Vitamin D in burn-injured patients

Vitamin D Deficiency Is Associated With Increased Length of Stay After Acute Burn Injury: A Multicenter Analysis

In burn patients, vitamin D deficiency has been associated with increased incidence of sepsis and infectious complications. The objective of this study was to assess the impact of vitamin D deficiency in adult burn patients on hospital length of stay (LOS). This was a multicenter retrospective study of adult patients at 7 burn centers admitted over a 3.5-year period, who had a 25-hydroxyvitamin D concentration drawn within the first 7 days of injury. Of 1147 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 < .001), acute kidney injury (AKI) requiring renal replacement therapy (7.3 vs 1.7%, P = .009), more days requiring vasopressors (mean 1.24 vs 0.58 days, P = .008), and fewer ventilator-free days of the first 28 days (mean 22.9 vs 25.1, P < .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, vitamin D deficiency was associated with longer LOS. In conclusion, patients with thermal injuries and vitamin D deficiency on admission have increased LOS and worsened clinical outcomes when compared with patients with nondeficient vitamin D concentrations.

Effect of vitamin D on clinical outcomes in patients with thermal injury

Evaluating complications and mortality risks in burn patients is crucial for effective treatment planning and improving survival rates. This study investigated the relationship between the serum vitamin D level and the clinical outcomes of adult burns patients. This was a prospective cohort of adult patients hospitalized due to thermal burns at a burn centre in the north of Iran. Based on the level of 25 hydroxyvitamin D measured upon admission, patients were divided into two groups of patients with sufficient 25 hydroxyvitamin D level and insufficient 25 hydroxyvitamin D level. Descriptive statistics were used for baseline demographics. Univariate analysis was conducted using Mann-Whitney U, Chi-square, independent samples, and Fisher's exact tests. A multivariate logistic regression was performed to adjust for the effects of confounding variables. Statistical analyses were conducted using SPSS 28.0 software. A total of 220 patients were included in the study. The average total body surface area burned was 30.52 ± 9.34. Patients with insufficient vitamin D levels had longer hospital stays (12.53 vs. 11.45) and longer stays in the intensive care unit (ICU) (3.32 vs. 2.40) than those with appropriate vitamin D levels. Participants with insufficient vitamin D levels exhibited a numerically higher incidence of infections than those with adequate levels (p < 0.05). The multivariate regression found that vitamin D deficiency levels were associated with increased infection rates and prolonged hospital stay. This study suggests that vitamin D deficiency is a significant risk factor for adverse clinical outcomes in burn patients. Further research is needed to confirm these associations and to explore potential interventions to optimize vitamin D status in this patient population.

Surviving Sepsis After Burn Campaign

INTRODUCTION

The Surviving Sepsis Campaign was developed to improve outcomes for all patients with sepsis. Despite sepsis being the primary cause of death after thermal injury, burns have always been excluded from the Surviving Sepsis efforts. To improve sepsis outcomes in burn patients, an international group of burn experts developed the Surviving Sepsis After Burn Campaign (SSABC) as a testable guideline to improve burn sepsis outcomes.

METHODS

The International Society for Burn Injuries (ISBI) reached out to regional or national burn organizations to recommend members to participate in the program. Two members of the ISBI developed specific "patient/population, intervention, comparison and outcome" (PICO) questions that paralleled the 2021 Surviving Sepsis Campaign [1]. SSABC participants were asked to search the current literature and rate its quality for each topic. At the Congress of the ISBI, in Guadalajara, Mexico, August 28, 2022, a majority of the participants met to create "statements" based on the literature. The "summary statements" were then sent to all members for comment with the hope of developing an 80% consensus. After four reviews, a consensus statement for each topic was created or "no consensus" was reported.

RESULTS

The committee developed sixty statements within fourteen topics that provide guidance for the early treatment of sepsis in burn patients. These statements should be used to improve the care of sepsis in burn patients. The statements should not be considered as "static" comments but should rather be used as guidelines for future testing of the best treatments for sepsis in burn patients. They should be updated on a regular basis.

CONCLUSION

Members of the burn community from the around the world have developed the Surviving Sepsis After Burn Campaign guidelines with the goal of improving the outcome of sepsis in burn patients.

Predictive value of perioperative peripheral blood cells counts for bacteremia and 90-day mortality in severe burn patients

OBJECTIVE

Burn bacteremia is related to immune barrier damage, but whether the level of circulating immune cells predicts outcomes in severe burns is still not clear. This study aimed to explore the predictive value of perioperative blood cells of the first surgery after burn for bacteremia and 90-day death.

METHODS

Data from severe burn patients treated at the First Affiliated Hospital of Sun Yat-sen University from 2011 to 2020 were retrospectively analyzed. Data on monocytes (M), lymphocytes (L), white blood cell-to-platelet ratio (WPR), neutrophil-to-lymphocyte ratio (NLR) in peripheral blood and changes in temperature (T-37) were collected at one day before(X0), the first day after (X1) and the third day after (X3) the primary surgery.Univariate and multivariate logistic regression were used to identify the independent risk factors of bacteremia and death within 90 days, which were used to establish the risk prediction models (xbac and x90d-m) in severely burned patients. Severe burn cases from two other burn centers were selected to verify the prediction models.

RESULTS

We analyzed 169 severe burn cases in the training dataset, with a 90-day mortality of 21.3% (36/169); 56 (33.1%) patients experienced burn bacteremia. Higher M0, WPR0, NLR0, NLR3, T3-37, ∆M (M0-M3) and lower M3, L3 were associated with higher risk of bacteremia (P < 0.05). Multivariate regression analysis showed that SOFA0, WPR0, M3, and T3-37 were independently associated with bacteremia. The prediction model for bacteremia Xbac = 0.1809 × SOFA0 + 6.532 × WPR0-1.171 × M3 + 0.6987 × T3-37- 2.297. TBSAB, SOFA0, and ∆M (M0-M3) were independently correlated with 90-day mortality. The risk prediction model X90d-m= 0.055 × TBSAB + 0.301 ×SOFA0 + 1.508 × ∆M - 7.196. External validation suggested that the specificity, sensitivity and AUC of the prediction model Xbac was 90.7%, 62.5% and 0.797, respectively; of the prediction model X90d-m was 69.2%, 90.0% and 0.873, respectively.

CONCLUSION

Peripheral M3, WPR0 and ∆M (M0-M3) during the primary surgery has reasonable predictive ability for bacteremia and 90-day mortality in severe burn patients, which could inform clinical antimicrobial judgment and prognostication.

Cholecalciferol-load films for the treatment of nasal burns caused by cauterization of the hypertrophied inferior turbinate: formulation, in vivo study, and clinical assessment

Nasal turbinate hypertrophy is among the most common nasal obstruction disorders, affecting the patient's quality of life significantly. Endoscopic submucosal diathermy is a prevalent cauterization procedure for treating turbinate hypertrophy. Regrettably, the nasal burn associated with diathermy typically heals slowly causing facial pain and nasal bleeding and possibly resulting in synechiae formation. In the current study, we have developed, for the first time, a polymeric film loaded with cholecalciferol for local treatment of nasal burns. The casting method was used to prepare films of different compositions of polymers such as chitosan, polyvinyl alcohol (PVA), Carbopol 971p (CP971p), and hydroxypropyl methylcellulose (HPMC) as well as a plasticizer. Several characterizations were performed for the cholecalciferol-loaded films (e.g. weight, thickness, content uniformity, surface pH, folding endurance, disintegration time, and in vitro release) to select the optimal formulation. The optimal formulation (F4) displayed compatibility between the used polymers and the drug. In vivo animal study was carried out to assess the healing efficacy of the formulated cholecalciferol-loaded film. The rabbits treated with the cholecalciferol-loaded film demonstrated significantly higher mRNA expression of the growth factor TGF-β and significantly lower mRNA expression of the proinflammatory cytokine TNF-α and IL-1β compared to the plain film treated group and the untreated control group. A randomized, single-blinded, parallel, controlled clinical trial was conducted on 20 patients scheduled to undergo endoscopic submucous diathermy. The results of the clinical study demonstrated significant reductions in facial pain and nasal bleeding scores for the nostrils treated with cholecalciferol-loaded films in comparison to the nostrils treated with plain films. Furthermore, the endoscopic examination showed good healing for 95% of the cholecalciferol-loaded film-treated nostrils. In conclusion, the optimized film can be considered an opportune approach for enhancing the healing rate of nasal burns and thus reducing the downsides of the diathermy procedure.

Nutrition after severe burn injury

PURPOSE OF REVIEW

Severe burn injury causes significant metabolic changes and demands that make nutritional support particularly important. Feeding the severe burn patient is a real challenge in regard to the specific needs and the clinical constraints. This review aims to challenge the existing recommendations in the light of the few recently published data on nutritional support in burn patients.

RECENT FINDINGS

Some key macro- and micro-nutrients have been recently studied in severe burn patients. Repletion, complementation or supplementation of omega-3 fatty acids, vitamin C, vitamin D, antioxidant micronutrients may be promising from a physiologic perspective, but evidence of benefits on hard outcomes is still weak due to the studies' design. On the contrary, the anticipated positive effects of glutamine on the time to discharge, mortality and bacteremias have been disproved in the largest randomized controlled trial investigating glutamine supplementation in burns. An individualized approach in term of nutrients quantity and quality may proof highly valuable and needs to be validated in adequate trials. The combination of nutrition and physical exercises is another studied strategy that could improve muscle outcomes.

SUMMARY

Due to the low number of clinical trials focused on severe burn injury, most often including limited number of patients, developing new evidence-based guidelines is challenging. More high-quality trials are needed to improve the existing recommendations in the very next future.

An update of the effects of vitamins D and C in critical illness

Many critically ill patients are vitamin D and vitamin C deficient and the current international guidelines state that hypovitaminoses should be compensated. However, uncertainty about optimal dosage, timing and indication exists in clinical routine, mainly due to the conflicting evidence. This narrative review discusses both micronutrients with regards to pathophysiology, clinical evidence of benefits, potential risks, and guideline recommendations. Evidence generated from the most recent clinical trials are summarized and discussed. In addition, pragmatic tips for the application of these vitamins in the clinical routine are given. The supplementations of vitamin D and C represent cost-effective and simple interventions with excellent safety profiles. Regarding vitamin D, critically ill individuals require a loading dose to improve 25(OH)D levels within a few days, followed by a daily or weekly maintenance dose, usually higher doses than healthy individuals are needed. For vitamin C, dosages of 100-200 mg/d are recommended for patients receiving parenteral nutrition, but needs may be as high as 2-3 g/d in acutely ill patients.

Periodontal damage after thermal inhalation injury - The impact of high temperature inhalation injury on long term periodontal health

PURPOSE

Thermal inhalation injury is a common, life-threatening problem in burned patients. Whether or not this single event of damage to the oral integrity causes long term health problems is yet to be examined.

MATERIAL AND METHODS

All consecutive burn patients between 2014 and 2017 of Marienhospital Stuttgart (MHS), Germany, with at least 10% of burned skin surface were included and compared. The Periodontal Screening Index as well as Vitamin D levels were examined. Vitamin D has been suspected to contribute to the genesis of periodontitis. Risk factors and subjective oral life quality were prompted.

RESULTS

We included a total of 32 patients, 15 of which had an inhalation injury in their medical history. Risk factors were examined via Renatus' questionnaire. While risk factors were equally distributed in both groups we saw a remarkable difference in periodontal integrity, with the Periodontal Screening Index (PSI) per sextant differing drastically (with inhalation injury: 2.40, without inhalation injury: 1.10, p < 0.001). Patients with an inhalation injury had a mean of 5.2 out of 6 possible sextants with a pathologic PSI (with the median being 6/6), while patients without an inhalation injury had a mean of 1.83 out of 6 (median: 1/6), p < 0.001. The oral health impact profile showed a difference as well, albeit without statistical significance (with inhalation injury: median = 11, without: median = 3.5, p = 0.414). A correlation between Serum Vitamin D levels and periodontal integrity could not be seen in this group.

CONCLUSION

Inhalation injury is a possible cause for periodontitis and hence impacts the quality of life of burned patients.

Prevalence and Impact of Vitamin D Deficiency in Critically Ill Cancer Patients Admitted to the Intensive Care Unit

Vitamin D deficiency is frequent in cancer patients and a risk factor for morbidity and mortality during critical illness. This single-center retrospective study analyzed 25-hydroxyvitamin D levels in critically ill cancer patients (n = 178; hematologic, n = 108; solid, n = 70) enrolled in a prospective ICU registry. The primary analysis was the prevalence of vitamin D deficiency (<20 ng/mL) and the severe deficiency (≤12 ng/mL). Secondary analyses included risk factors for vitamin D deficiency and its impact on ICU, hospital, and 1-year mortality. The prevalence of vitamin D deficiency and severe deficiency was 74% (95% CI: 67-80%) and 54% (95% CI: 47-61%). Younger age, relapsed/refractory disease, and a higher sepsis-related organ failure assessment (SOFA) score were independent risk factors for vitamin D deficiency (p < 0.05). After adjusting for relapsed/refractory disease, infection, the SOFA score, and the early need for life-supporting interventions, severe vitamin D deficiency was an independent predictor of hospital mortality (OR: 2.21, 95% CI: 1.03-4.72, p = 0.04) and 1-year mortality (OR: 3.40, 95% CI: 1.50-7.71, p < 0.01), but not of ICU mortality. Conclusion: Vitamin D deficiency is common in critically ill cancer patients requiring ICU admission, but its impact on short-term mortality in this group is uncertain. The observed association of severe vitamin D deficiency with the post-ICU outcome warrants clinical consideration and further study.

25-Hydroxycholecalciferol Concentration Is Associated with Protein Loss and Serum Albumin Level during the Acute Phase of Burn Injury

Background: Burned patients have an increased need for vitamin D supply related to the maintenance of calcium–phosphate homeostasis and the regulation of cell proliferation/differentiation. This study aimed to analyze the concentration of 25-hydroxycholecalciferol and its relationship with severe condition after burn injury. Methods: 126 patients were enrolled in the study. Patients were qualified due to thermal burns—over 10% of total body surface area. On the day of admission, the following parameters were assessed: 25-hydroxycholecalciferol concentration, total protein concentration, albumin concentration, aspartate transaminase activity, alanine transaminase activity, albumin concentration, creatinine concentration, c-reactive protein concentration, procalcitonin concentration, and interleukin-6 concentration. Results: Almost all patients (92%) in the study group had an improper level of vitamin D (<30 ng/mL), with the average of 11.6 ± 10.7 ng/mL; 17.5% of patients had levels of vitamin D below the limit of determination—under 3 ng/mL. The study showed that there are several factors which correlated with vitamin D concentration during the acute phase of burn injury, including: total protein (r = 0.42, p < 0.01), albumin, (r = 0.62, p < 0.01), percentage of body burns (r = 0.36, p < 0.05), aspartate aminotransferase (r = 0.21, p < 0.05), and c-reactive protein (r = 0.22, p < 0.05). We did not find any significant correlation between vitamin D concentration and body mass index. Conclusions: The burn injury has an enormous impact on the metabolism and the risk factors of the deficiency for the general population (BMI) have an effect on burned patients. Our study showed that concentration of 25-hydroxycholecalciferol is strongly correlated with serum albumin level, even more than total burn surface area and burn degrees as expected. We suspect that increased supplementation of vitamin D should be based on albumin level and last until albumin levels are balanced.

The association between vitamin D levels and burn factors in different burn types

Background

Patients with burns present with different clinical features depending on the types of burn injury and burn patients with lower levels of vitamin D have worse prognoses and more complications. The study aims to investigate the association between vitamin D levels and burn factors according to each burn type in relation to early intensive rehabilitation therapy initiated for inpatients with burns.

Methods

In this retrospective study, we enrolled 757 of 1716 inpatients who underwent rehabilitative therapy between May 2013 and April 2017. Burn types were divided into flame burn, electrical burn and other burns, including scalding, contact and chemical burns. Age, burned body surface area (BSA), wound healing time (WHT), length of hospital stay (LOS) and body mass index were analysed between vitamin D deficient and non-deficient patient groups using Student’s t-tests, or Mann-Whitney U test and among three burn types using one-way analysis of variance (ANOVA) or Kruskal-Wallis one-way ANOVA. The relationship between vitamin D levels and burn factors was evaluated using Pearson's or Spearman's correlation coefficient tests, and multiple linear regression analysis in different burn groups.

Results

In total, 88.9% patients were vitamin D deficient, and these patients had a larger burned BSA (p = 0.015) and longer WHT and LOS (all p < 0.001) than non-deficient patients. Burned BSA, WHT and vitamin D levels showed significant differences in their mean values according to three burn types (all p < 0.001). WHT was a communal factor significantly associated with vitamin D levels in all three burn types (p < 0.05). The WHT cut-off points to predict vitamin D deficiency were 55 days for flame burn (p < 0.001) and 62.5 days for electrical burn (p = 0.001).

Conclusions

WHT across all three burn types was a common factor associated with vitamin D levels for inpatients with burns who had undergone rehabilitative therapy. Electrical burn patients with vitamin D deficiency, even those with a low burned BSA percentage, showed prolonged wound healing over a two-month post-burn period. Independent of burned BSA, nutritional intervention concerning vitamin D in relation to burn wound healing should be considered to guide early initiation of intensive rehabilitation therapy.

Impact of insufficient admission vitamin D serum concentrations on sepsis incidence and clinical outcomes in patients with thermal injury

INTRODUCTION

In burn patients, vitamin D has been studied primarily in the pediatric population and focused mainly on the correlation with bone marker measurements and incidence of fractures. There is an association between vitamin D deficiency and the development of sepsis in non-burn critically-ill patients. However, there is limited data on vitamin D concentrations and clinical outcomes in burn patients, such as sepsis. The objective of this study is to evaluate the impact of vitamin D concentrations on the incidence of sepsis in adult burn patients.

METHODS

This was a retrospective cohort of patients 18 years of age and older admitted between February 1, 2016 and February 28, 2018 to an American Burn Association (ABA) verified burn center with diagnosis of burn injury. The primary endpoint was incidence of sepsis using the ABA 2007 Sepsis Consensus Criteria between patients with adequate vitamin D concentrations (25[OH]D > 20 ng/mL) and insufficient vitamin D (25[OH]D < 20 ng/mL) concentrations measured on admission. Descriptive statistics were used for baseline demographics. Univariate analysis was conducted using Chi-square, Fisher's exact test or Mann-Whitney U test, as appropriate.

RESULTS

A total of 115 patients were screened and 107 patients were included in this study. Sixty three patients (58.9%) had insufficient vitamin D concentrations. Patient demographics were overall similar between groups. The median total body surface area burned was 14.6% in the insufficient vitamin D group, and 12.1% in the adequate vitamin D group (p = 0.2). There was a trend towards greater incidence of sepsis in the insufficient vitamin D group in the univariate analysis (15.9% vs. 4.5%, p = 0.07). The multivariable logistic regression analysis found that adequate vitamin D concentrations was associated with a reduction in the incidence of sepsis (OR 0.10, 95% CI 0.01-0.88). The insufficient vitamin D group had a longer median hospital LOS (19 [IQR 11-37] vs 11.5 [IQR 7-20] days, p < 0.05), longer intensive care unit LOS (17 [IQR 10-37] vs 5 [IQR 2-19.5] days, p < 0.05) and fewer ventilator free days (26 [IQR 18-28] vs 28 [IQR 27-28] days, p < 0.05). There was no difference in mortality between groups (p = 0.69).

CONCLUSIONS

Patients with adequate vitamin D concentrations on admission had a reduction in the incidence of sepsis as compared to patients with insufficient vitamin D concentrations. Insufficient vitamin D concentrations may contribute to other worsened clinical outcomes in burn patients. Our findings set the stage for future, multicenter studies to determine the role of vitamin D supplementation in burn patients.

The Association Between Postburn Vitamin D Deficiency and the Biomechanical Properties of Hypertrophic Scars

Fibroblasts, keratinocytes, mast cells, and other cells participate in hypertrophic scar formation and express the vitamin D receptor. We investigated the association between vitamin D deficiency and the biomechanical properties of hypertrophic burn scars. This cross-sectional study analyzed 486 participants enrolled from May 1, 2013 to April 30, 2017. When complete wound healing was agreed with by the two opinions, blood sampling and scar evaluation were performed. The values of melanin and erythema, trans-epidermal water loss (TEWL), and scar distensibility and elasticity were measured using pigment- and TEWL-measuring devices and a suction skin elasticity meter. 25(OH) vitamin D deficiency was defined as plasma level of <20 ng/ml. The vitamin D-deficient patients had significantly higher mean values of scar melanin and TEWL (P = .032, P = .007), whereas scar erythema level was similar. They also showed significantly lower values of Uf (final distensibility; P < .001), Ua/Uf (gross elasticity; P < .001) and Ur/Uf (biological elasticity; P = .014), and higher value of Uv/Ue (viscoelasticity or potency against interstitial fluid shift; P = .016). In multiple linear regression analysis, Uf, Ua/Uf, Uv/Ue, and Ur/Uf were significantly affected by 25(OH)-vitamin D level in deficient patients (Uf, P = .017; Ua/Uf, P = .045; Uv/Ue, P = .024; Ur/Uf, P = .021). Our results demonstrated that vitamin D deficiency was significantly related to increased pigmentation, decreased skin barrier function, low scar distensibility and elasticity, and slow interstitial fluid movement in burn patients.

Vitamin D and critical illness: what endocrinology can learn from intensive care and vice versa

The prevalence of vitamin D deficiency in intensive care units ranges typically between 40 and 70%. There are many reasons for being or becoming deficient in the ICU. Hepatic, parathyroid and renal dysfunction additionally increases the risk for developing vitamin D deficiency. Moreover, therapeutic interventions like fluid resuscitation, dialysis, surgery, extracorporeal membrane oxygenation, cardiopulmonary bypass and plasma exchange may significantly reduce vitamin D levels. Many observational studies have consistently shown an association between low vitamin D levels and poor clinical outcomes in critically ill adults and children, including excess mortality and morbidity such as acute kidney injury, acute respiratory failure, duration of mechanical ventilation and sepsis. It is biologically plausible that vitamin D deficiency is an important and modifiable contributor to poor prognosis during and after critical illness. Although vitamin D supplementation is inexpensive, simple and has an excellent safety profile, testing for and treating vitamin D deficiency is currently not routinely performed. Overall, less than 800 patients have been included in RCTs worldwide, but the available data suggest that high-dose vitamin D supplementation could be beneficial. Two large RCTs in Europe and the United States, together aiming to recruit >5000 patients, have started in 2017, and will greatly improve our knowledge in this field. This review aims to summarize current knowledge in this interdisciplinary topic and give an outlook on its highly dynamic future.

Additional Vitamin and Mineral Support for Patients with Severe Burns: A Nationwide Experience from a Catastrophic Color-Dust Explosion Event in Taiwan

Major burn injuries, which encompass ≥20% of the total body surface area (TBSA), are the most severe form of trauma because of the stress response they provoke, which includes hypermetabolism, muscle wasting, and stress-induced diabetes. In 2015, a color-dust explosion disaster occurred in the Formosa Fun Coast of Taiwan and injured 499 people, who were transferred via a nationwide emergency delivery system. Some recommendations are currently available regarding vitamin and mineral support for wound healing and recovery in severe burns, but there is a lack of evidence to confirm the benefits. Thus, the current study aimed to investigate the effects of additional vitamin and mineral support for patients with severe burn injuries. Sixty-one hospitalized individuals with major burns (full thickness and ≥20% TBSA) were classified into the supplement (n = 30) and control (n = 31) groups, according to whether they received supplementation with additional vitamins, calcium, and magnesium. There were significant differences between the supplement and control groups in the incidence of wound infection (30.0% vs. 77.4%, p < 0.001), sepsis (13.3% vs. 41.9%, p = 0.021), and hospitalization days (51.80 vs. 76.81, p = 0.025). After adjustment, logistic regression analysis revealed that, compared to those in the control group, patients in the supplement group had a lower risk for wound infection (OR 0.11; 95% CI 0.03–0.43; p = 0.002) and sepsis (OR 0.09; 95% CI 0.01–0.61; p = 0.014). Supplementation of multiple vitamins, calcium, and magnesium reduced the risk of wound infection and sepsis, shortened the time of hospitalization, and can be considered for use in major burns.