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Pérez-Torres D, Martín-Luengo AI, Cuenca-Rubio C, Berezo-García JÁ, Díaz-Rodríguez C, Canas-Pérez I, Fernández-Rodríguez ML, Colmenero-Calleja C, Sánchez-Ballesteros J, Blanco-Schweizer P, Ticona-Espinoza TG, Piqueras-Pérez JM. Selective decontamination of the digestive tract in a burns unit reduces the incidence of hospital-acquired infections: A retrospective before-and-after cohort study. Med Intensiva 2024:S2173-5727(24)00139-5. [PMID: 38897897 DOI: 10.1016/j.medine.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 05/17/2024] [Indexed: 06/21/2024]
Abstract
OBJECTIVE To evaluate the effect of selective decontamination of the digestive tract (SDD) on hospital-acquired infections (HAIs) in patients with acute burn injury requiring admission to a Burns Unit (BU). DESIGN Retrospective before-and-after cohort study, between January 2017 and June 2023. SDD was implemented in March 2019, dividing patients into two groups. SETTING Four-bed BU, in a referral University Hospital in Spain. PATIENTS All the patients admitted during the study period were eligible for analysis. Patients who died or were discharged within 48hours of admission, and patients with an estimated survival less than 10% not considered for full escalation of therapy were excluded. INTERVENTION SDD comprised the administration of a 4-day course of an intravenous antibiotic, and an oral suspension and oral topical paste of non-absorbable antibiotics during the stay in the BU. MAIN VARIABLE OF INTEREST Incidence of HAIs during the stay in the BU. SECONDARY OUTCOMES incidence of specific types of infections by site (bacteremia, pneumonia, skin and soft tissue infection) and microorganism (Gram-positive, Gram-negative, fungi), and safety endpoints. RESULTS We analyzed 72 patients: 27 did not receive SDD, and 45 received SDD. The number of patients who developed HAIs were 21 (77.8%) and 21 (46.7%) in the non-SDD and the SDD groups, respectively (p=0.009). The number of hospital-acquired infectious episodes were 2.52 (1.21-3.82) and 1.13 (0.54-1.73), respectively (p=0.029). CONCLUSIONS SDD was associated with a reduced incidence of bacterial HAIs and a decrease in the number of infectious episodes per patient.
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Affiliation(s)
- David Pérez-Torres
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain; Unidad de Quemados, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain; Programa de Optimización del Uso de Antimicrobianos (PROA), Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain.
| | - Ana Isabel Martín-Luengo
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain; Unidad de Quemados, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - Cristina Cuenca-Rubio
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - José Ángel Berezo-García
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain; Unidad de Quemados, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - Cristina Díaz-Rodríguez
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain; Unidad de Quemados, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - Isabel Canas-Pérez
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - María Lorena Fernández-Rodríguez
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain; Unidad de Quemados, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - Cristina Colmenero-Calleja
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - Jesús Sánchez-Ballesteros
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain; Unidad de Quemados, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - Pablo Blanco-Schweizer
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain; Unidad de Quemados, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - Thalia Gloria Ticona-Espinoza
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - José María Piqueras-Pérez
- Unidad de Quemados, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain; Servicio de Cirugía Plástica, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain
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Xiao S, Pan Z, Li H, Zhang Y, Li T, Zhang H, Ning J. The impact of inhalation injury on fluid resuscitation in major burn patients: a 10-year multicenter retrospective study. Eur J Med Res 2024; 29:283. [PMID: 38735989 PMCID: PMC11089777 DOI: 10.1186/s40001-024-01857-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 04/23/2024] [Indexed: 05/14/2024] Open
Abstract
BACKGROUND It remains unclear whether additional fluid supplementation is necessary during the acute resuscitation period for patients with combined inhalational injury (INHI) under the guidance of the Third Military Medical University (TMMU) protocol. METHODS A 10-year multicenter, retrospective cohort study, involved patients with burns ≥ 50% total burn surface area (TBSA) was conducted. The effect of INHI, INHI severity, and tracheotomy on the fluid management in burn patients was assessed. Cumulative fluid administration, cumulative urine output, and cumulative fluid retention within 72 h were collected and systematically analyzed. RESULTS A total of 108 patients were included in the analysis, 85 with concomitant INHI and 23 with thermal burn alone. There was no significant difference in total fluid administration during the 72-h post-burn between the INHI and non-INHI groups. Although no difference in the urine output and fluid retention was shown in the first 24 h, the INHI group had a significantly lower cumulative urine output and a higher cumulative fluid retention in the 48-h and 72-h post-burn (all p < 0.05). In addition, patients with severe INHI exhibited a significantly elevated incidence of complications (Pneumonia, 47.0% vs. 11.8%, p = 0.012), (AKI, 23.5% vs. 2.9%, p = 0.037). For patients with combined INHI, neither the severity of INHI nor the presence of a tracheotomy had any significant influence on fluid management during the acute resuscitation period. CONCLUSIONS Additional fluid administration may be unnecessary in major burn patients with INHI under the guidance of the TMMU protocol.
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Affiliation(s)
- Shuao Xiao
- Department of Plastic and Burn Surgery, Second Affiliated Hospital of Air Force Medical University, 569 Xinsi Road, Baqiao District, Xi'an, 710038, China
| | - Zeping Pan
- Department of Plastic and Burn Surgery, Joint Logistics Support Force of Chinese PLA, No. 927 Hospital Bao Yun Road, Puer, 665000, Yunnan, China
| | - Hang Li
- Department of Plastic and Burn Surgery, Second Affiliated Hospital of Air Force Medical University, 569 Xinsi Road, Baqiao District, Xi'an, 710038, China
| | - Yuheng Zhang
- Department of Orthopedics, Western Theater Air Force Hospital of PLA, Chengdu, 610011, China
| | - Tian Li
- School of Basic Medicine, Fourth Military Medical University, 169 Changle West Rd, Xi'an, 710032, China.
| | - Hao Zhang
- Department of Plastic and Burn Surgery, Joint Logistics Support Force of Chinese PLA, No. 927 Hospital Bao Yun Road, Puer, 665000, Yunnan, China.
| | - Jinbin Ning
- Department of Plastic and Burn Surgery, Second Affiliated Hospital of Air Force Medical University, 569 Xinsi Road, Baqiao District, Xi'an, 710038, China.
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Herdy Guerra Avila JE, Aniceto Santana L, Rabelo Suzuki D, Maldaner da Silva VZ, Duarte ML, Mizusaki Imoto A, Ferreira Amorim F. Frequency, complications, and mortality of inhalation injury in burn patients: A systematic review and meta-analysis protocol. PLoS One 2024; 19:e0295318. [PMID: 38652713 PMCID: PMC11037524 DOI: 10.1371/journal.pone.0295318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 11/19/2023] [Indexed: 04/25/2024] Open
Abstract
INTRODUCTION Burns are tissue traumas caused by energy transfer and occur with a variable inflammatory response. The consequences of burns represent a public health problem worldwide. Inhalation injury (II) is a severity factor when associated with burn, leading to a worse prognosis. Its treatment is complex and often involves invasive mechanical ventilation (IMV). The primary purpose of this study will be to assess the evidence regarding the frequency and mortality of II in burn patients. The secondary purposes will be to assess the evidence regarding the association between IIs and respiratory complications (pneumonia, airway obstruction, acute respiratory failure, acute respiratory distress syndrome), need for IMV and complications in other organ systems, and highlight factors associated with IIs in burn patients and prognostic factors associated with acute respiratory failure, need for IMV and mortality of II in burn patients. METHODS This is a systematic literature review and meta-analysis, according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). PubMed/MEDLINE, Embase, LILACS/VHL, Scopus, Web of Science, and CINAHL databases will be consulted without language restrictions and publication date. Studies presenting incomplete data and patients under 19 years of age will be excluded. Data will be synthesized through continuous (mean and standard deviation) and dichotomous (relative risk) variables and the total number of participants. The means, sample sizes, standard deviations from the mean, and relative risks will be entered into the Review Manager web analysis software (The Cochrane Collaboration). DISCUSSION Despite the extensive experience managing IIs in burn patients, they still represent an important cause of morbidity and mortality. Diagnosis and accurate measurement of its damage are complex, and therapies are essentially based on supportive measures. Considering the challenge, their impact, and their potential severity, IIs represent a promising area for research, needing further studies to understand and contribute to its better evolution. The protocol of this review is registered on the International prospective register of systematic reviews platform of the Center for Revisions and Disclosure of the University of York, United Kingdom (https://www.crd.york.ac.uk/prospero), under number RD42022343944.
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Affiliation(s)
- Juliana Elvira Herdy Guerra Avila
- Culdade de Ciências de Saúde - Universidade de Brasília-UnB, Programa de Pós-Graduação em Ciências da Saúde, FaBrasilia (DF), Brazil
| | - Levy Aniceto Santana
- Programa de Pós-Graduação em Ciências da Saúde, Escola Superior de Ciências da Saúde (ESCS), Brasilia (DF), Brazil
| | - Denise Rabelo Suzuki
- Programa de Pós-Graduação em Ciências da Saúde, Coordenação de Cursos Pós-Graduação Stricto Sensu, Escola Superior de Ciências da Saúde (ESCS), Brasilia (DF), Brazil
| | - Vinícius Zacarias Maldaner da Silva
- Universidade de Brasília, Brasilia (DF), Brazil and Programa de Pós Graduação em Ciências do Movimento Humano e Reabilitação, Universidade Evangélica de Goiás, Goiás, Brazil
| | - Marcio Luís Duarte
- Radiology Professor of Universidade de Ribeirão Preto, Campus Guarujá, Guarujá-SP, Brazil
| | - Aline Mizusaki Imoto
- Programa de Pós-Graduação em Ciências da Saúde, Coordenação de Cursos Pós-Graduação Stricto Sensu, Escola Superior de Ciências da Saúde (ESCS), Brasilia (DF), Brazil
| | - Fábio Ferreira Amorim
- Programa de Pós-Graduação em Ciências da Saúde, Coordenação de Pesquisa e Comunicação Científica, Escola Superior de Ciências da Saúde (ESCS), Brasilia (DF), Brazil
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Yu J, Kong YG, Park JY, Kim HY, Kwon M, Han YJ, Lee N, Seo YJ, Kim YK. Chart-Derived Frailty Index and 90-Day Mortality After Burn Surgery. J Surg Res 2024; 293:291-299. [PMID: 37806214 DOI: 10.1016/j.jss.2023.08.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 07/31/2023] [Accepted: 08/29/2023] [Indexed: 10/10/2023]
Abstract
INTRODUCTION Frailty is a reduced physiological reserve condition associated with postoperative morbidity and mortality. The chart-derived frailty index (CFI) can measure frailty using demographic and laboratory values. We evaluated the association of preoperative CFI with 90-d mortality after burn surgery. METHODS This large retrospective study included burn intensive care unit (ICU) patients between 2012 and 2021 and calculated CFI using the sum of the following five variables: age >70 y, body mass index <18.5 kg/m2, hematocrit <35%, albumin <3.4 g/dL, and creatinine >2.0 mg/dL; high CFI was a score of 3-5. Postoperative 90-d mortality rate, major adverse cardiac events (MACE), pneumonia, continuous renal replacement therapy (CRRT) requirement, and prolonged ICU stay (>60 d) were evaluated. RESULTS Of 1118 patients, 147 (13.1%) had high CFI. High CFI patients had a higher 90-d mortality rate than did low CFI patients (38.8% versus 22.6%, P < 0.001). A high CFI was significantly associated with postoperative 90-d mortality (hazard ratio = 4.124, 95% confidence interval = 2.980-5.707, P < 0.001) in multivariate Cox regression analysis. Kaplan-Meier analysis revealed significantly different postoperative 90-d mortality rates between patients with high and low CFIs (log-rank test, P < 0.001). Incidences of postoperative MACE, pneumonia, the need for CRRT, and prolonged ICU stay were significantly higher in patients with high CFIs than in those with low CFIs. CONCLUSIONS Preoperative high CFI was associated with increased 90-d mortality, MACE, pneumonia, CRRT requirement, and ICU stay following burn surgery.
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Affiliation(s)
- Jihion Yu
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yu-Gyeong Kong
- Department of Anesthesiology and Pain Medicine, CHA Gangnam Medical Center, CHA University School of Medicine, Seoul, Republic of Korea
| | - Jun-Young Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hee Yeong Kim
- Department of Anesthesiology and Pain Medicine, National Medical Center, Seoul, Republic of Korea
| | - Miyoung Kwon
- Department of Anesthesiology and Pain Medicine, National Medical Center, Seoul, Republic of Korea
| | - Yun Jae Han
- Department of Anesthesiology and Pain Medicine, National Medical Center, Seoul, Republic of Korea
| | - Narae Lee
- Department of Anesthesiology and Pain Medicine, Hangang Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Young Joo Seo
- Department of Anesthesiology and Pain Medicine, Hangang Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea.
| | - Young-Kug Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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Christel H, Aubry SC, Florence T, Nora EB, Lisa W, Tomislav P, Frédéric L. Optimization of intravenous administration of hydroxocobalamin in pediatric emergencies - HYDROX-OPTIMIS study. Int Emerg Nurs 2023; 71:101353. [PMID: 37871551 DOI: 10.1016/j.ienj.2023.101353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 08/28/2023] [Accepted: 09/10/2023] [Indexed: 10/25/2023]
Abstract
INTRODUCTION Procedures to prepare and infuse intravenous drugs are poorly documented. OBJECTIVE To determinate the optimal mode of hydroxocobalamin administration in children in emergency care. METHODS We identified three modes of administration: (1) connect infusion tubing to the vial, start the infusion and interrupt it when the desired dose has been delivered; (2) remove from the vial the volume corresponding to the excessive dose and connect infusion tubing and (3) extract from the vial the required volume to be delivered and infuse directly. EXPERIMENTAL STUDY 25 nurses performed each of these three procedures for children weighting 15 and 30 kg. Speed and precision were primary end-points; ease, safety and drug economy were secondary end-points. RESULTS Mode 3 was the fastest (42[37-61] sec) followed by modes 1 and 2 (p < 0.05). Mode 3 was the most precise (100[100-100]%) followed by modes 1 and 2 (p = 0.001). Mode 3 was the easiest (10.0[9.0-10.0]) followed by modes 2 and 3 (p = 0.001). Modes 1 and 3 allowed administration of a second dose whereas mode 2 did not. CONCLUSION Taking the required volume from the vial and infuse directly was the fastest, the most precise, the easiest and most economical mode of administration. It should be recommended.
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Affiliation(s)
- Hilaire Christel
- SAMU 93 - UF Research-Teaching-Quality University Paris 13, Sorbonne Paris Cité, Inserm U942 Avicenne Hospital, 125, rue de Stalingrad, 93009 Bobigny, France.
| | - Saint-Cast Aubry
- SAMU 93 - UF Research-Teaching-Quality University Paris 13, Sorbonne Paris Cité, Inserm U942 Avicenne Hospital, 125, rue de Stalingrad, 93009 Bobigny, France.
| | | | - El Barrak Nora
- SAMU 93 - UF Research-Teaching-Quality University Paris 13, Sorbonne Paris Cité, Inserm U942 Avicenne Hospital, 125, rue de Stalingrad, 93009 Bobigny, France.
| | - Weisslinger Lisa
- SAMU 93 - UF Research-Teaching-Quality University Paris 13, Sorbonne Paris Cité, Inserm U942 Avicenne Hospital, 125, rue de Stalingrad, 93009 Bobigny, France.
| | - Petrovic Tomislav
- SAMU 93 - UF Research-Teaching-Quality University Paris 13, Sorbonne Paris Cité, Inserm U942 Avicenne Hospital, 125, rue de Stalingrad, 93009 Bobigny, France.
| | - Lapostolle Frédéric
- SAMU 93 - UF Research-Teaching-Quality University Paris 13, Sorbonne Paris Cité, Inserm U942 Avicenne Hospital, 125, rue de Stalingrad, 93009 Bobigny, France.
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Niimi Y, Baljinnyam T, Fukuda S, Andersen CR, Salsbury JR, Lee JO, Prough DS, Enkhbaatar P. Effects of nebulized adipose-derived mesenchymal stem cells on acute lung injury following smoke inhalation in sheep. Int Immunopharmacol 2023; 123:110638. [PMID: 37494838 DOI: 10.1016/j.intimp.2023.110638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/07/2023] [Accepted: 07/09/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Treatment of ARDS caused by smoke inhalation is challenging with no specific therapies available. The aim of this study was to test the efficacy of nebulized adipose-derived mesenchymal stem cells (ASCs) in a well-characterized, clinically relevant ovine model of smoke inhalation injury. MATERIAL AND METHODS Fourteen female Merino sheep were surgically instrumented 5-7 days prior to study. After induction of acute lung injury (ALI) by cooled cotton smoke insufflation into the lungs (under anesthesia and analgesia), sheep were placed on a mechanical ventilator for 48 hrs and monitored for cardiopulmonary hemodynamics in a conscious state. ASCs were isolated from ovine adipose tissue. Sheep were randomly allocated to two groups after smoke injury: 1) ASCs group (n = 6): 10 million ASCs were nebulized into the airway at 1 hr post-injury; and 2) Control group (n = 8): Nebulized with saline into the airways at 1 hr post-injury. ASCs were labeled with green fluorescent protein (GFP) to trace cells within the lung. ASCs viability was determined in bronchoalveolar lavage fluid (BALF). RESULTS PaO2/FiO2 in the ASCs group was significantly higher than in the control group (p = 0.001) at 24 hrs. Oxygenation index: (mean airway pressure × FiO2/PaO2) was significantly lower in the ASCs group at 36 hr (p = 0.003). Pulmonary shunt fraction tended to be lower in the ASCs group as compared to the control group. GFP-labelled ASCs were found on the surface of trachea epithelium 48 hrs after injury. The viability of ASCs in BALF was significantly lower than those exposed to the control vehicle solution. CONCLUSION Nebulized ASCs moderately improved pulmonary function and delayed the onset of ARDS.
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Affiliation(s)
- Yosuke Niimi
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-1102, USA
| | - Tuvshintugs Baljinnyam
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-1102, USA; Department of Pharmacology and Toxicology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-1102, USA
| | - Satoshi Fukuda
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-1102, USA
| | - Clark R Andersen
- Department of Biostatistics, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-1102, USA
| | - John R Salsbury
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-1102, USA
| | - Jong O Lee
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-1102, USA
| | - Donald S Prough
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-1102, USA
| | - Perenlei Enkhbaatar
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-1102, USA.
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Hu C, Ji H, Gong Y, Yang X, Jia Y, Liu Y, Ji G, Wang X, Wang M. Wet-adhesive γ-PGA/ε-PLL hydrogel loaded with EGF for tracheal epithelial injury repair. J Mater Chem B 2023; 11:8666-8678. [PMID: 37622289 DOI: 10.1039/d3tb01550e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
Following the global COVID-19 pandemic, the incidence of tracheal epithelial injury is increasing. However, the repair of tracheal epithelial injury remains a challenge due to the slow renewal rate of tracheal epithelial cells (TECs). In traditional nebulized inhalation treatments, drugs are enriched in the lungs or absorbed into the blood, reducing drug concentration at the tracheal injury site. In this study, we prepared an epidermal growth factor (EGF)-loaded gamma-polyglutamic acid (γ-PGA)/epsilon-poly-L-lysine (ε-PLL) (PP) hydrogel (EGF@PP) to promote the repair of tracheal epithelial injury. Epidermal growth factor promotes the proliferation of TECs and enhances vascularization, thereby accelerating injury repair. The PP hydrogel exhibits outstanding wet adhesion, slow drug release, and antibacterial and anti-inflammatory properties, making it suitable for application in the airways and creating an environment conducive to epithelial repair. Here, we established a rabbit model of tracheal injury using a laser to destroy the tracheal epithelium and delivered EGF@PP powder to the injury site under fiberoptic bronchoscopy guidance. Our findings revealed that this was an effective therapeutic strategy for accelerating the repair of tracheal epithelial injury.
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Affiliation(s)
- Chuang Hu
- Department of Thoracic Surgery, Shanghai Key Laboratory of Tissue Engineering, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200001, China.
| | - Haoran Ji
- Department of Thoracic Surgery, Shanghai Key Laboratory of Tissue Engineering, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200001, China.
| | - Yan Gong
- Department of Thoracic Surgery, Shanghai Key Laboratory of Tissue Engineering, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200001, China.
| | - Xuhui Yang
- Department of Thoracic Surgery, Shanghai Key Laboratory of Tissue Engineering, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200001, China.
| | - Yunxuan Jia
- Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200001, China
| | - Yuanhao Liu
- Department of Thoracic Surgery, Shanghai Key Laboratory of Tissue Engineering, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200001, China.
| | - Guangyu Ji
- Department of Thoracic Surgery, Shanghai Key Laboratory of Tissue Engineering, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200001, China.
| | - Xiansong Wang
- Department of Thoracic Surgery, Shanghai Key Laboratory of Tissue Engineering, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200001, China.
| | - Mingsong Wang
- Department of Thoracic Surgery, Shanghai Key Laboratory of Tissue Engineering, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200001, China.
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Habarth-Morales TE, Rios-Diaz AJ, Isch E, Qi L, Ni R, Caterson EJ. Increased Incidence of Suspected Smoke Inhalation During the Coronavirus Disease 2019 Pandemic: A National Database Study. J Burn Care Res 2023; 44:945-948. [PMID: 36260537 PMCID: PMC9620764 DOI: 10.1093/jbcr/irac155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Indexed: 11/13/2022]
Abstract
The COVID-19 pandemic has forced many Americans to adapt their daily routines. In 2020, there was a significant increase in house fires according to the National Fire Prevention Association (NFPA). The objective of this study was to characterize the changes in suspected smoke inhalations (SSIs) during the first year of the pandemic in the National Emergency Medical Services Information System (NEMSIS). The NEMSIS database was queried for all EMS transports captured between 2017 and 2020. Differences in the incidences of SSIs and fire dispatches in 2020 were estimated using Poisson regression models. There was a 13.4% increase in the incidence of fire dispatches and a 15% increase in SSIs transported in 2020 compared to the previous 3 years. The incidence rate ratio of both fire dispatches (1.271; 95% CI: 1.254-1.288; P < .001) and SSI (1.152; 95% CI: 1.070-1.241; P < .001) was significantly elevated in 2020. The increases in fire dispatches and SSIs observed in the NEMSIS database are in concordance with other literature indicating the increase in fire incidence and morbidity observed during the pandemic. These results should inform fire prevention outreach efforts and resource allocation in burn centers in the event of future pandemic.
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Affiliation(s)
- Theodore E Habarth-Morales
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States of America
- Division of Plastic Surgery, Department of Surgery, Nemours Children’s Health, Wilmington, DE, United States of America
| | - Arturo J Rios-Diaz
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, United States of America
| | - Emily Isch
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, United States of America
| | - Lucy Qi
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States of America
| | - Rose Ni
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States of America
| | - Edward J Caterson
- Division of Plastic Surgery, Department of Surgery, Nemours Children’s Health, Wilmington, DE, United States of America
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9
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Analyses of physical factors that contribute to the blood carboxyhemoglobin saturation in autopsy cases of house fire fatalities. Leg Med (Tokyo) 2023; 62:102233. [PMID: 36898281 DOI: 10.1016/j.legalmed.2023.102233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 02/11/2023] [Accepted: 03/01/2023] [Indexed: 03/08/2023]
Abstract
The authors analyzed data from forensic autopsies of 75 patients who died as a result of house fires to clarify the physical factors that affect blood carboxyhemoglobin (COHb) saturation. Blood COHb saturation levels were significantly lower in patients who survived in the hospital. No significant differences were found in the blood COHb saturation levels between patients who died immediately at the scene and those who were pronounced dead at the receiving hospital without heartbeat being restored. The COHb saturation levels were significantly different among the groups of patients classified by the amount of soot. Although age, coronary artery stenosis, and blood alcohol concentration did not significantly affect blood COHb saturation, on comparing patients who died in the same fire, lower COHb saturation was observed in two patients, one with severe coronary artery stenosis and other with severe alcohol intoxication. To accurately interpret blood COHb saturation during forensic autopsy, the heartbeat status (present or absent) at the time of the rescue and the amount of soot in the trachea must be determined. Low levels of COHb saturation may be observed in fatalities with severe coronary atherosclerosis or severe alcohol intoxication.
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10
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Sandhu A, Herron JBT, Martin NA. Burns management in the military and humanitarian setting. BMJ Mil Health 2022; 168:467-472. [PMID: 33361439 DOI: 10.1136/bmjmilitary-2020-001672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 10/25/2020] [Accepted: 10/27/2020] [Indexed: 11/04/2022]
Abstract
Burns are an unpredictable element of the modern battlespace and humanitarian operations. Most military burns are small and may not be a significant challenge for deployed healthcare assets but usually render the individual combat ineffective until healed. However, larger burns represent a more significant challenge because of the demand for fluid resuscitation therapy, early surgical intervention and regular wound management that can rapidly deplete surgical capabilities. Beyond the initial injury, longer-term consequences, such as psychological morbidity and loss of functional independence, are rarely considered as part of an ongoing care plan. Globally, most of the morbidity and mortality associated with burns are seen in less economically developed countries and are frequently associated with conflicts and natural disasters, but with simple interventions and resources, outcomes in these environments can be markedly improved. Prehospital providers should be confident to manage the initial assessment of a burn, including triaging for evacuation and packaging for safe transfer. This article provides an overview for prehospital providers on the management of thermal burns in military and humanitarian settings, with additional considerations for the management of chemical and electrical injuries.
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Affiliation(s)
| | | | - N A Martin
- Joint Hospital Group South East, Aldershot, UK
- St Andrew's Burns Service, Chelmsford, UK
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11
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Factors Associated With Mechanical Ventilation Duration in Pediatric Burn Patients in a Regional Burn Center in the United States. Pediatr Crit Care Med 2022; 23:e536-e540. [PMID: 36040074 DOI: 10.1097/pcc.0000000000003068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Among burned children who arrive at a burn center and require invasive mechanical ventilation (IMV), some may have prolonged IMV needs. This has implications for patient-centered outcomes as well as triage and resource allocation decisions. Our objective was to identify factors associated with the duration of mechanical ventilation in pediatric patients with acute burn injury in this setting. DESIGN Single-center, retrospective cohort study. SETTING Registry data from a regional, pediatric burn center in the United States. PATIENTS Children less than or equal to 18 years old admitted with acute burn injury who received IMV between January 2005 and December 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Ventilator days were defined as any full or partial day having received IMV via an endotracheal tube or tracheostomy, not inclusive of time spent ventilated for procedures. Of 5,766 admissions for acute burn care, 4.3% ( n = 249) required IMV with a median duration of 10 days. A multivariable model for freedom from mechanical ventilation showed that the presence of inhalational injury (subhazard ratio [sHR], 0.62; 95% CI, 0.46-0.85) and burns to the head and neck region (sHR, 0.94; 95% CI, 0.90-0.98) were associated with increased risk of remaining mechanically ventilated at any time point. Older (sHR, 1.03; 95% CI, 1.01-1.04) and male children (sHR, 1.39; 95% CI, 1.05-1.84) were more likely to discontinue mechanical ventilation. A majority of children (94.8%) survived to hospital discharge. CONCLUSIONS The presence of inhalational injury and burns to the head and neck region were associated with a longer duration of mechanical ventilation. Older age and male gender were associated with a shorter duration of mechanical ventilation. These factors should help clinicians better estimate a burned child's expected trajectory and resource-intensive needs upon arrival to a burn center.
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12
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Dries DJ, Perry JF, Tawfik PN. A Rationale for Safe Ventilation with Inhalation Injury: An Editorial Review. J Burn Care Res 2022; 43:irac061. [PMID: 35511894 DOI: 10.1093/jbcr/irac061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Indexed: 11/14/2022]
Abstract
Lung injury from smoke inhalation manifests as airway and parenchymal damage, at times leading to the acute respiratory distress syndrome. From the beginning of this millennium, the approach to mechanical ventilation in the patient with ARDS was based on reduction of tidal volume to 6 milliliters/kilogram of ideal body weight, maintaining a ceiling of plateau pressure, and titration of driving pressure (plateau pressure minus PEEP). Beyond these broad constraints, there is little specification for the mechanics of ventilator settings, consideration of the metabolic impact of the disease process on the patient, or interaction of patient disease and ventilator settings. Various studies suggest that inhomogeneity of lung injury, which increases the risk of regional lung trauma from mechanical ventilation, may be found in the patient with smoke inhalation. We now appreciate that energy transfer principles may affect optimal ventilator management and come into play in damaged heterogenous lungs. Mechanical ventilation in the patient with inhalation injury should consider various factors. Self-injurious respiratory demand by the patient can be reduced using analgesia and sedation. Dynamic factors beginning with rate management can reduce the incidence of potentially damaging ventilation. Moreover, preclinical study is underway to examine the flow of gas based on the ventilator mode selected, which may also be a factor triggering regional lung injury.
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Affiliation(s)
| | - John F Perry
- Chair of Trauma Surgery University of Minnesota, U.S.A
| | - Pierre N Tawfik
- Fellow Pulmonary and Critical Care Medicine University of Minnesota, U.S.A
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13
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Shaikh N, Chanda AH, Rahman MA, Nainthramveetil MM, Kumar A, Mathias RM, Nashwan AJ. Inhalational injury and use of heparin & N-acetylcysteine nebulization: A case report. Respir Med Case Rep 2022; 37:101640. [PMID: 35345568 PMCID: PMC8956813 DOI: 10.1016/j.rmcr.2022.101640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/08/2022] [Accepted: 03/17/2022] [Indexed: 11/30/2022] Open
Abstract
Inhalational injury to the upper and lower airway occurs due to thermal or chemical irritation causing airway edema, capillary leak, mucin, and fibrin debris forming clots and soot. The use of unfractionated heparin (UFH) nebulization was found to be effective by dissolving airway clots. We report a case of inhalational burn injury where UFH nebulization led to a better outcome. A healthy male was trapped in a residential room during a fire in the building. He sustained facial, neck, upper chest, and left upper extremity burns accounting for 25% of body surface area. He was intubated at the site and started on supportive care. In the surgical intensive care unit, bronchoscopy showed severe tracheobronchial burn injury; a thorough lavage was done, started on UFH and N-acetylcysteine nebulization (NAC). The patient improved, and his trachea was extubated on day 6. In our patient, unfractionated heparin nebulization was beneficial as the patient was extubated early without landing to acute respiratory distress syndrome.
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Affiliation(s)
- Nissar Shaikh
- Surgical Intensive Care Department, Hamad General Hospital (HGH), Hamad Medical Corporation (HMC), Doha, Qatar
| | - Arshad H. Chanda
- Surgical Intensive Care Department, Hamad General Hospital (HGH), Hamad Medical Corporation (HMC), Doha, Qatar
| | - Mohammad A. Rahman
- Surgical Intensive Care Department, Hamad General Hospital (HGH), Hamad Medical Corporation (HMC), Doha, Qatar
| | - Mohammed M. Nainthramveetil
- Surgical Intensive Care Department, Hamad General Hospital (HGH), Hamad Medical Corporation (HMC), Doha, Qatar
| | - Ashish Kumar
- Surgical Intensive Care Department, Hamad General Hospital (HGH), Hamad Medical Corporation (HMC), Doha, Qatar
| | - Ranjan M. Mathias
- Surgical Intensive Care Department, Hamad General Hospital (HGH), Hamad Medical Corporation (HMC), Doha, Qatar
| | - Abdulqadir J. Nashwan
- Nursing Department, Hazm Mebaireek General Hospital (HMGH), Hamad Medical Corporation (HMC), Doha, Qatar
- Corresponding author. P.O.Box 3050, Doha, Qatar.
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14
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Sasaki J, Matsushima A, Ikeda H, Inoue Y, Katahira J, Kishibe M, Kimura C, Sato Y, Takuma K, Tanaka K, Hayashi M, Matsumura H, Yasuda H, Yoshimura Y, Aoki H, Ishizaki Y, Isono N, Ueda T, Umezawa K, Osuka A, Ogura T, Kaita Y, Kawai K, Kawamoto K, Kimura M, Kubo T, Kurihara T, Kurokawa M, Kobayashi S, Saitoh D, Shichinohe R, Shibusawa T, Suzuki Y, Soejima K, Hashimoto I, Fujiwara O, Matsuura H, Miida K, Miyazaki M, Murao N, Morikawa W, Yamada S. Japanese Society for Burn Injuries (JSBI) Clinical Practice Guidelines for Management of Burn Care (3rd Edition). Acute Med Surg 2022; 9:e739. [PMID: 35493773 PMCID: PMC9045063 DOI: 10.1002/ams2.739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/29/2022] [Accepted: 02/03/2022] [Indexed: 01/28/2023] Open
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15
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Allam NM, Badawy MM. Does High-Frequency Chest Wall Oscillation Have an Impact on Improving Pulmonary Function in Patients With Smoke Inhalation Injury? J Burn Care Res 2021; 42:300-304. [PMID: 32860696 DOI: 10.1093/jbcr/iraa147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Smoke inhalation results in bronchospasm of the trachea, increasing secretion of mucus, casts formation, and improvement of blood flow of the airway. High frequency chest wall oscillation is a common modality used for clearing mucus secretion in patients suffering from hypersecretion of thick mucus and used also to help cough clearance. This study aimed to detect the effect of high frequency chest wall oscillation in improving pulmonary function in burn patients suffering from smoke inhalation. Sixty smoke inhalation injury patients were randomly distributed into two groups of equal size. Group A: received high frequency chest wall oscillation and conventional chest physical therapy (breathing exercises, early ambulation, and cough training) thrice per week for 8 weeks. Group B: received traditional chest physical therapy (breathing exercises, early ambulation, and cough training) thrice per week for 8 weeks. Pulmonary function test (forced vital capacity, forced expiratory volume in the first second and peak expiratory flow rate) was measured at enrollment and after 8 weeks by using spirometer. Pulmonary function increased significantly posttreatment when compared with that pretreatment in groups A and B (P > .001). Also, they increased significantly in group A compared with that of group B posttreatment (P > .05). High-frequency chest wall oscillation have an impact on improving pulmonary function and should be handled to be a part of the pulmonary rehabilitation plan for smoke inhalation injury patients.
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Affiliation(s)
- Nesma M Allam
- Department of Physical Therapy for Surgery, Faculty of Physical Therapy, Cairo University, Egypt
| | - Manar M Badawy
- Department of Physical Therapy for Cardiovascular, Pulmonary Disorders and Geriatrics, Faculty of Physical Therapy, Misr University for Science and Technology, Egypt
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16
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Yu J, Kim HY, Kong YG, Park JH, Seo YJ, Kim YK. De Ritis ratio as a predictor of 1-year mortality after burn surgery. Burns 2021; 47:1865-1872. [PMID: 33832798 DOI: 10.1016/j.burns.2021.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/06/2021] [Accepted: 02/05/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Burn is an overwhelming injury. The De Ritis ratio, defined as aspartate aminotransferase to alanine aminotransferase ratio, can be used to predict poor outcomes. We evaluated the risk factors, including the De Ritis ratio, associated with 1-year mortality after burn surgery. METHODS Patients who underwent burn surgery from 2009 to 2019 were retrospectively evaluated. Multivariate Cox regression analysis was conducted to evaluate the risk factors for 1-year mortality after burn surgery. Receiver operating characteristic (ROC) curve analysis of the De Ritis ratio was performed to predict postoperative 1-year mortality. Kaplan-Meier survival analysis was also conducted. Other postoperative outcomes, such as durations of hospital and intensive care unit stays, acute kidney injury, and major adverse cardiac events, were evaluated. RESULTS One-year mortality after burn surgery occurred in 247 (19.9%) of 1244 patients. The risk factors for 1-year mortality after burn surgery were the De Ritis ratio, age, American Society of Anesthesiologists physical status, diabetes mellitus, total body surface area burned, inhalation injury, serum creatinine level, and serum albumin level. The area under the ROC curve for the De Ritis ratio was 0.716 (optimal cutoff=1.9). The 1-year mortality rate after burn surgery was significantly higher in patients with a De Ritis ratio >1.9 than in those with a De Ritis ratio ≤1.9 (35.8% vs. 11.8%, P<0.001). The survival rate was significantly higher in patients with a De Ritis ratio ≤1.9 than in those with a De Ritis ratio >1.9 (log-rank test, P<0.001). Intensive care unit stay, acute kidney injury, and major adverse cardiac events were significantly higher in patients with a De Ritis ratio >1.9 than in those with a De Ritis ratio ≤1.9 (P=0.006, P<0.001, and P<0.001, respectively). CONCLUSIONS The preoperative De Ritis ratio was a risk factor for 1-year mortality after burn surgery. The De Ritis ratio >1.9 was significantly associated with an increased 1-year mortality after burn surgery. These findings emphasized the importance of identifying burn patients with an increased De Ritis ratio to reduce the mortality after burn surgery.
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Affiliation(s)
- Jihion Yu
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hee Yeong Kim
- Department of Anesthesiology and Pain Medicine, National Medical Center, Seoul, Republic of Korea
| | - Yu-Gyeong Kong
- Department of Anesthesiology and Pain Medicine, Hangang Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Ji Hyun Park
- Department of Anesthesiology and Pain Medicine, National Medical Center, Seoul, Republic of Korea
| | - Young Joo Seo
- Department of Anesthesiology and Pain Medicine, Hangang Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea.
| | - Young-Kug Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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17
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Lowery AS, Dion G, Thompson C, Weavind L, Shinn J, McGrane S, Summitt B, Gelbard A. Incidence of Laryngotracheal Stenosis after Thermal Inhalation Airway Injury. J Burn Care Res 2020; 40:961-965. [PMID: 31332446 DOI: 10.1093/jbcr/irz133] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Inhalation injury is independently associated with burn mortality, yet little information is available on the incidence, risk factors, or functional outcomes of thermal injury to the airway. In patients with thermal inhalation injury, we sought to define the incidence of laryngotracheal stenosis (LTS), delineate risk factors associated with LTS development, and assess long-term tracheostomy dependence as a proxy for laryngeal function. Retrospective cohort study of adult patients treated for thermal inhalation injury at a single institution burn critical care unit from 2012 to 2017. Eligible patients' records were assessed for LTS (laryngeal, subglottic, or tracheal stenosis). Patient characteristics, burn injury characteristics, and treatment-specific covariates were assessed. Descriptive statistics, Mann-Whitney U-tests, odds ratio, and chi-square tests compared LTS versus non-LTS groups. Of 129 patients with thermal inhalation injury during the study period, 8 (6.2%) developed LTS. When compared with the non-LTS group, patients with LTS had greater mean TBSA (mean 30.3, Interquartile Range 7-57.5 vs 10.5, Interquartile Range 0-15.12, P = .01), higher grade of inhalation injury (mean 2.63 vs 1.80, P = .05), longer duration of intubation (12.63 vs 5.44; P < .001), and greater inflammatory response (mean white blood cell count on presentation 25.8 vs 14.9, P = .02, mean hyperglycemia on presentation 176.4 vs 136.9, P = .01). LTS patients had a significantly higher rate of tracheostomy dependence at last follow-up (50 vs 1.7%, P < .001). Six percent of patients with thermal inhalation injury develop LTS. LTS was associated with more severe thermal airway injury, longer duration of intubation, and more severe initial host inflammation. Patients with inhalation injury and LTS are at high risk for tracheostomy dependence. In burn patients with thermal inhalation injury, laryngeal evaluation and directed therapy should be incorporated early into multispecialty pathways of care.
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Affiliation(s)
- Anne Sun Lowery
- Department of Otolaryngology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Greg Dion
- Department of Otolaryngology and Head and Neck Surgery, Brooke Army Medical Center, Fort Sam Houston, Houston, Texas
| | - Callie Thompson
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center
| | - Liza Weavind
- Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center
| | - Justin Shinn
- Department of Otolaryngology and Head and Neck Surgery, Vanderbilt University Medical Center
| | - Stuart McGrane
- Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center
| | - Blair Summitt
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alexander Gelbard
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center
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18
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Miyagawa N, Kobayashi M, Kawazoe Y, Nomura R, Kushimoto S. Extensive inhalation injury treated with veno-venous extracorporeal membrane oxygenation followed by systemic corticosteroid administration: A case report. BURNS OPEN 2020. [DOI: 10.1016/j.burnso.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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19
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Stockly OR, Wolfe AE, Carrougher GJ, Stewart BT, Gibran NS, Wolf SE, McMullen K, Bamer AM, Kowalske K, Cioffi WG, Zafonte R, Schneider JC, Ryan CM. Inhalation injury is associated with long-term employment outcomes in the burn population: Findings from a cross-sectional examination of the Burn Model System National Database. PLoS One 2020; 15:e0239556. [PMID: 32966317 PMCID: PMC7511001 DOI: 10.1371/journal.pone.0239556] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 09/08/2020] [Indexed: 12/23/2022] Open
Abstract
Introduction Inhalation injuries carry significant acute care burden including prolonged ventilator days and length of stay. However, few studies have examined post-acute outcomes of inhalation injury survivors. This study compares the long-term outcomes of burn survivors with and without inhalation injury. Methods Data collected by the Burn Model System National Database from 1993 to 2019 were analyzed. Demographic and clinical characteristics for adult burn survivors with and without inhalation injury were examined. Outcomes included employment status, Short Form-12/Veterans Rand-12 Physical Composite Score (SF-12/VR-12 PCS), Short Form-12/Veterans Rand-12 Mental Composite Score (SF-12/VR-12 MCS), and Satisfaction With Life Scale (SWLS) at 24 months post-injury. Regression models were used to assess the impacts of sociodemographic and clinical covariates on long-term outcome measures. All models controlled for demographic and clinical characteristics. Results Data from 1,871 individuals were analyzed (208 with inhalation injury; 1,663 without inhalation injury). The inhalation injury population had a median age of 40.1 years, 68.8% were male, and 69% were White, non-Hispanic. Individuals that sustained an inhalation injury had larger burn size, more operations, and longer lengths of hospital stay (p<0.001). Individuals with inhalation injury were less likely to be employed at 24 months post-injury compared to survivors without inhalation injury (OR = 0.63, p = 0.028). There were no significant differences in PCS, MCS, or SWLS scores between groups in adjusted regression analyses. Conclusions Burn survivors with inhalation injury were significantly less likely to be employed at 24 months post-injury compared to survivors without inhalation injury. However, other health-related quality of life outcomes were similar between groups. This study suggests distinct long-term outcomes in adult burn survivors with inhalation injury which may inform future resource allocation and treatment paradigms.
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Affiliation(s)
- Olivia R. Stockly
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, United States of America
| | - Audrey E. Wolfe
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, United States of America
| | | | - Barclay T. Stewart
- Department of Surgery, University of Washington, Seattle, WA, United States of America
- Harborview Injury Prevention and Research Center, Seattle, WA, United States of America
| | - Nicole S. Gibran
- Department of Surgery, University of Washington, Seattle, WA, United States of America
| | - Steven E. Wolf
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, United States of America
| | - Kara McMullen
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, United States of America
| | - Alyssa M. Bamer
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, United States of America
| | - Karen Kowalske
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - William G. Cioffi
- Department of Surgery, Brown University, Rhode Island Hospital, Providence, RI, United States of America
| | - Ross Zafonte
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, United States of America
| | - Jeffrey C. Schneider
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, United States of America
- * E-mail:
| | - Colleen M. Ryan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
- Shriners Hospitals for Children—Boston, Boston, MA, United States of America
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20
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Coulter MJ, Mickelson RC, Dye JL, Shannon KB, Ambrosio AA. Serious Inhalation Injuries From Military Operations in Afghanistan, Iraq, and Syria. J Intensive Care Med 2020; 36:1061-1065. [PMID: 32914702 DOI: 10.1177/0885066620956618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To characterize serious inhalation injuries seen during recent military operations, and assess whether bronchoscopic severity findings were associated with clinical presentation and outcomes. METHODS Service members who suffered inhalation injuries while deployed to Iraq, Afghanistan, or Syria from 2001-2018 were identified using ICD-9 and 10 codes from the Expeditionary Medical Encounter Database (EMED), which is abstracted from patient records in forward-deployed medical facilities. Further information including demographics, mechanism of injury, mortality, total burn surface area (TBSA), degree of facial burn, total Injury Severity Score (ISS), and first post-injury bronchoscopy notes were collected. Patients were excluded with ISS less than 16 or without sufficient details regarding bronchoscopy. Injuries were grouped based on bronchoscopic Abbreviated Injury Scores (AIS) into low-grade (AIS of 1), moderate-grade (AIS of 2), or high-grade (AIS of 3 or 4). RESULTS 91 patients met inclusion criteria, with no significant differences in age, gender, paygrade, or service branch between degrees of injury. There were no statistical correlations between grade of injury and battle versus non-battle injury, blast versus non-blast mechanism, TBSA, or degree of facial burn. High-grade injuries had significantly higher ISS than low or moderate-grade injuries. After adjusting for ISS, the odds ratio of death was 10.4 (95% CI 1.47 to 74.53) for those with high-grade and 3.7 (95% CI 0.45 to 32.30) for those with moderate-grade compared to low-grade injuries. CONCLUSION In this cohort of deployed military members with inhalation injuries, initial bronchoscopic severity findings are strongly associated with mortality even after adjusting for ISS. The AIS may be an important prognostic tool in all of those with serious inhalation injuries.
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Affiliation(s)
- Michael J Coulter
- Department of Otolaryngology/Head and Neck Surgery, 19938Naval Medical Center, San Diego, CA, USA
| | - Roxanne C Mickelson
- Department of Otolaryngology/Head and Neck Surgery, 19938Naval Medical Center, San Diego, CA, USA
| | - Judy L Dye
- Leidos, San Diego, CA, USA.,Naval Health Research Center, San Diego, CA, USA
| | - Kaeley B Shannon
- Naval Health Research Center, San Diego, CA, USA.,Axiom Resource Management, Inc, Falls Church, VA, USA
| | - Art A Ambrosio
- Department of Otolaryngology/Head and Neck Surgery, 19938Naval Medical Center, San Diego, CA, USA.,Virtual Medical Center Indo-Pacific, 19938Naval Medical Center San Diego, CA, USA
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21
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Dyson K, Baker P, Garcia N, Braun A, Aung M, Pilcher D, Smith K, Cleland H, Gabbe B. To intubate or not to intubate? Predictors of inhalation injury in burn‐injured patients before arrival at the burn centre. Emerg Med Australas 2020; 33:262-269. [DOI: 10.1111/1742-6723.13604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/19/2020] [Accepted: 07/22/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Kylie Dyson
- Department of Epidemiology and Preventive Medicine Monash University Melbourne Victoria Australia
- Centre for Research and Evaluation Ambulance Victoria Melbourne Victoria Australia
| | - Paul Baker
- Victorian Adult Burns Service Alfred Hospital Melbourne Victoria Australia
| | - Nicole Garcia
- Victorian Adult Burns Service Alfred Hospital Melbourne Victoria Australia
| | - Anna Braun
- Victorian Adult Burns Service Alfred Hospital Melbourne Victoria Australia
| | - Myat Aung
- Intensive Care Unit Alfred Hospital Melbourne Victoria Australia
| | - David Pilcher
- Intensive Care Unit Alfred Hospital Melbourne Victoria Australia
| | - Karen Smith
- Centre for Research and Evaluation Ambulance Victoria Melbourne Victoria Australia
| | - Heather Cleland
- Victorian Adult Burns Service Alfred Hospital Melbourne Victoria Australia
- Central Clinical School Monash University Melbourne Victoria Australia
| | - Belinda Gabbe
- Department of Epidemiology and Preventive Medicine Monash University Melbourne Victoria Australia
- Health Data Research UK Swansea University Medical School Swansea UK
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22
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Phelps MK, Olson LM, Patel MAVB, Thompson MJ, Murphy CV. Nebulized Heparin for Adult Patients With Smoke Inhalation Injury: A Review of the Literature. J Pharm Technol 2020; 36:130-140. [PMID: 34752548 DOI: 10.1177/8755122520925774] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Objective: To review the clinical effects of nebulized heparin and N-acetylcysteine (NAC) in patients with smoke inhalation injury (IHI) and provide recommendations for use. Data Sources: A search of PubMed, MEDLINE, and Scopus databases was completed from database inception through April 15, 2020, using terms: heparin, acetylcysteine, smoke inhalation injury, and burn injury. Study Selection and Data Extraction: All studies pertaining to efficacy and safety of nebulized heparin and/or NAC for IHI in adult patients were evaluated. Reference lists were reviewed for additional publications. Nonhuman studies, non-English, and case report publications were excluded. Data Synthesis: Eight studies were included. Four demonstrated positive outcomes, 3 demonstrated no benefit or possible harm, and 1 assessed safety. Supporting trials treated patients within 48 hours of injury with 10 000 units of nebulized heparin with NAC for 7 days or until extubation. Two trials with negative findings treated patients within 72 hours, or unspecified, with 5000 units of nebulized heparin with NAC for 7 days, while the third used 25 000 units within 36 hours but was grossly underpowered for analysis. Clinical findings include reduced duration of mechanical ventilation and improved lung function with possible increase risk of pneumonia and no evidence of increased bleeding risk. Conclusions: Nebulized heparin may improve oxygenation and reduce duration of mechanical ventilation in IHI. If nebulized heparin is used, 10 000 units every 4 hours alternating with NAC and albuterol at 4-hour intervals is recommended. Sterile technique should be emphasized. Monitoring for bronchospasm or new-onset pneumonia should be considered.
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Affiliation(s)
- Megan K Phelps
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | | | - Molly J Thompson
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Claire V Murphy
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Chest physical therapy reduces pneumonia following inhalation injury. Burns 2020; 47:198-205. [PMID: 32711901 DOI: 10.1016/j.burns.2020.06.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 06/19/2020] [Accepted: 06/29/2020] [Indexed: 11/23/2022]
Abstract
PURPOSE The purpose of this study was to clarify the efficacy of chest physiotherapy (CPT) in patients with inhalation injury in the acute phase. PATIENTS AND METHODS This was a single-institution retrospective study of patients with inhalation injury admitted to the Chukyo Hospital Burn Center from April 2004 to March 2014 who required endotracheal intubation for respiratory care. The patients were divided into two groups: the CPT group and the conventional physical therapy group. We compared the two groups according to the incidence of pneumonia, length of ICU/hospital stay, and level of activities of daily living at discharge. To match subject backgrounds, we conducted a propensity score matching analysis, and using a Cox regression analysis, we evaluated the effect of CPT on the first pneumonia event. RESULTS Of 271 patients admitted to the burn center, 139 patients were included. The incidence of pneumonia in the CPT group was significantly lower and these patients required fewer days until they could sit on the edge of the bed compared with the conventional physical therapy group. In a Cox regression model, the hazard ratio for the first incidence of pneumonia in the CPT group vs. the conventional therapy group was 0.27 (95% confidence interval: 0.13-0.54, P = 0.0002) after propensity score matching. CONCLUSIONS CPT reduces the incidence of pneumonia and facilitates patient mobilization following inhalation injury.
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Smoke inhalation injury: bronchoscopy findings. Can J Anaesth 2020; 67:1431-1432. [PMID: 32583242 DOI: 10.1007/s12630-020-01749-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 06/17/2020] [Accepted: 06/20/2020] [Indexed: 10/24/2022] Open
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Chotalia M, Pirrone C, Mangham T, Torlinska B, Mullhi R, England K, Torlinski T. The Predictive Applicability of Liberal vs Restrictive Intubation Criteria in Adult Patients With Suspected Inhalation Injury-A Retrospective Cohort Study. J Burn Care Res 2020; 41:1290-1296. [PMID: 32504540 DOI: 10.1093/jbcr/iraa092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
This study compares the ability of liberal vs restrictive intubation criteria to detect prolonged intubation and inhalation injury in burn patients with suspected inhalation injury. Emerging evidence suggests that using liberal criteria may lead to unnecessary intubation in some patients. A single-center retrospective cohort study was conducted in adult patients with suspected inhalation injury admitted to intensive care at Queen Elizabeth Hospital, Birmingham between April 2016 and July 2019. Liberal intubation criteria, as reflected in local guidelines, were compared to restrictive intubation criteria, as outlined in the American Burn Association guidelines. The number of patients displaying positive characteristics from either guideline was compared to the number of patients who had prolonged intubation (more than 48 hours) and inhalation injury. In detecting a need for prolonged intubation (n = 85), the liberal criteria had greater sensitivity (liberal = 0.98 [0.94-1.00] vs restrictive = 0.84 [0.75-0.93]; P = .013). However, the restrictive criteria had greater specificity (restrictive = 0.96 [0.89-1.00] vs liberal = 0.48 [0.29-0.67]; P < .001). In detecting inhalation injury (n = 72), the restrictive criteria were equally sensitive (restrictive = 0.94 [0.87-1.00] vs liberal = 0.98 [0.84-1.00]; P = .48) and had greater specificity (restrictive = 0.86 [0.72-1.00] vs liberal = 0.04 [0.00-0.13]; P < .001). In patients who met liberal but not restrictive criteria, 65% were extubated within 48 hours and 90% did not have inhalation injury. Liberal intubation criteria were more sensitive at detecting a need for prolonged intubation, while restrictive criteria were more specific. Most patients intubated based on liberal criteria alone were extubated within 48 hours. Restrictive criteria were highly sensitive and specific at detecting inhalation injury.
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Affiliation(s)
- Minesh Chotalia
- Department of Anaesthetics and Critical Care, West Midlands Burns Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Christine Pirrone
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Australia
| | - Thomas Mangham
- Department of Anaesthetics and Critical Care, West Midlands Burns Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Barbara Torlinska
- Centre for Patient Reported Outcome Research, Institute of Applied Health Research, University of Birmingham,, UK
| | - Randeep Mullhi
- Department of Anaesthetics and Critical Care, West Midlands Burns Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Kaye England
- Department of Anaesthetics and Critical Care, West Midlands Burns Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Tomasz Torlinski
- Department of Anaesthetics and Critical Care, West Midlands Burns Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK
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Jayawardena A, Lowery AS, Wootten C, Dion GR, Summitt JB, McGrane S, Gelbard A. Early Surgical Management of Thermal Airway Injury: A Case Series. J Burn Care Res 2020; 40:189-195. [PMID: 30445620 DOI: 10.1093/jbcr/iry059] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Inhalation injury is an independent risk factor in burn mortality, imparting a 20% increased risk of death. Yet there is little information on the natural history, functional outcome, or pathophysiology of thermal injury to the laryngotracheal complex, limiting treatment progress. This paper demonstrates a case series (n = 3) of significant thermal airway injuries. In all cases, the initial injury was far exceeded by the subsequent immune response and aggressive fibroinflammatory healing. Serial examination demonstrated progressive epithelial injury, mucosal inflammation, airway remodeling, and luminal compromise. Histologic findings in the first case demonstrate an early IL-17A response in the human airway following thermal injury. This is the first report implicating IL-17A in the airway mucosal immune response to thermal injury. Their second and third patients received Azithromycin targeting IL-17A and showed clinical responses. The third patient also presented with exposed tracheal cartilage and underwent mucosal reconstitution via split-thickness skin graft over an endoluminal stent in conjunction with tracheostomy. This was associated with rapid abatement of mucosal inflammation, resolution of granulation tissue, and return of laryngeal function. Patients who present with thermal inhalation injury should receive a thorough multidisciplinary airway evaluation, including early otolaryngologic evaluation. New early endoscopic approaches (scar lysis and mucosal reconstitution with autologous grafting over an endoluminal stent), when combined with targeted medical therapy aimed at components of mucosal airway inflammation (local corticosteroids and systemic Azithromycin targeting IL-17A), may have potential to limit chronic cicatricial complications.
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Affiliation(s)
- Asitha Jayawardena
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anne S Lowery
- Department of Otolaryngology, Vanderbilt University Medical School, Nashville, Tennessee
| | - Christopher Wootten
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gregory R Dion
- Department of Otolaryngology, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - J Blair Summitt
- Department of Plastic Surgery, Vanderbilt University Medical Center, Acute Burn Services, Nashville, Tennessee
| | - Stuart McGrane
- Department of Plastic Surgery, Vanderbilt University Medical Center, Acute Burn Services, Nashville, Tennessee
| | - Alexander Gelbard
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
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Tracy LM, Dyson K, Mercier LL, Cleland H, McInnes JA, Cameron PA, Singer Y, Edgar DW, Darton A, Gabbe BJ. Variation in documented inhalation injury rates following burn injury in Australia and New Zealand. Injury 2020; 51:1152-1157. [PMID: 31806382 DOI: 10.1016/j.injury.2019.11.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 11/12/2019] [Accepted: 11/15/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The negative impact of inhalation injuries on in-hospital outcomes for burn patients is well known, but the burns community is yet to form a consensus on diagnostic criteria and clinical definitions. The diagnosis of inhalation injuries is consequently highly subjective. This study aimed to assess the variation in the rate of documented inhalation injury for adult patients in Australian and New Zealand burn units. METHODS Data for sequential admissions collected from eight adult burn centres across Australia and New Zealand between July 2009 and June 2016 were extracted from the Burns Registry of Australia and New Zealand (BRANZ). Inhalation injury was classified in two ways: (i) a field in the BRANZ data dictionary, and (ii) through a series of International Classification of Disease 10th Revision Australian Modification (ICD-10-AM) codes. Variation in inhalation injury prevalence was assessed using descriptive statistics, funnel plots, logistic regression, and predicted probabilities. RESULTS There were 11,206 admissions to BRANZ sites over the study period. Inhalation injury prevalence was the highest at Site D (13.1% for the BRANZ field and 11.8% for the ICD-10-AM codes), but there was significant variation between the contributing sites and the inhalation injury classification methods. CONCLUSION There is significant variation in the prevalence of documented inhalation injury among Australian and New Zealand burns units. The variation in the prevalence of documented inhalation injury across Australian and New Zealand sites reinforces the need for a consensus definition in the diagnosis of these injuries. Further work is required to improve data quality and reconcile the differences between clinical and ICD-10-AM coding prevalence before changes in clinical practice can be recommended from these data.
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Affiliation(s)
- Lincoln M Tracy
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne 3004, Australia.
| | - Kylie Dyson
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne 3004, Australia
| | - Laura Le Mercier
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne 3004, Australia
| | - Heather Cleland
- Victorian Adult Burn Service, Alfred Hospital, 55 Commercial Road, Melbourne 3004, Australia; Central Clinical School, Monash University, 99 Commercial Road, Melbourne 3004, Australia
| | - Judith A McInnes
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne 3004, Australia
| | - Peter A Cameron
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne 3004, Australia; Emergency & Trauma Centre, Alfred Hospital, 55 Commercial Road, Melbourne 3004, Australia
| | - Yvonne Singer
- Victorian Adult Burn Service, Alfred Hospital, 55 Commercial Road, Melbourne 3004, Australia
| | - Dale W Edgar
- Burn Injury Research Node, The University of Notre Dame, 19 Mouat Street, Fremantle 6959, Australia; State Adult Burn Unit, Fiona Stanley Hospital, 11 Warren Drive, Murdoch 6150, Australia
| | - Anne Darton
- Statewide Burn Injury Service, Agency for Clinical Innovation Royal North Shore Hospital, Reserve Road, St Leonards 2065, Australia
| | - Belinda J Gabbe
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne 3004, Australia; Health Data Research UK, Swansea University Medical School, Swansea University, Singleton Park, Swansea, Wales SA28PP, United Kingdom
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Lemoine S, Grognard G, Chabernaud JL, Jost D, Travers S, Prunet B. Pediatric victims involved in urban fires in Paris and its suburbs: Epidemiology, prehospital care, and lessons learned. Arch Pediatr 2020; 27:196-201. [PMID: 32331913 DOI: 10.1016/j.arcped.2020.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 12/18/2019] [Accepted: 03/28/2020] [Indexed: 10/24/2022]
Abstract
AIM The literature includes few reports on the prehospital care of pediatric casualties of urban house fires. Here we aimed to describe the epidemiology of pediatric fire victims, focusing on their injuries, prehospital care, and survival. METHODS This retrospective study included children under 15 years of age who were victims of urban house fires and who received care from prehospital medical teams. The variables analyzed included epidemiology, specific care provided by prehospital emergency services, the number of cardiac arrests, and survival rates. RESULTS Over the 15-month study period, 365 house fires required the presence of at least one prehospital medical team. Casualties of these fires included 121 pediatric victims (median age, 4 years [interquartile range: 2-9 years]). All children were initially treated by a prehospital medical team that was not specialized in pediatrics. Six children (4.9%) received secondary treatment from a pediatric support team. Of the 121 children, 114 (94.2%) suffered from smoke inhalation and seven (5.8%) from burns. Two patients who were in cardiac arrest at their initial medical care did not survive. CONCLUSION Pediatric fire casualties were initially managed by prehospital medical teams that were not specialized in pediatrics. As in adults, the main injuries were secondary to smoke inhalation, but this has increased toxicity in children. Prehospital teams not specialized in pediatrics can optimize their practice via the sharing of experiences, team training, and cognitive aid checklist for pediatric fire victims.
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Affiliation(s)
- S Lemoine
- Paris fire brigade medical emergency department, 1, place Jules-Renard 75017 Paris, France.
| | - G Grognard
- SMUR pédiatrique (SAMU 75), hôpital Necker, 149, rue de Sèvres, 75015 Paris, France
| | - J-L Chabernaud
- SMUR pédiatrique (SAMU 92), hôpital Antoine-Béclère, 157, rue porte de Trivaux, 92140 Clamart, France
| | - D Jost
- Paris fire brigade medical emergency department, 1, place Jules-Renard 75017 Paris, France
| | - S Travers
- Paris fire brigade medical emergency department, 1, place Jules-Renard 75017 Paris, France
| | - B Prunet
- Paris fire brigade medical emergency department, 1, place Jules-Renard 75017 Paris, France
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Jayawardena ADL, Bouhabel S, Sheridan RL, Hartnick CJ. Laryngotracheal Reconstruction in the Pediatric Burn Patient: Surgical Techniques and Decision Making. J Burn Care Res 2020; 41:882-886. [PMID: 32112103 DOI: 10.1093/jbcr/iraa032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The management of laryngotracheal stenosis (LTS) in the pediatric burn patient is complex and requires a multidisciplinary approach. The mainstay of treatment for LTS is laryngotracheal reconstruction (LTR), however, limited reports of burn-specific LTR techniques exist. Here, we provide insight into the initial airway evaluation, surgical decision making, anesthetic challenges, and incision modifications based on our experience in treating patients with this pathology. The initial airway evaluation can be complicated by microstomia, trismus, and neck contractures-the authors recommend treatment of these complications prior to initial airway evaluation to optimize safety. The surgical decision making regarding pursuing single-stage LTR, double-stage LTR, and 1.5-stage LTR can be challenging-the authors recommend 1.5-stage LTR when possible due to the extra safety of rescue tracheostomy and the decreased risk of granuloma, which is especially important in pro-inflammatory burn physiology. Anesthetic challenges include obtaining intravenous access, securing the airway, and intravenous induction-the authors recommend peripherally inserted central catheter when appropriate, utilizing information from the initial airway evaluation to secure the airway, and avoidance of succinylcholine upon induction. Neck and chest incisions are often within the TBSA covered by the burn injury-the authors recommend modifying typical incisions to cover unaffected skin whenever possible in order to limit infection and prevent wound healing complications. Pediatric LTR in the burn patient is challenging, but can be safe when the surgeon is thoughtful in their decision making.
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Affiliation(s)
- Asitha D L Jayawardena
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston
| | - Sarah Bouhabel
- Department of Otolaryngology-Head and Neck Surgery, McGill University Health Center, Montréal, Canada
| | | | - Christopher J Hartnick
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston
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Matsumura K, Yamamoto R, Kamagata T, Kurihara T, Sekine K, Takuma K, Kase K, Sasaki J. A novel scale for predicting delayed intubation in patients with inhalation injury. Burns 2020; 46:1201-1207. [PMID: 31982185 DOI: 10.1016/j.burns.2019.12.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 12/17/2019] [Accepted: 12/31/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Strategies to predict delayed airway obstruction in patients with inhalation injury have not been extensively studied. This study aimed to develop a novel scale, predicting the need for Delayed Intubation after inhalation injury (PDI) score. METHODS We retrospectively identified patients with inhalation injury at four tertiary care centers in Japan between 2012 and 2018. We included patients aged 15 or older and excluded those intubated within 30 min after hospital arrival. Predictors for delayed intubation were identified with univariate analyses and scored on the basis of odds ratios. The PDI score was evaluated with the area under the receiver operating characteristic (AUROC) curve and compared with other scaling systems for burn injuries. RESULTS Data from 158 patients were analyzed; of these patients, 18 (11.4%) were intubated during the delayed phase. Signs of respiratory distress, facial burn, and pharyngolaryngeal swelling observed on laryngoscopy, were identified as predictors for delayed intubation. The discriminatory power of the PDI (AUROC curve = 0.90; 95% confidence interval, 0.83 to 0.97; p < 0.01) was higher than that of the other scaling systems. CONCLUSIONS We developed a novel scale for predicting delayed intubation in inhalation injury. The score should be further validated with other population.
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Affiliation(s)
- Kazuki Matsumura
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan.
| | - Tomohiro Kamagata
- Department of Emergency and Critical Care Medicine, Tokyo Saiseikai Central Hospital, 1-4-17 Mita, Minatoku, Tokyo, 108-0073, Japan
| | - Tomohiro Kurihara
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Kazuhiko Sekine
- Department of Emergency and Critical Care Medicine, Tokyo Saiseikai Central Hospital, 1-4-17 Mita, Minatoku, Tokyo, 108-0073, Japan
| | - Kiyotsugu Takuma
- Department of Emergency Medicine, Kawasaki Municipal Kawasaki Hospital, 12-1 Shinkawadori, Kawasakiku, Kanagawa, 210-0013, Japan
| | - Kenichi Kase
- Department of Emergency Medicine, Saiseikai Utsunomiya Hospital, 911-1 Takebayashimachi, Utsunomiya, Tochigi, 321-9574, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
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Song LC, Chen XX, Meng JG, Hu M, Huan JB, Wu J, Xiao K, Han ZH, Xie LX. Effects of different corticosteroid doses and durations on smoke inhalation-induced acute lung injury and pulmonary fibrosis in the rat. Int Immunopharmacol 2019; 71:392-403. [DOI: 10.1016/j.intimp.2019.03.051] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 03/06/2019] [Accepted: 03/26/2019] [Indexed: 12/27/2022]
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Tawiah B, Yu B, Yuen AC, Yuen RK, Xin JH, Fei B. Thermal, crystalline and mechanical properties of flame retarded Poly(lactic acid) with a PBO-like small molecule - Phenylphosphonic Bis(2-aminobenzothiazole). Polym Degrad Stab 2019. [DOI: 10.1016/j.polymdegradstab.2019.03.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Moshrefi S, Sheckter CC, Shepard K, Pereira C, Davis DJ, Karanas Y, Rochlin DH. Preventing Unnecessary Intubations: A 5-Year Regional Burn Center Experience Using Flexible Fiberoptic Laryngoscopy for Airway Evaluation in Patients With Suspected Inhalation or Airway Injury. J Burn Care Res 2019; 40:341-346. [DOI: 10.1093/jbcr/irz016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Shawn Moshrefi
- Regional Burn Center, Santa Clara Valley Medical Center, San Jose, California
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, California
| | - Clifford C Sheckter
- Regional Burn Center, Santa Clara Valley Medical Center, San Jose, California
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, California
| | - Kimberly Shepard
- Division of Otolaryngology, Santa Clara Valley Medical Center, San Jose, California
| | - Clifford Pereira
- Regional Burn Center, Santa Clara Valley Medical Center, San Jose, California
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, California
| | - Drew J Davis
- Regional Burn Center, Santa Clara Valley Medical Center, San Jose, California
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, California
| | - Yvonne Karanas
- Regional Burn Center, Santa Clara Valley Medical Center, San Jose, California
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, California
| | - Danielle H Rochlin
- Regional Burn Center, Santa Clara Valley Medical Center, San Jose, California
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, California
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Cachafeiro Fuciños L, Sánchez Sánchez M, García de Lorenzo Y Mateos A. Mechanical ventilation in critically ill burn patient with inhalation injury: Can we avoid it? Med Intensiva 2019; 44:54-56. [PMID: 30971340 DOI: 10.1016/j.medin.2019.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 02/26/2019] [Accepted: 02/28/2019] [Indexed: 10/27/2022]
Affiliation(s)
- L Cachafeiro Fuciños
- Grupo de trabajo Disfunción y fallo orgánico en la agresión, Servicio de Medicina Intensiva, Hospital Universitario La Paz, Instituto de Investigación Hospital Universitario La Paz (IdiPaz), Madrid, España.
| | - M Sánchez Sánchez
- Grupo de trabajo Disfunción y fallo orgánico en la agresión, Servicio de Medicina Intensiva, Hospital Universitario La Paz, Instituto de Investigación Hospital Universitario La Paz (IdiPaz), Madrid, España
| | - A García de Lorenzo Y Mateos
- Grupo de trabajo Disfunción y fallo orgánico en la agresión, Servicio de Medicina Intensiva, Hospital Universitario La Paz, Instituto de Investigación Hospital Universitario La Paz (IdiPaz), Madrid, España
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Impact of an Acinetobacter baumannii outbreak on kidney events in a burn unit: A targeted machine learning analysis. Am J Infect Control 2019; 47:435-438. [PMID: 30503627 DOI: 10.1016/j.ajic.2018.09.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 09/11/2018] [Accepted: 09/11/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Multidrug-resistant (MDR) bacteria outbreaks represent a major threat in intensive care units. Patients may then be exposed to drug-related direct toxicity during such outbreaks. The objective of this study was to explore the impact of an outbreak of imipenem-resistant Acinetobacter baumannii (IR-AB) on renal outcomes. METHODS We performed a before-and-after observational study in a French burn intensive care unit during an IR-AB outbreak: a 13-month period before (period A, October 2013-October 2014) and a 13-month period after outbreak control (period B, December 2014-December 2015). A total of 409 patients were included, 195 during period A and 214 during period B. The main endpoint was major adverse kidney events at day 90 (MAKE 90). Secondary endpoints were acute kidney injury (AKI) and persistent renal dysfunction. RESULTS Incidence of MAKE 90 was 15.9% during period A versus 11.2% during period B (P = .166) and AKI 28.2% versus 18.7% (P = .023). The use of colistin was associated with renal outcomes in univariate analysis. After adjustment of potential confounding factors using a targeted Machine Learning Analysis (ie, IR-AB-related infection, septic shock, severity scores, other nephrotoxics, chronic kidney disease, serum creatinine at admission, Staphylococcus aureus), colistin remained associated with the risk of MAKE and AKI (relative risk = 2.909, 95% confidence interval [CI] [1.364, 6.204], P = .006 for MAKE 90, and relative risk = 2.14, 95% CI [1.52, 3.02], P<.0001 for AKI). CONCLUSIONS The episode of IR-AB outbreak was associated with an increased risk of kidney events, which appears to be driven by the use of colistin.
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Development of clinical process measures for pediatric burn care: Understanding variation in practice patterns. J Trauma Acute Care Surg 2019; 84:620-627. [PMID: 29140950 DOI: 10.1097/ta.0000000000001737] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND There has been little systematic examination of variation in pediatric burn care clinical practices and its effect on outcomes. As a first step, current clinical care processes need to be operationally defined. The highly specialized burn care units of the Shriners Hospitals for Children system present an opportunity to describe the processes of care. The aim of this study was to develop a set of process-based measures for pediatric burn care and examine adherence to them by providers in a cohort of pediatric burn patients. METHODS We conducted a systematic literature review to compile a set of process-based indicators. These measures were refined by an expert panel of burn care providers, yielding 36 process-based indicators in four clinical areas: initial evaluation and resuscitation, acute excisional surgery and critical care, psychosocial and pain control, and reconstruction and aftercare. We assessed variability in adherence to the indicators in a cohort of 1,076 children with burns at four regional pediatric burn programs in the Shriners Hospital system. The percentages of the cohort at each of the four sites were as follows: Boston, 20.8%; Cincinnati, 21.1%; Galveston, 36.0%; and Sacramento, 22.1%. The cohort included children who received care between 2006 and 2010. RESULTS Adherence to the process indicators varied both across sites and by clinical area. Adherence was lowest for the clinical areas of acute excisional surgery and critical care, with a range of 35% to 48% across sites, followed by initial evaluation and resuscitation (range, 34%-60%). In contrast, the clinical areas of psychosocial and pain control and reconstruction and aftercare had relatively high adherence across sites, with ranges of 62% to 93% and 71% to 87%, respectively. Of the 36 process indicators, 89% differed significantly in adherence between clinical sites (p < 0.05). Acute excisional surgery and critical care exhibited the most variability. CONCLUSION The development of this set of process-based measures represents an important step in the assessment of clinical practice in pediatric burn care. Substantial variation was observed in practices of pediatric burn care. However, further research is needed to link these process-based measures to clinical outcomes. LEVEL OF EVIDENCE Therapeutic/care management, level IV.
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Spinou A, Koulouris NG. Current clinical management of smoke inhalation injuries: a reality check. Eur Respir J 2018; 52:52/6/1802163. [PMID: 30523210 DOI: 10.1183/13993003.02163-2018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 11/16/2018] [Indexed: 11/05/2022]
Affiliation(s)
- Arietta Spinou
- Health Sport and Bioscience, University of East London, London, UK
| | - Nikolaos G Koulouris
- 1st Respiratory Medicine Dept, National and Kapodistrian University of Athens, Medical School, Athens, Greece
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Xiao P, Sun S, Cao J, Wang J, Li H, Hou S, Ding H, Liu Z, Fang Y, Bai S, Qin X, Yu F, Liu J, Wang X, Lv Q, Fan H. Expression profile of microRNAs in bronchoalveolar lavage fluid of rats as predictors for smoke inhalation injury. Burns 2018; 44:2042-2050. [DOI: 10.1016/j.burns.2018.07.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 06/08/2018] [Accepted: 07/19/2018] [Indexed: 02/08/2023]
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Barcellos LG, Silva APPD, Piva JP, Rech L, Brondani TG. Characteristics and outcome of burned children admitted to a pediatric intensive care unit. Rev Bras Ter Intensiva 2018; 30:333-337. [PMID: 30304085 PMCID: PMC6180472 DOI: 10.5935/0103-507x.20180045] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 05/10/2018] [Indexed: 11/24/2022] Open
Abstract
Objective To analyze the characteristics and outcomes of children hospitalized for
burns in a pediatric trauma intensive care unit for burn patients. Methods An observational study was conducted through the retrospective analysis of
children (< 16 years) admitted to the pediatric trauma intensive care
unit for burn victims between January 2013 and December 2015.
Sociodemographic and clinical variables were analyzed including the causal
agent, burned body surface, presence of inhalation injury, length of
hospital stay and mortality. Results The study analyzed a sum of 140 patients; 61.8% were male, with a median age
of 24 months and an overall mortality of 5%. The main cause of burns was
scalding (51.4%), followed by accidents involving fire (38.6%) and electric
shock (6.4%). Mechanical ventilation was used in 20.7% of the cases.
Associated inhalation injury presented a relative risk of 6.1 (3.5 - 10.7)
of needing ventilatory support and a relative risk of mortality of 14.1 (2.9
- 68.3) compared to patients without this associated injury. A significant
connection was found between burned body surface and mortality (p <
0.002), reaching 80% in patients with a burned area greater than 50%.
Patients who died had a significantly higher Tobiasen Abbreviated Burn
Severity Index than survivors (9.6 ± 2.2 versus 4.4
± 1.1; p < 0.001). A Tobiasen Abbreviated Burn Severity Index
≥ 7 represented a relative risk of death of 68.4 (95%CI 9.1 -
513.5). Conclusion Scalding burns are quite frequent and are associated with high morbidity.
Mortality is associated with the amount of burned body surface and the
presence of inhalation injury. Special emphasis should be given to accidents
involving fire, reinforcing proper diagnosis and treatment of inhalation
injury.
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Affiliation(s)
- Luciana Gil Barcellos
- Unidade de Terapia Intensiva de Trauma Pediátrico, Hospital Municipal de Pronto Socorro de Porto Alegre - Porto Alegre (RS), Brasil.,Unidade de Tratamento Intensivo Pediátrico, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Ana Paula Pereira da Silva
- Unidade de Terapia Intensiva de Trauma Pediátrico, Hospital Municipal de Pronto Socorro de Porto Alegre - Porto Alegre (RS), Brasil.,Unidade de Emergência Pediátrica, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Jefferson Pedro Piva
- Serviço de Emergência e Medicina Intensiva Pediátrica, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil.,Departamento de Pediatria, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Leandra Rech
- Programa de Residência em Pediatria e Terapia Intensiva, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil.,Unidade de Terapia Intensiva Pediátrica, Hospital Moinhos de Vento - Porto Alegre (RS), Brasil
| | - Tamires Goulart Brondani
- Programa de Terapia Intensiva Pediátrica, Hospital da Criança Santo Antônio - Porto Alegre (RS), Brasil
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Abstract
This pilot study was conducted to profile safety of nebulized racemic epinephrine when used as a therapy for smoke inhalation injury in severely burned children. We enrolled 16 patients who were 7 to 19 years of age ([mean ± SD], 12 ± 4 years) with burns covering more than 30% of the TBSA (55 ± 17%) and smoke inhalation injury, as diagnosed by bronchoscopy at burn center admission. Patients were randomized to receive either standard of care (n = 8), which consisted of nebulized acetylcysteine, nebulized heparin, and nebulized albuterol, or to receive standard of care plus nebulized epinephrine (n = 8). Primary endpoints were death, chest pain, and adverse changes in cardiopulmonary hemodynamics (arrhythmia, arterial blood pressure, electrocardiographic [ST segment] changes, and peak inspiratory pressure). Additional endpoints included total days on ventilator, pulmonary function, and physiological cardiopulmonary measurements at intensive care unit discharge. No adverse events were observed during or after the nebulization of epinephrine, and no deaths were reported that were attributable to the administration of nebulized epinephrine. The groups did not significantly differ with regard to age, sex, burn size, days on ventilator, pulmonary function, or cardiopulmonary fitness. Results of this pilot trial indicate epinephrine to be safe when administered to pediatric burn patients with smoke inhalation injury. Current data warrant future efficacy studies with a greater number of patients.
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Ergan B, Nava S. The use of bronchoscopy in critically ill patients: considerations and complications. Expert Rev Respir Med 2018; 12:651-663. [PMID: 29958019 DOI: 10.1080/17476348.2018.1494576] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Flexible bronchoscopy has been well established for diagnostic and therapeutic purposes in critically ill patients. Areas covered: This review outlines the clinical evidence of the utility and safety of flexible bronchoscopy in the intensive care unit, as well as specific considerations, including practical points and potential complications, in critically ill patients. Expert commentary: Its ease to learn and perform and its capacity for bedside application with relatively few complications make flexible bronchoscopy an indispensable tool in the intensive care unit setting. The main indications for flexible bronchoscopy in the intensive care unit are the visualization of the airways, sampling for diagnostic purposes and management of the artificial airways. The decision to perform flexible bronchoscopy can only be made by trade-offs between potential risks and benefits because of the fragile nature of the critically ill. Flexible bronchoscopy-associated serious adverse events are inevitable in cases of a lack of expertise or appropriate precautions.
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Affiliation(s)
- Begum Ergan
- a Department of Pulmonary and Critical Care , School of Medicine, Dokuz Eylul University , Izmir , Turkey
| | - Stefano Nava
- b Department of Clinical , Integrated and Experimental Medicine (DIMES), Respiratory and Critical Care Unit, S. Orsola-Malpighi Hospital, Alma Mater University , Bologna , Italy
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Tracheostomy and mortality in patients with severe burns: A nationwide observational study. Burns 2018; 44:1954-1961. [PMID: 29980328 DOI: 10.1016/j.burns.2018.06.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 04/27/2018] [Accepted: 06/15/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Tracheostomy is often performed in patients with severe burns who are undergoing prolonged mechanical ventilation. However, the appropriate timing of tracheostomy and its effect on mortality remain unknown. The aim of this study was to determine whether tracheostomy can reduce mortality in patients with severe burns. METHODS Using the Japanese Diagnosis Procedure Combination database from April 2010 to March 2014, we extracted data on adult patients with severe burns (burn index score of ≥15) who started mechanical ventilation within 3days of admission. We estimated the hazard ratio for 28-day in-hospital mortality associated with tracheotomy performed from day 5 to 28. We adjusted for baseline and time-dependent confounders using inverse probability of treatment weighting methods and fitted a marginal structural Cox proportional hazard model. RESULTS We identified 680 eligible patients (94 in the tracheostomy group, 2289 person-days; 586 in the non-tracheostomy group, 11,197 person-days). Patients who underwent a tracheostomy had worse prognostic factors for mortality. After adjustment for these factors, the hazard ratio for 28-day mortality associated with tracheostomy compared with non-tracheostomy was 0.73 (95% confidence interval, 0.39-1.34). CONCLUSIONS There was no significant association between 28-day in-hospital mortality and early tracheostomy in adult patients with severe burns.
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Affiliation(s)
- Robert L Sheridan
- Burn Service, Boston Shriners Hospital for Children; Division of Burns, Massachusetts General Hospital; and Department of Surgery, Harvard Medical School, Boston, MA
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Costa DL, Santos TDD, Real AA, Sbruzzi G, Pasqualoto AS, Albuquerque IMD. Acute clinical manifestations in toxic smoke inhalation victims: systematic review of observational studies. FISIOTERAPIA EM MOVIMENTO 2018. [DOI: 10.1590/1980-5918.031.ao03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract Introduction: Lung injuries from toxic smoke inhalation are the main causes of death in fire victims; however, information regarding the acute effects on the respiratory system after smoke inhalation and its constituents in closed environments are still scarce in literature. Objective: To investigate the acute clinical manifestations observed in victims of smoke inhalation during enclosed-space fires by means of systematic review. Methods: A systematic search was conducted in the following databases: MEDLINE (via PubMed), Lilacs, Scopus and Web of Science. There were no appliedrestrictions in terms of thepublication date. In addition, a manual search was performed on the references of published studies. Observational studies assessing the prevalence of acute clinical manifestations in victims of toxic smoke inhalation in closed environments were included. Results: Of the 4,603 articles identified, eight were included, comprising a total of 233 patients. The signs and symptoms were identified and ranked according to frequency. Dyspnea (58.80%, six studies), carbonaceous sputum (54.51%, four studies), hoarseness (39.91%, three studies), wheezing (34.33%, five studies) and sore throat (33.90%, two studies) were the most frequent acute clinical manifestations of smoke inhalation. Besides these, chest pain and pulmonary edema were observed, respectively in 13.30%, 5.15% of the studies. Conclusion: The results suggest that dyspnea, carbonaceous sputum, hoarseness, wheezing and sore throat were the most frequent acute clinical manifestations in victims of smoke inhalation. Further studies of a higher level of evidence and greater methodological rigor are required.
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Ashraf U, Bajantri B, Roa-Gomez G, Venkatram S, Cantin A, Diaz-Fuentes G. Nebulized heparin and N-acetylcysteine for smoke inhalational injury: A case report. Medicine (Baltimore) 2018; 97:e0638. [PMID: 29742703 PMCID: PMC5959399 DOI: 10.1097/md.0000000000010638] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
RATIONALE Every year, ∼40,000 people suffer burn-related injuries in the United States. Despite recent advances, the odds of dying from exposure to fire, flames, or smoke are one in ∼1500. Smoke inhalation causes injury to the airways via a complex physiological process, and the treatment is mainly supportive. Many recent interventions aim to decrease the formation of fibrin casts, the main cause of airway damage in these patients. Among these, treatment with a combination of nebulized heparin and N-acetylcysteine (NAC) has shown benefit. PATIENT CONCERNS We describe the case of a 58-year-old man who presented after smoke inhalation during a fire. Soot was found in the nostrils when he was admitted to our hospital, and after he began coughing up carbonaceous material, he was electively intubated and placed on volume assist control ventilation. DIAGNOSIS Bronchoscopy on the first day of intensive care confirmed the injury from smoke inhalation and revealed mucosal edema and soot involving the tracheobronchial tree. INTERVENTIONS AND OUTCOMES Inhaled unfractionated heparin of 10,000 IU in 3 mL of 0.9% normal saline alternating every 2 hours with 3 mL of 20% NAC was started 48 hours after admission and continued for 7 days. Bronchoscopy on the fifth day of intensive care showed significant improvement in airway edema and a resolution of soot. LESSONS On the basis of our experience with this case and limited literature, we posit that nebulized heparin and NAC may be of benefit in patients with inhalational smoke-induced lung injury and mild-to-severe lung injury scores.
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Affiliation(s)
- Umair Ashraf
- Division of Pulmonary and Critical Care Medicine, BronxCare Health System, Affiliated with Icahn School of Medicine at Mount Sinai
| | - Bharat Bajantri
- Division of Pulmonary and Critical Care Medicine, BronxCare Health System, Affiliated with Icahn School of Medicine at Mount Sinai
| | | | - Sindhaghatta Venkatram
- Division of Pulmonary and Critical Care Medicine, BronxCare Health System, Affiliated with Icahn School of Medicine at Mount Sinai
| | - Amanda Cantin
- Department of Pharmacy, BronxCare Health System, Bronx, NY
| | - Gilda Diaz-Fuentes
- Division of Pulmonary and Critical Care Medicine, BronxCare Health System, Affiliated with Icahn School of Medicine at Mount Sinai
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Foncerrada G, Culnan DM, Capek KD, González-Trejo S, Cambiaso-Daniel J, Woodson LC, Herndon DN, Finnerty CC, Lee JO. Inhalation Injury in the Burned Patient. Ann Plast Surg 2018; 80:S98-S105. [PMID: 29461292 PMCID: PMC5825291 DOI: 10.1097/sap.0000000000001377] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Inhalation injury causes a heterogeneous cascade of insults that increase morbidity and mortality among the burn population. Despite major advancements in burn care for the past several decades, there remains a significant burden of disease attributable to inhalation injury. For this reason, effort has been devoted to finding new therapeutic approaches to improve outcomes for patients who sustain inhalation injuries.The three major injury classes are the following: supraglottic, subglottic, and systemic. Treatment options for these three subtypes differ based on the pathophysiologic changes that each one elicits.Currently, no consensus exists for diagnosis or grading of the injury, and there are large variations in treatment worldwide, ranging from observation and conservative management to advanced therapies with nebulization of different pharmacologic agents.The main pathophysiologic change after a subglottic inhalation injury is an increase in the bronchial blood flow. An induced mucosal hyperemia leads to edema, increases mucus secretion and plasma transudation into the airways, disables the mucociliary escalator, and inactivates hypoxic vasocontriction. Collectively, these insults potentiate airway obstruction with casts formed from epithelial debris, fibrin clots, and inspissated mucus, resulting in impaired ventilation. Prompt bronchoscopic diagnosis and multimodal treatment improve outcomes. Despite the lack of globally accepted standard treatments, data exist to support the use of bronchoscopy and suctioning to remove debris, nebulized heparin for fibrin casts, nebulized N-acetylcysteine for mucus casts, and bronchodilators.Systemic effects of inhalation injury occur both indirectly from hypoxia or hypercapnia resulting from loss of pulmonary function and systemic effects of proinflammatory cytokines, as well as directly from metabolic poisons such as carbon monoxide and cyanide. Both present with nonspecific clinical symptoms including cardiovascular collapse. Carbon monoxide intoxication should be treated with oxygen and cyanide with hydroxocobalamin.Inhalation injury remains a great challenge for clinicians and an area of opportunity for scientists. Management of this concomitant injury lags behind other aspects of burn care. More clinical research is required to improve the outcome of inhalation injury.The goal of this review is to comprehensively summarize the diagnoses, treatment options, and current research.
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Affiliation(s)
- Guillermo Foncerrada
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, USA
- Shriners Hospitals for Children - Galveston, Galveston, Texas, USA
| | - Derek M. Culnan
- JMS Burn and Reconstructive Center at Merit Health Central, Jackson, MS, USA
| | - Karel D. Capek
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, USA
- Shriners Hospitals for Children - Galveston, Galveston, Texas, USA
| | - Sagrario González-Trejo
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, USA
- Shriners Hospitals for Children - Galveston, Galveston, Texas, USA
| | - Janos Cambiaso-Daniel
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, USA
- Shriners Hospitals for Children - Galveston, Galveston, Texas, USA
| | - Lee C. Woodson
- Shriners Hospitals for Children - Galveston, Galveston, Texas, USA
- Department of Anesthesiology, University of Texas Medical Branch Galveston, Texas, USA
| | - David N. Herndon
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, USA
- Shriners Hospitals for Children - Galveston, Galveston, Texas, USA
| | - Celeste C. Finnerty
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, USA
- Shriners Hospitals for Children - Galveston, Galveston, Texas, USA
| | - Jong O. Lee
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, USA
- Shriners Hospitals for Children - Galveston, Galveston, Texas, USA
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Burns in Children. J Burn Care Res 2018; 38:e618-e624. [PMID: 28328667 DOI: 10.1097/bcr.0000000000000536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Children have a great deal to gain from recent and future advances in burn care. A very broad range of realized and potential developments are involved. These will be very briefly reviewed within the context of four areas: 1) early evaluation and care issues, 2) acute surgical and critical care issues, 3) rehabilitation and reconstruction issues, and 4) organizational and outcomes issues.
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Salaria ON, Suthar R, Abdelfattah S, Hoyos J. Perioperative Management of an Airway Fire: A Case Report. A A Pract 2018; 10:5-9. [PMID: 29293488 DOI: 10.1213/xaa.0000000000000620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Accidental fire can occur with upper airway injury and can be fatal if inappropriately managed. Effective communication between the anesthetic and the surgical teams can reduce the risk of such an adverse event. Understanding the interaction between fuel, oxidizer, and ignition source in an airway fire may also reduce the incidence. The literature on upper airway thermal injury has focused on prevention and intraoperative management, but few studies have described postburn management. In this report, we describe the intraoperative occurrence of an airway fire during a surgical tracheostomy and subsequent patient management.
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Affiliation(s)
- Osman Nawazish Salaria
- From the Miami Beach Anesthesiology Associates, Inc, Department of Anesthesiology, Mount Sinai Medical Center, Miami, Florida
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Sheridan RL. Fire-Related Inhalation Injury. N Engl J Med 2016; 375:1904-1905. [PMID: 27959659 DOI: 10.1056/nejmc1611256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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