Dohern Kym

Inhalation injury in burn patients: Establishing the link between diagnosis and prognosis

This study was to re-evaluate inhalation injury as a prognostic factor in burn patients and to determine the factors that should be considered when refining the definition of inhalation injury. A total of 192 burn patients (152 men, 40 women; mean age, 46.1±13.8 years) who were suspected to have an inhalation injury and underwent bronchoscopy between January 2010 and June 2012 were included in this prospective observational study. All patients underwent bronchoscopy within 24h of sustaining the burn. The bronchoscopic findings were classified as normal, mild, moderate, and severe. Mechanical ventilation was administered, when required. Age, percentage of TBSA burned, ABSI score, requirement of mechanical ventilation and PF ratio, but not inhalation injury, COHb level, and bronchoscopic grades, significantly differed between the survivors and non-survivors (p<0.05). Mechanical ventilation (adjusted odds ratio [OR]: 9.787) and severe inhalation injury on bronchoscopy (adjusted OR: 45.357) were independent predictors of mortality on multivariate logistic regression analysis. Inhalation injury diagnosed through history does not predict mortality from burns. Other components such as severity of inhalation injury determined using bronchoscopy, and administration of mechanical ventilation might help predict the morbidity and mortality of burn patients with inhalation injury and all of the factors should be considered when the definition of inhalation injury is refined.

Epidemiological trends and risk factors in major burns patients in South Korea: A 10-year experience

PURPOSE To determine epidemiological trends among burns patients admitted to our burns center during 2003-2012, and the usefulness of the Abbreviated Burns Severity Index (ABSI) for predicting burns-related mortality. METHODS We retrospectively reviewed the data of 4481 burns patients. We analyzed the epidemiological trends and ABSI scores using Student t-test and one-way analysis of variance (continuous variables), chi-square test (categorical variables) and stepwise logistic-regression analysis (predictors of mortality). RESULTS The mean age and male-to-female ratio were 39.9±19.7 years and 2.88, respectively. ABSI scores decreased from 7.7±3.0 in 2003 to 6.9±3.0 in 2012. Mortality rate improved from 24.5% in 2003 to 15.8% in 2012. Burns were caused by flames (67.3%), scalding (22.0%) and electrical (7.5%), chemical (1.6%) and contact (1.5%) injuries. Scalding and flames were the most common causes in patients aged ≤20 years and ≥21 years, respectively. Female sex, inhalation injury, full-thickness burns, large total body surface area (TBSA) burned and old age predicted mortality. ABSI scores <4 and >14 were associated with 0.7% and >90% mortality, respectively. CONCLUSIONS The mortality of major burns has decreased but remains high. ABSI scores predict burns-related mortality.

The application of cultured epithelial autografts improves survival in burns

This prospective observational study was performed to analyze the clinical outcomes of patients with massive burns treated using cultured epithelial autografts (CEAs) and to determine the association of this treatment with survival outcomes. During 2006–2013, total 177 massive‐burns subjects treated with (96 subjects) or without (81 subjects) CEAs. Data were analyzed using the independent t test or chi‐square test. Multivariate logistic regression, Kaplan–Meier survival, and Cox regression analyses were performed to evaluate the factors that influenced mortality. Age, percentage of total body surface area burned, incidence of inhalation injury, allograft‐application rate, Abbreviated Burn Severity Index score, length of hospital stay, and mortality significantly differed between the CEA and noncultured epithelial autograft groups. Mortality and other clinical parameters did not differ between the sheet‐type and spray‐type CEA groups. Allograft application (odds ratio, 4.44; p < 0.01) significantly influenced CEA application. The CEA group showed significantly higher survival rates (p = 0.05). Cultured epithelial autografting had a hazard ratio of 0.55 (p = 0.02) and 0.59 (p = 0.05) according to the uni‐ and multivariate Cox regression analysis, respectively. In conclusion, early and aggressive allograft application is required to facilitate CEA application. Furthermore, the use of CEAs was associated with a lower mortality, but this result should be interpreted with caution as the groups were not randomized.

Evaluation of diagnostic biomarkers for acute kidney injury in major burn patients

Purpose Acute kidney injury (AKI) in major burn patients is a common complication with high morbidity and mortality. The mainstream treatment is early diagnosis and rapid termination and prevention of the underlying insult. Therefore, its essential to identify early biomarkers predicting AKI. Methods A total of 85 patients who were admitted to the burn intensive care unit from June 2012 to July 2013 were included in this prospective cohort study. Ten biomarkers (blood urea nitrogen, serum creatinine, urine creatinine, cystatin C, cystatin C glomerular filtration rate, AST, lacate dehydrogenase [LD], creatine kinase, lactic acid, and myoglobin) were obtained at time of admission and evaluated as diagnostic biomarkers to predicting AKI and early AKI. Results Out of 85 patients, 35 patients were dead and overall mortality was 41.2%. The mean age was 49.4 years and mean percentage of total body surface area was 53.2%. Area under the curve (AUC) of receiver operating characteristic curve of biomarkers on predicting AKI were 0.746, 0.718, and 0.717 in LD, lactic acid, and serum creatinine, respectively. AUC of cystatin C predicting AKI was much lower at 0.555. AUC of biomarkers on predicting early AKI were 0.833, 0.816, 0.790, and 0.759 in LD, serum creatinine, AST, and serum myoglobin. Conclusion LD, lactic acid and serum creatinine were acceptable as diagnostic biomarkers of AKI and LD, serum creatinine, AST, and serum myoglobin were reasonable as diagnostic biomarkers of early AKI. However, cystatin C was an unfavorable biomarker in major burn patients.

Serum cystatin C and microalbuminuria in burn patients with acute kidney injury.

This study was aimed at evaluating the effectiveness of serum cystatin C and microalbuminuria as diagnostic markers for acute kidney injury (AKI) in major burn patients.

Analysis of prognostic factors for acute kidney injury with continuous renal replacement therapy in severely burned patients

BACKGROUND Acute kidney injury (AKI) is a critical complications in severely burned patients associated with high morbidity and mortality. The purpose of this study was to investigate the impact of severity of AKI at the time of continuous renal replacement therapy (CRRT) start on patient outcome and to identify the prognostic factors in severely burned patients with CRRT application. METHODS From January 2007 to June 2010, 84 burn patients with more than 40% of total body surface area (TBSA) burned who treated with continuous renal replacement therapy for acute kidney injury were analyzed retrospectively. RESULTS There was no significant difference of mortality by the severity of AKI at the time of CRRT start. However, the mean TBSA burned, abbreviated burn severity index, arterial pH, partial pressure of carbon dioxide (PaCO2) and blood urea nitrogen (BUN)/creatinine (Cr) ratio had a statistical significance to predict mortality in receiver operation characteristic curve. In a multivariate logistic regression analysis, only sepsis had an independent association with mortality. CONCLUSIONS The severity of the AKI at the time of CRRT start did not have significant relationship with patient outcome. CRRT can be applied to minimize the complication of AKI including electrolyte imbalance and volume overload. Because only the presence of sepsis was independently associated with mortality, treatment for sepsis should be focused to improve the survival of the severely burned patients with CRRT.

Epidemiology of electrical injury: Differences between low- and high-voltage electrical injuries during a 7-year study period in South Korea

Background and Aims: Electrical burns are uncommon, but they result in high morbidity and mortality due to severe tissue damage. The purpose of this study is to analyze epidemiological variables of electrical injuries and identify preventable measures through them. Material and Methods: We retrospectively analyzed the clinical records of 625 patients admitted to Hangang Sacred Heart Hospital’s Department of Plastic Surgery from January 2005 to December 2011. We divided the patients into two groups: (1) low-voltage injury (under 1000 V) and (2) high-voltage injury (over 1000 V). We reviewed the following variables: age, sex, total burn surface area, injury type and mode, and surgical modalities. Results and Conclusions: The mean age of all patients was 33.4 ± 18.2 years. The ratio of males to females was 13.5 in the whole group. The mean total body surface are burned was 14.0% ± 13.8% in total. The majority of electrical burns in the low-tension group and high-tension group occurred in patients under 20 years and in patients aged 40–59 years, respectively. Steel chopstick insertions and high-voltage electrical work/repair were the most common injury modes in the low-tension group and the high-tension group, respectively. Groin and abdominal distant flap surgeries were commonly performed in both groups. It is recommended that these risks be prevented through education and safety measures to reduce the incidence of electrical injuries.

Effects of pain Scrambler therapy for management of burn scar pruritus: A pilot study

PURPOSE Pain Scrambler therapy is a patient-specific electrocutaneous nerve stimulation device. Burn pruritus is a common form of chronic and disabling neuropathic pain that is often difficult to treat effectively. Pruritus is mediated by histamines, which are effector molecules stored in mast cells and released locally during injury or inflammation. Burn pruritus may be accompanied by peripheral neuropathic pain, which may result from injury to sensory nerves that hampers conductance of neuronal messages along the large A and small C afferent fibers to the spinal cord. In this study, we investigated the effect of pain Scrambler therapy on burn scar pruritus. METHODS Sixteen subjects were recruited to participate in this study. The subjects complained of severe pruritus that was rated at least 5 on the visual analogue scale (VAS), despite treatments with antihistamines, gabapentin medication, and other physical modalities. Each Scrambler Therapy with the MC-5A Pain Scrambler Therapy® technology device was performed for 40min daily (Monday through Friday) for 10 consecutive days. The stimulus was increased to the maximum intensity bearable by the individual patient without causing any additional pain or discomfort. The numerical rating scale (NRS), 5-D Itch Scale, and Leuven Itch Scale were administered and evaluated immediately before Scrambler therapy, and then immediately after 5 and 10 therapy sessions. RESULTS For all 16 patients, NRS showed mean values of 6.75±1.13 before therapy, 5.06±1.53 after 5 sessions, and 4.13±1.45 after 10 sessions. The NRS values before therapy and after 10 sessions were significantly different (p<0.05). Pruritus frequency, severity, and consequences scores on the Leuven Itch Scale after Scrambler therapy were also significantly different (p<0.05). Duration, degree, direction, and disability scores on the 5-D Itch Scale were also significantly different (p<0.05). CONCLUSIONS Scrambler therapy is a non-invasive, non-medicinal modality that significantly reduced burn-associated pruritus. Scrambler therapy should be considered as a treatment option for burn survivors with severe pruritus.

Management of neck contractures by single-stage dermal substitutes and skin grafting in extensive burn patients.

Purpose Severe neck contracture is a problem that must be resolved by priority. We consider the best contracture treatment to be the full-thickness skin graft. However, clinicians often encounter patients, especially extensive burn patients, who have insufficient donor sites for the full-thickness skin graft. We treated extensive burn patients with neck scar contractures with a split-thickness skin graft (STSG) combined with dermal substitutes. The purpose of this study was to evaluate clinical outcomes of neck contracture treatment in extensive burn patients performing STSG with dermal substitutes as adjuvant treatment. Methods We analyzed the retrospective clinical and photographic records of 28 patients with severe neck contracture who were admitted to Hallym University Hangang Sacred Heart Hospital, Seoul, Korea, from January 2012 to December 2012. We performed STSG in combination with dermal substitutes to minimize the degree of contracture. Results The overall take rate of skin to dermal substitutes was 95.9%, and no grafts failed to affect recontracture except in one patient with a partial loss of artificial dermis who underwent a follow-up skin graft without any problems. Excellent/good outcomes were shown in 27 out of 28 patients. Conclusion In extensive burn patients, skin grafting in combination with dermal substitutes can be an alternative to STSG alone for contracture release.

Does inhalation injury predict mortality in burns patients or require redefinition

Inhalation injury is known to be an important factor in predicting mortality in burns patients. However, the diagnosis is complicated by the heterogeneous presentation and inability to determine the severity of inhalation injury. The purpose of this study was to identify clinical features of inhalation injury that affect mortality and the values that could predict the outcome more precisely in burns patients with inhalation injury. This retrospective observational study included 676 burns patients who were over 18 years of age and hospitalized in the Burns Intensive Care Unit between January 2012 and December 2015. We analyzed variables that are already known to be prognostic factors (age, percentage of total body surface area (%TBSA) burned, and inhalation injury) and factors associated with inhalation injury (carboxyhemoglobin and PaO2/FiO2 [PF] ratio) by univariate and multivariate logistic regression. Age group (odds ratio [OR] 1.069, p<0.001), %TBSA burned (OR 1.100, p<0.001), and mechanical ventilation (OR 3.774, p<0.001) were identified to be significant predictive factors. The findings for presence of inhalation injury, PF ratio, and carboxyhemoglobin were not statistically significant in multivariate logistic regression. Being in the upper inhalation group, the lower inhalation group, and having a PF ratio <100 were identified to be significant predictors only in univariate logistic regression analysis (OR 4.438, p<0.001; OR 2.379, p<0.001; and OR 2.765, p<0.001, respectively). History and physical findings are not appropriate for diagnosis of inhalation injury and do not predict mortality. Mechanical ventilation should be recognized as a risk factor for mortality in burns patients with inhalation injury.