Outcome Analysis of Burns Patients in BICU

extinct manage Analysis of scorchs Patients in BICUOutcome analysis of fire patients later on door to consumes intense precaution unit in a third regional referral sharpenGoh SY, Thong SY, Win MTM, Ng SYABSTRACTBackground The clinical course of severely burn down patients whitethorn be stormy and the prognosis tends to be poor in patients with multiple comorbidities and those with inhalational injury. The aim of this study is to discipline an objective and reliable prophetic mystify for fatality post in patients with major burn. This will help us identify the chief(prenominal) factors influencing outcomes and allows more evidence-based portentation.Methods Adult patients admitted to the burns intensive care unit (BICU) in a major tertiary referral center from 2008-2011 are selected. Demographic factors, types, severity and complications of burn injury as intimately as outcomes are reviewed.ResultsIn the 4-year period, 181 patients were admitted to BICU. fee-tail a ge (SD) was 41 (16) old age old. Mean (SD) total clay rear area burn was 37.2 (30.2%). Mortality was 39.5%. Mean (SD) length of stay in the BICU and hospital for patients who ultimately survived were 8.4 (13.4) and 28.5 (37.9) days respectively.Lower airway burns has a of import relationship with the surfacement of nephritic distress after multivariate analysis (Odds ratio 5.1, Confidence interval 1.1- 24.0). Greater total body control surface burns, development of acute respiratory distress syndrome and older patients with more extensive burns predispose to death rate rate as shown in table 2.In our cohort of patients, the probability of death whitethorn be estimated by this equationProbability of death= (1+ey)-1y= -7.008+0.04(TBSA) +1.791(ARDS)*+0.054(Age+TBSA)*= ARDS (0=no, 1=yes)ConclusionWe excite developed a predictive model for fatality rate in major burn patients. This may be useful in prognosis during early stages of care.IntroductionSurvival after burns injur y has improved tremendously all over the last few decadeswith the refinement of fluid resuscitation, better intensive care and early surgical censure1as about of the strategies that have significantly limitd patient outcomes. These advancements have contributed to lowering death rate rates in burns patients in Singapore to 4.5% amidst 2003-20052. Despite these advancements, however, overall mortality rates of patients with major burns remain high. legion(predicate) factors such as age, percentage body surface area burns and inhalational injuries3 have been prove to influence the prognosis and outcomes in this group of patients. The combination of these predictive factors into scoring systems that would yield an expected mortality rate for each given patient has been the subject of many studies4-6.However, most of these studies have non been performed or formalise in our local population.A robust predictive model would be useful for clinicians as a more evidence-based appro ach for counselling and prognostication at an early stage of intercession. We can even cast further treatment and intervention based on prognosis and other clinical factors. A convertible model will also provide an opportunity for audit and a basis against which new treatment modalities may be compared.Therefore, the objective of this study was to identify the prognostic variables influencing outcome in patients admitted to our burns intensive care unit and to develop a predictive model for mortality in patients with major burns.Methodsclinical careThe burns centre at the Singapore General infirmary is a major tertiary referral centre for burns injury in Singapore as well as the Southeast Asia region. Burn patients presenting at the Accident and Emergency department are assessed by the plastic surgerical team, who decide if the patient requires admission to the specialised burns unit or the burns intensive care unit. The extent and depth of burns were assessed and documented.All patients requiring intensive care, such as those with major burns, are haemodynamically unstable, or have sustained inhalational injury requiring mechanistic ventilation, are managed by a team consisting of at least a plastic surgical specialist and an anaesthetist.These patients received fluid resuscitation according to the Parklands formula. Adequacy of fluid therapy was assessed by endpoints such as hourly urine output, arterial blood pressure and central venous pressure. Early enteral nutrition, automatic ventilation and vasoactive support were initiated as required. Early surgery for escharotomy, burns excision and grafting were carried out as early as possible.PatientsThis study was approved by our centres institutional review board. The aesculapian checkup records of all burns patients admitted to the burns intensive care unit at the Singapore General Hospital over a 4-year period between January 2008 and December 2011 were reviewed retrospectively. Information includin g demographics, comorbidities, mechanism of injury, total body surface area (TBSA) burned, incidence of inhalation injury, complications such as organ failure, length of hospital stay and mortality were recorded and entered into a database.Statistical AnalysisStatistical analyses were conducted using the Statistical Package for the Social Sciences (SPSS rendering 17, SPSS Inc., Chicago, IL). Data are presented as mean and standard deviationfor continuous variables and proportions for categorical variables. Univariate comparisons of proportions and means were respectively make using Chi Square test, Fisher exact test and t test. Logistic regression and analog regression analysis was applied to study the relationship between the variables and mortality and length of stay, respectively. Variables with a slick relationship with mortality or p0.05.ResultsPatient profileDuring the 4-year study period, a total of 182 patients were admitted to the burns intensive care unit (BICU).These patient characteristics are presented in table 1. The mean age of these patients was 40.5 +/- 16 years old, with males comprising a larger percentage of the cohort (79.1%).Mean total body surface area (TBSA) burned was 37.2 +/- 30.2%. Most of the patients were healthy prior to their burns, with only a small minority having any significant medical issues. A high proportion of the patients suffered inhalational burns (83%). However, only 26 out of the 182 patients (14.3%) fulfilled the criteria for ARDS. Other significant patient characteristics and details of their burns injuries are listed in Table 1. Flame burn was the commonest injury aetiology in our patient population (88.4%). Table 2 shows the mechanism of burn injuries suffered by our group of patients. space of stayThe mean length of stay was 20.9 days. The survivors spent a mean of 8.4 days in ICU, as opposed to 6.9 days for the non-survivors. The majority of patients who survived to discharge were discharged home (table 3 ).TBSA, albumin level and sepsis were found to be significant predictors of LOS, yielding a final predictive model ofLOS = 41.608 0.234(TBSA) 0.919 (albumin) + 16.14 (sepsis*)Where *=presence of sepsis (yes=1, no=0)MortalityOut of the 182 patients, a total of 65 patients or 35.9 % did not survive the hospital stay. The mean age of these patients was 42.1 years. Mean TBSA involved was 66.8% (compared with a mean of 20.6% in the survivor group). In our analysis, we found that the non-survivor group had significantly larger TBSA burns (pTo develop the predictive model, we analysed the variables in univariate analysis. Variables with a plausible relationship with mortality or pA predictive model for mortality was thus developed as followsProbability of death = (1+ey)-1Where y = -7.008 + 0.04 (TBSA) + 1.791 (ARDS)* + 0.054( Age+TBSA)* = ARDS (no=0, yes =1)DiscussionIn this study, we elucidated the risk factors that contribute to mortality in patients admitted to the BICU, and developed a predictive model for mortality incorporating these factors. Previous mortality studies have sought to establish prognostic variables associated with burn mortality. In 1961 Baux described in a French thesis a simple empiric formula, stating that mortality rate was the sum of age and percentage area burned7. Inhalational injury was then found to be an important predictive factor and this was included in a mortality probability equation reported by Clark et al in 19868. The abbreviated burn severity index (ABSI), which is in widespread use, assigns numerical determine according to the severity of 5 prognostic variables (age, gender, inhalational injury, %TBSA and presence of full thickness burns). The sum of these variables yields a predicted mortality rate9. Similar predictive factors have been found to be germane(predicate) in several other studies3,10,11. However, these studies generated super variable predictive models, highlighting the need for individualised models for dif ferent patient groups.Our study is unique as it is one of only a handful of studies based on an Asian population2,12-14 , with even fewer attempting to develop predictive mortality models5. In addition, we only included burns intensive care unit patients in our study, as opposed to the entire burn population. Advancements in medical care and aggressive early excision and grafting of burns have led to a global reduction in burn mortality in recent times. In Singapore, the overall mortality for burns victims was found to be 4.5% between 2003 and 200512. This cash advance has also been evident in severe burns victims, with mortality falling annually from 60% in 2000 to 30% in 20032. However, death rate remains high in this group of patients, and it is our aim to boldness at the outcomes and predictive factors determining mortality in this susceptible group, and to develop a clinically relevant predictive model targeted at them.Our study found that TBSA, age+TBSA and ARDS were signifi cant predictive factors affect mortality in our ICU patients. Inhalational injury, generally accepted as a prognostic factor8,9, was not found to be significantly associated with death in our patient group. There could be several explanations for this finding. In our series, 151 or 83% of our patients were diagnosed with inhalational burns. This is a very high percentage compared to most of the other studies, though it is not entirely surprising. Our patient cohort consisted entirely of ICU patients. This unique group of patients have either sustained major burns or inhalational burns that have required ventilatory support. . The remaining 17% of patients that might have been in ICU due to reasons other than inhalational injuries may not have been sufficient in outcome to demonstrate a survival advantage, if any. Secondly the lack of universally accepted diagnostic criteria means that the diagnosing of inhalational injury can vary widely between different institutions and intensi vists, using either clinical run or fibreoptic bronchoscopy, or a combination of both. Hence it has been suggested that, the need for invasive ventilation, the determination of which is distant less complicated than the diagnosis of inhalational injury, may be a better marker for mortality risk6. In our study, we found that the presence of acute respiratory distress syndrome (ARDS), a common complication associated with major burns or severe inhalational injury, was directly associated with death. This could be an indication that the severity of inhalational injury, rather than the presence of it, may be a more suitable prognostic indicator for death, particularly in the group of patients requiring intensive care management.Since this is a retrospective study, we were not only able to collect data relating to the patients characteristics at presentation, but also susbequent clinical data as treatment progressed, such as development of ARDS, sepsis and renal failure. Clearly these factors are important as response to therapy is a vital determinant to patient outcomes. However, comprehension of these variables may not be possible at patient presentation, the point at which prediction of mortality is sometimes vital for determining the direction and aggressiveness of therapy. Perhaps future prospective trials can discover at determining predictive factors that influence mortality at various stages of treatment, creating a superior prognostic tool with which we may advise patients and families, guide therapy and perform internal audit and research.Clinicians utilising any kind of predictive model to estimate mortality probability in the clinical setting should always proceed with caution. These may be used as a tool to aid clinical decisions regarding treatment but should not replace sound clinical judgment. Neither should the outcomes be judged solely upon whether the patient lives or dies, without scant devotion for the quality of life after the hospital st ay. These endpoints are a lot more difficult to assess, and in the absence of a standardized tool the incorporation of quality of life indicators into prognostic scoring systems may still be a long way away.ConclusionIn our study, we have developed a predictive model for mortality in our cohort of burn patients admitted to the burns intensive care unit. The near step would be to validate the model in future prospective studies. A validated model can potentially help teams involved in tough clinical decisions to prognosticate and formulate treatment plans for severely burned patients. It also serves to show that further studies need to be done to validate and come up with a more robust model. We did not find a significant relationship between inhalational injury and mortality in our study, a finding consistent with several other studies.