of survivability of patients with extensive burns in Nepal.

Thermal fatalities in Pretoria: A 5-year retrospective review

In South Africa, research on burn mortality has emanated primarily from specialised burn centres and has focused on specific age groups and hospital-based fatalities. This study describes the demographic profile and the pathology of trauma related to burn fatalities as seen at the Pretoria Medico-Legal Laboratory (PTA MLL), a large urban medico-legal mortuary over a 5-year period from January 2011 to December 2015. Mortuary admission records and autopsy reports were used to gather information on demographics, circumstances of injury, apparent manner and cause of death, pathology of burns, toxicology and histology reports and identification of the decedents. RESULTS: Of the 9558 unnatural deaths admitted to the PTA MLL during this time period, 291 (3.0%) of the fatalities met the inclusion criteria. The male:female ratio was 2.9:1. Most fatalities occurred between the ages of 0-4 years. One hundred and forty-two (142) decedents were charred beyond recognition. Identification was confirmed in 134 (94.4%) of the charred remains. In 208 (69.8%) of the cases the manner of death was deemed to be accidental, 23 (7.9%) were homicidal and 11 (3.8%) were suicides. Two hundred and fifty-five (87.4%) of the fatalities were as a result of open flames/fires. Shack fires were responsible for 105 (36%) of all fatalities. In 32 (11.0%) cases of open flame/fire fatalities where death occurred at the scene of injury, more than one fatality was reported per incident. In 122 (79.2%) of scene fatalities, soot deposition was noted in the upper and lower airways. Forty-five (32.8%) of hospital fatalities occurred within 24 h of admission. The most common complications in hospital fatalities were from the respiratory system. The mean blood alcohol concentrations (BAC) was 0.09 g/100 ml. The mean carboxyhaemoglobin concentrations (COHb) was 19.9%. All available cyanide results were negative. CONCLUSION: The study is the first of its kind in South Africa to generate bimodal descriptive statistics for burn fatalities. Approximately 3% of unnatural deaths at the PTA-MLL were due to burns, occurring at a rate of ±1 death per week. The data provides a platform for funding, collaborative research, planning and development of public health programs.

Identification of Potential Transcriptional Biomarkers Differently Expressed in Both S. aureus- and E. coli-Induced Sepsis via Integrated Analysis

Sepsis is a critical, complex medical condition, and the major causative pathogens of sepsis are both Staphylococcus aureus (S. aureus) and Escherichia coli (E. coli). Genome-wide studies identify differentially expressed genes for sepsis. However, the results for the identification of DEGs are inconsistent or discrepant among different studies because of heterogeneity of specimen sources, various data processing methods, or different backgrounds of the samples. To identify potential transcriptional biomarkers that are differently expressed in S. aureus- and E. coli-induced sepsis, we have analyzed four microarray datasets from GEO database and integrated results with bioinformatics tools. 42 and 54 DEGs were identified in both S. aureus and E. coli samples from any three different arrays, respectively. Hierarchical clustering revealed dramatic differences between control and sepsis samples. GO functional annotations suggested that DEGs in the S. aureus group were mainly involved in the responses of both defense and immune regulation, but DEGs in the E. coli group were mainly related to the regulation of endopeptidase activity involved in the apoptotic signaling pathway. Although KEGG showed inflammatory bowel disease in the E. coli group, the KEGG pathway analysis showed that these DEGs were mainly involved in the tumor necrosis factor signaling pathway, fructose metabolism, and mannose metabolism in both S. aureus- and E. coli-induced sepsis. Eight common genes were identified between sepsis patients with either S. aureus or E. coli infection and controls in this study. All the candidate genes were further validated to be differentially expressed by an ex-vivo human blood model, and the relative expression of these genes was performed by qPCR. The qPCR results suggest that GK and PFKFB3 might contribute to the progression of S. aureus-induced sepsis, and CEACAM1, TNFAIP6, PSTPIP2, SOCS3, and IL18RAP might be closely linked with E. coli-induced sepsis. These results provide new viewpoints for the pathogenesis of both sepsis and pathogen identification.

Admission factors associated with the in-hospital mortality of burns patients in resource-constrained settings: A two-year retrospective investigation in a South African adult burns centre

OBJECTIVE

Little is known concerning the factors associated with in-hospital mortality of trauma patients in resource-constrained settings, not least in burns centres. We investigated this question in the adult burns centre at Tygerberg Hospital in Cape Town. We further assessed whether the Abbreviated Burn Severity Index (ABSI) is an accurate predictive score of mortality in this setting.

METHODS

Medical records of all patients admitted with fresh burns over a two-year period (2015 and 2016) were scrutinized to obtain data on patient, injury and admission-related characteristics. Association with in-hospital mortality was investigated for flame burns using logistic regressions and expressed as odds ratios (ORs). The mortality prediction of the ABSI score was assessed using sensitivity and specificity analyses.

RESULTS

Overall the in-hospital mortality was 20.4%. For the 263 flame burns, while crude ORs suggested gender, burn depth, burn size, inhalation injury, and referral status were all individually significantly associated with mortality, only the association with female gender, not being referred and burn size remained significant after adjustments (adjusted ORs = 3.79, 2.86 and 1.11 (per percentage increase in size) respectively). For the ABSI score, sensitivity and specificity were 84% and 86% respectively.

CONCLUSION

In this specialised centre, mortality occurs in one in five patients. It is associated with a few clinical parameters, and can be predicted using the ABSI score.

Burn intensive care treatment over the last 30 years: Improved survival and shift in case-mix

PURPOSE

Mortality in burn intensive care unit (ICU) has been decreasing and treatment appears to be changing. The aims of this study: (1) examine outcome in burn patients, (2) examine changes in ICU indication and (3) explore the influence of a changing case-mix.

METHODS

Retrospective study in patients admitted to ICU (1987-2016). Four groups were specified: major burns (≥15% TBSA), inhalation injury with small injury (<15% TBSA, inhalation injury), watchful waiting (<15% TBSA, without inhalation injury), tender loving care (patients withheld from treatment). Logistic regression was performed to evaluate the relation between case-mix and outcome.

RESULTS

Overall mortality decreased to 7%. Mortality of major burns decreased by 15%. The major burn group decreased by 36%. The inhalation injury and watchful waiting group increased by 9% and 21%. The percentage of ventilated patients increased by 14% in the major burn group. 40% of patients were ventilated in the watchful waiting group.

CONCLUSIONS

After correction for case-mix, survival improved, mainly in the major burn group. Case-mix shifted towards inhalation injury and watchful waiting. Growth of the watchful waiting group is not necessarily harmful. However, the increase of mechanical ventilation could be. We suggest raising awareness for risks and consequences of mechanical ventilation.

Subgroup analysis of continuous renal replacement therapy in severely burned patients

Continuous renal replacement therapy (CRRT) is administered to critically ill patients with renal injuries as renal replacement or renal support. We aimed to identify predictors of mortality among burn patients receiving CRRT, and to investigate clinical differences according to acute kidney injury (AKI) status. This retrospective observational study evaluated 216 Korean burn patients who received CRRT at a burn intensive care unit. Patients were categorized by AKI status. Data were collected regarding arterial pH, laboratory results, ratio of arterial oxygen partial pressure to fractional inspired oxygen (PF ratio), and urine production. Among surviving patients, CRRT duration and the sequential organ failure assessment score were 6.5 days and 4.7 in the non-AKI group and 23.4 days and 7.4 in the AKI group, respectively (p = 0.003 and p = 0.008). On logistic regression analyses, mortality was significantly associated with a pH of <7.2 (p = 0.004), potassium levels of >5.0 mEg/L (p = 0.045), creatinine levels of >2.0 mg/dL (p = 0.011), lactate levels of >2 mmol/L (p<0.001), a PF ratio of <200 (p = 0.042), and a platelet count of <100,000/μL (p<0.001). In the AKI group, poor outcomes were associated with a pH of <7.2, potassium levels of <5.0 mEg/L, lactate levels of >2 mmol/L, and a platelet count of <100,000/μL, while good outcomes were associated with creatinine levels of >2 mg/dL. In the non-AKI group, poor outcomes were associated with lactate levels of >1.5 mmol/L, a PF ratio of <200, and a platelet count of <100,000/μL, while good outcomes were associated with creatinine levels of >1.2 mg/dL. Duration of the CRRT application and the requirement for either renal replacement or renal support at the initiation of CRRT application are important considerations depending on its application.

A model of recovery from inhalation injury and cutaneous burn in ambulatory swine

Inhalation injury commonly accompanies thermal injury, increasing the likelihood of mortality and multiple organ dysfunction (MOD). Large animal models have given important insight into the pathophysiology of this injury; however recapitulating late MOD has remained difficult. The current report describes experiments using a smoke inhalation and burn model, with follow-up of ambulatory swine for 14days with bronchoscopy, CT scanning, and bronchoalveolar lavage fluid (BALF)/blood collection. Clinically, animals cleared airway damage in the first several days after-injury. This was mirrored with erythematous airways on day 2 after-injury, which resolved by the end of the experiment, as did parenchymal damage seen on CT. An initial rise in the protein content of BALF immediately after-injury was followed by a dramatic increase in the concentration of leukocytes. Circulating neutrophils increased while lymphocytes decreased; both correlated with cell counts in BALF. IL8 levels in BALF increased 30-fold and remained elevated throughout the experiment. IL1ra increased circulation immediately after-injury, and afterwards in BALF. Other cytokines (TNFα, IL12) transiently increased in BALF (and decreased in circulation) on day 2. Taken together, these results display a remarkable capability for the lungs to recover in the absence of intubation, with further evidence of the role of cytokines such as IL8 and IL1ra. The possible exacerbating effects of clinical practices such as ventilation and bronchoscopies should be considered.

Return to work after specialised burn care: A two-year prospective follow-up study of the prevalence, predictors and related costs

BACKGROUND

Burn injuries may cause long-term disability and work absence, and therefore result in high healthcare and productivity costs. Up to now, detailed information on return to work (RTW) and productivity costs after burns is lacking.

AIMS

The aim of this study was to accurately assess RTW after burn injuries, to identify predictors of absenteeism and to calculate healthcare and productivity costs from a societal perspective.

METHODS

A prospective cohort study was conducted in the burn centre of Rotterdam, the Netherlands, including all admitted working-age patients from 1 August 2011 to 31 July 2012. At 3, 12 and 24 months post-burn, patients were sent a questionnaire: including the Work and Medical Consumption questionnaire for the assessment of work absence and medical consumption and the EQ-5D-3L plus a cognitive dimension to assess post-burn and pre-burn quality of life (QOL). Cost analyses were from a societal perspective according the micro-costing method and the friction cost method was applied for the calculation of productivity loss. Univariate logistic regression was used to identify predictors of absenteeism at three months.

RESULTS

A total of 104 patients were included in the study with a mean total body surface area (TBSA) burned of 8% (median 4%). 66 respondents were pre-employed, at 3 months 70% was back at work, at 12 months 92% and 8% had not returned to work at time of final follow-up at 24 months. Predictors of absenteeism at 3 months were: TBSA, length of stay, ICU-admission and surgery. Mean costs related to loss in productivity were €11.916 [95% CI 8.930-14.902] and accounted for 30% of total costs in pre-employed respondents in the first two years.

CONCLUSION

This two-year follow-up study demonstrates that burn injuries cause substantial and prolonged productivity loss amongst burn survivors with mixed burn severity. This absenteeism contributes to already high societal costs of burn injuries. Predictors of absenteeism found in this study were primarily fixed patient and treatment related factors, future studies should focus on modifiable factors, in order to improve RTW outcomes. Also, more attention in the rehabilitation trajectory is needed to optimally support RTW in burn survivors.

Modified first world mortality scores can be used in a regional South African burn service with resource limitations

INTRODUCTION

Survival following a major burn is highly dependent on the availability of scare and expensive resources such as critical care services, modern dressings and access to operating theatres. Scoring systems, which predict mortality have been developed and can be used to identify patients in whom the outlay of these resources is futile. The aim of this study was to analyse the mortality at a regional South African burn service and to see if these scoring models developed in a resource rich environment were applicable to our setting.

METHODS

Consecutive admissions to the Edendale burn service, South Africa were collected from patient records over a 2-year period from July 2013 to June 2015. Demographic, burn details and final outcome (lived or died) were captured for statistical analysis. Each patient was scored using the Modified Baux, Coste et al., Belgian Outcome of Burn Injury (BOBI) and Abbreviated Burn Severity Index (ABSI) scores. Validation of models and inferential statistics were done to determine new breakpoints more applicable to our sample.

RESULTS

A total of 748 patients were included in the sample, with a mortality rate of 7.1%. The mean Modified Baux score was 27 (range 1-134), with the new breakpoint of 40 predicting 74% of the mortalities compared to the 42% predicted by the old breakpoint of 75. The mean ABSI score was 4 (range 2-15), with a lower break point of 6 predicting 75% of deaths compared to 42% with the old breakpoint of 8. The mean Coste score for the sample was 12 (range 0-100). With a suggested break point of 85 (predicting 50% mortality), only 6% of mortalities were predicted. The new break point of 17 predicted 91% of deaths. The original break point for the BOBI score was 6 (range 0-7). This included 42% of deaths. With a new breakpoint of 1, 74% of deaths were predicted.

DISCUSSION

Our data has shown that in our environment a significant number of fatalities occur in patients with potentially salvageable burns, and the breakpoints for the mortality prediction scores such as, the Modified Baux score, Coste et al. score, BOBI and ABSI scores are much lower than high-income countries. However these mortality predictive scores can be used in a resource scarce South African setting to triage patients into risk categories by lowering the breakpoints. This may facilitate early and more aggressive management of high-risk burn patients, improving survival rates, as well as efficient and judicious use of critical care and other resources.