Odhran P. Shelley

The Baux score is dead. Long live the Baux score: A 27-year retrospective cohort study of mortality at a regional burns service

Background: To assess trends in mortality after burn injuries treated in a regional specialist burns service between 1982 and 2008. Methods: Patient and burn-specific information and mortality were collated from written admission ledgers and the hospital coding department for 11,109 patients. The data set was divided into age cohorts (0–14, 15–44, 45–64, and >65 years) and time cohorts (1982–1991, 1992–2000, and 2000–2008). Lethal area 50 (LA50) was calculated by logistic regression and probit analysis. Mortality was related to the Baux score (age + total % burned surface area) by logistic regression. Results: In the time period 2000 to 2008, the LA50 values with approximate 95% confidence intervals (CIs) were 100% (CI, 85.5–100%) in the 0 to 14 cohort (LA10, 78.3%; CI, 64.1–92.5%), 76.4% (CI, 69.1–83.8%) in the 15 to 44 cohort, 58.6% (CI, 50.8–66.5%) in the 45 to 64 cohort, and 30.8% (CI, 24.7–36.9%) in the >65 cohort. The point of futility (the Baux Score at which predicted mortality is 100%) was 160 and the Baux50 (the Baux score at which predicted mortality is 50%) was 109.6 (CI, 105.9–113.4) in the 2000 to 2008 cohort. Conclusions: Mortality is markedly improved over earlier data from this study and other historical series and compares favorably with outcomes published from the US National Burn Repository. The Baux Score continues to provide an indication of the risk of mortality. Survival after major burn injury is increasingly common, and decisions by nonspecialist about initial triage, management, and futility of care should be made after consultation with a specialist burn service.

The use of the Cortrak Enteral Access System™ for post-pyloric (PP) feeding tube placement in a Burns Intensive Care Unit

INTRODUCTION 50% of critically ill patients fail to reach caloric targets with NG feeding. PP feeding may enhance caloric intake. PP feeding can be continued throughout theatre in patients with a secure airway. Blind PP tube placement is difficult. CEAS has been developed to assist tube placement and eliminate check X-rays of tube position. METHOD All BITU patients with CEAS PP feeding tube placement were identified. Notes and X-rays were reviewed. Tube position, calorie deficit and time off feed were recorded. RESULTS 44 tubes were placed in 21 patients using CEAS. 84% were PP, 16% NG. Position correlated to X-ray findings in 86%. In 16% position was NG on CEAS but was PP on X-ray. 10 patients required both CXR and AXR to confirm position, the remainder required CXR only. Time off feed varied from 0-24 h (mean 7.4 h). Calorie deficit ranged from 0-2465 kCal (mean 858 kCal). Average wait for X-ray was 3.4h. If X-ray wait was eliminated calorie deficit would be reduced by 45% to 393 kCal. CONCLUSION The Cortrak system is safe and effective on BITU. It reduces calorie deficit, reduces X-ray exposure and is cost effective. We recommend its use on BITU.

Body Mass Index (BMI) and mortality in patients with severe burns: is there a "tilt point" at which obesity influences outcome?

BACKGROUND Obesity is a serious health hazard. Despite advances in burn care severely obese patients with large burns have higher mortality compared with normal-weight patients. The Body Mass Index is the universal measure to define and classify obesity. This study aims to evaluate the effect of Body Mass Index (BMI) on mortality of severe burn patients. METHODS A retrospective study of 95 patients treated over 2-year period in a dedicated burn ITU. Mortality was studied in relation to BMI as well as demographic, burn characteristics well as length of hospital stay. Logistic regression model and non-parametric comparison tests were used for analysis. RESULTS Mean age was 42 ± 22 years (mean ± SD), Total Burn Surface area (TBSA) 33 ± 16%, BMI 29 ± 7.5 (kg/m²) and hospital stay was 37 ± 33 days. Incidence of inhalation injury was 29% and over all mortality was 19%. By logistic regression age, TBSA and inhalation injury were separately associated with mortality. Patients with BMI ≥ 35 (kg/m²) had significantly higher mortality compared with patients with BMI < 25 (kg/m²) [p=0.037 (Fishers exact test)]. CONCLUSIONS Body Mass Index ≥ 35 (kg/m²) is a tilt point, which is associated with a higher than predicted mortality following burns when compared to burned patients with a normal BMI.

Comfort care in burns: The Burn Modified Liverpool Care Pathway (BM-LCP)

INTRODUCTION Despite advances in burn care some injuries remain non survivable. Good end of life care for these patients is arguably as important as life prolonging care. The Liverpool Care Pathway is a useful tool for providing good quality end of life care. It has previously been modified for the acute setting. We modified it further specifically for use in burn care in 2007 and would like to share our experience of using it. METHODS A retrospective case series of deaths occurring between 01/01/08 and 31/12/09 is presented and adherence to the Burn Modified Liverpool Care Pathway (BM-LCP) is assessed. RESULTS There were 22 deaths over the study period with a mean TBSA of 55%. Mean Acute Burn Severity Index score (ABSI) 12.5. A decision of futility was made in 14 cases, 11 of these were started on the BM-LCP. 7 were started on the pathway at the time of admission. Mean time from decision to start the pathway to death 11 h (range 3-48). There were no variances from the pathway. CONCLUSION The BM-LCP appears to be an appropriate tool for assisting in end of life care in burns and when used appears to improve end of life care. We recommend its use and would encourage others to implement its use.

The Belgian severity prediction model compared to other scoring systems in a burn intensive care population

We read with interest the paper by Brusselaers et al. [1] which was itself the validation of work done by the Belgian Outcome in Burn Injury Study Group [2]. The development of a reliable and user-friendly tool for the prediction of burn mortality will prove useful for audit, research and at the bedside. We have compared three different scoring systems; The Abbreviated Burn Severity Index [3] that proposed by Ryan [4] and this one. When applied to a cohort of 105 consecutive burns intensive care patients from a 2-year period, the Belgian model proved most accurate.