Leopoldo C Cancio

Fungal Wound Infection (Not Colonization) Is Independently Associated With Mortality in Burn Patients

Objective:To analyze the occurrence of fungal wound infection (FWI) after thermal injury and its relationship to mortality. Background:FWI is an uncommon but potentially lethal complication of severe thermal injury. Methods:The records of patients with thermal burns admitted to a single burn center (1991–2002) were reviewed. Analyses accounted for total burn size (TBS, percentage body surface area), full-thickness burn size (FTBS, percentage body surface area), age, inhalation injury, sex, and fungal-status category. Fungal colonization and infection were determined histopathologically. Results:Criteria for inclusion were met by 2651 patients. Each patient’s fungal-status category was defined according to the deepest level of fungal involvement observed during the hospital course: no fungus (2476 patients), fungal wound colonization (FWC, 121 patients), or fungal wound infection (FWI, 54 patients). Median TBS (9%, 47%, 64%, respectively) and mortality (5%, 27%, 76%, respectively) varied significantly among fungal-status groups. Logistic regression was used to detect significant independent associations. FWI was associated with higher TBS. Mortality was associated with TBS, FTBS, inhalation injury, FWI, and age. Unlike FWI, FWC was not independently related to mortality, the greater observed mortality in FWC being explained by other variables such as TBS. The odds ratio for FWI (8.16) suggested about the same mortality impact as augmenting TBS by 33%. A midrange TBS of 30% to 60% was required for most of the detectable association of FWI with mortality. Conclusions:FWI accompanies larger burns and is associated with mortality in burn patients, particularly in those with TBS 30% to 60%. This association is independent of burn size, inhalation injury, and age.

Wound healing trajectories in burn patients and their impact on mortality

The rate of wound healing and its effect on mortality has not been well described. The objective of this article is to report wound healing trajectories in burn patients and analyze their effects on in-hospital mortality. The authors used software (WoundFlow) to depict burn wounds, surgical results, and healing progression at multiple time points throughout admission. Data for all patients admitted to the intensive care unit with ≥ 20% TBSA burned were collected retrospectively. The open wound size (OWS), which includes both unhealed burns and unhealed donor sites, was measured. We calculated the rate of wound closure (healing rate), which we defined as the change in OWS/time. We also determined the time delay (DAYS) from day of burn until day on which there was a reduction in OWS < 10%. Data are medians [interquartile range]. There were 38 patients with complete data; 25 had documentation of successful healing (H), and 13 did not (NH). H differed from NH on age (38 years [32–57] vs 63 [51–74]), body mass index (27 [21–28] vs 32 [19–52]), 24-hour fluid resuscitation (12 L [10–16] vs 18 [15–20]), pressors during first 48 hours (72% vs 100%), use of renal replacement therapy (32% vs 92%), and mortality (4% vs 100%). Repeated measures analysis of covariance showed a significant difference between survivors and nonsurvivors on OWS as a function of time (P<.001). Patients with a positive healing rate (+2%/day) after postburn day 20 had 100% survival whereas those with a negative healing rate (−2%/day) had 100% mortality. For H patients, median DAYS was 41 (28–54); median DAYS/TBSA was 1.3 (1.0–1.9). Survivors had a 0.62% drop in OWS/day, or 4.3%/week. In this cohort of patients with ≥ 20% TBSA, there was a difference in mortality after postburn day 20, between patients with a positive healing rate (+2%/day, 100% survival) and those with a negative healing rate (−2%/day, 100% mortality, P < .05).

Burns associated with wars and disasters

Military operations and civilian mass casualty disasters provide among the most difficult scenarios in burn-patient management. At the same time, they historically have also led to changes in care. The purpose of this chapter is to review experience with burn care during current combat operations in Iraq and Afghanistan, and to highlight the lessons learned from a century of major peacetime fire disasters.