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Organ dysfunction among patients with major burns
Linköping University, Department of Clinical and Experimental Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Sinnescentrum, Department of Plastic Surgery, Hand surgery UHL.
2011 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The number of patients who are admitted for in-hospital care in Sweden because of burns is about 12/100,000, and only a small proportion of these have larger burns. Among them, and particularly among those who die in hospital, a condition referred to as “organ dysfunction” is common and an important factor in morbidity and mortality. The fact that the time of the initial event is known, and the magnitude of the insult is quantifiable, makes the burned patient ideal to be studied. In this doctoral thesis organ dysfunction and mortality were studied in a descriptive, prospective, exploratory study (no interventions or control groups) in patients admitted consecutively to a national burn centre in Sweden.

The respiratory dysfunction that is seen after burns was found to be equally often the result of acute respiratory distress syndrome and inhalation injury. We found little support for the idea that this early dysfunction is caused by pneumonia, ventilator-induced lung injury, or sepsis. Acute kidney injury (AKI) was also common, and mortality was associated with severity. Importantly, renal dysfunction recovered among the patients who survived. Pulmonary dysfunction and systemic inflammatory response syndrome developed before the onset of AKI. Sepsis was a possible aggravating factor for AKI in 48% of 31 patients; but we could find no support for the idea that late AKI was mainly associated with sepsis. We found that older age (over 60 years), greater TBSA%, and respiratory dysfunction were associated with increased mortality, but there was no association between the overall mortality and sex. We also found that early transient liver dysfunction was common, and recorded early hepatic “hyper”- function among many young adults. Persistent low values indicating severe liver dysfunction were found among patients who eventually died.

We conclude from this investigation that overall organ dysfunction is an early and common phenomenon among patients with severe burns. Our data suggest that the prognosis of organ dysfunction among these patients is good, and function recovers among most survivors. Multiple organ failure was, however, the main cause of death. The findings of the early onset in respiratory dysfunction and a delay in signs of sepsis are congruous with the gutlymphatic hypothesis for the development of organ dysfunction, and the idea of the lung as an inflammatory engine for its progression. We think that the early onset favours a syndrome in which organ dysfunction is induced by an inflammatory process mediated by the effect of the burn rather than being secondary to sepsis.

Our data further suggest that clinical strategies to improve burn care further should be focused on early interventions, interesting examples of which include: selective decontamination of the gastrointestinal tract to prevent translocation of gut-derived toxic and inflammatory factors; optimisation of fluid replacement during the first 8 hours after injury by goal-directed resuscitation; and possible improvement in the fluid treatment given before admission.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press , 2011. , 70 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1248
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-70061ISBN: 978-91-7393-155-7 (print)OAI: oai:DiVA.org:liu-70061DiVA: diva2:435095
Public defence
2011-09-08, Berzeliussalen, Campus US, Linköpings universitet, Linköping, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2011-08-17 Created: 2011-08-17 Last updated: 2012-03-13Bibliographically approved
List of papers
1. Acute respiratory distress syndrome is as important as inhalation injury for the development of respiratory dysfunction in major burns
Open this publication in new window or tab >>Acute respiratory distress syndrome is as important as inhalation injury for the development of respiratory dysfunction in major burns
2008 (English)In: Burns, ISSN 0305-4179, E-ISSN 1879-1409, Vol. 34, no 4, 441-451 p.Article in journal (Refereed) Published
Abstract [en]

Respiratory dysfunction is common after major burns. The pathogenesis is, however, still under debate. The aim was to classify and examine underlying reasons for respiratory dysfunction after major burns. Consecutive adult patients (n = 16) with a total burned body surface area of 20% or more who required mechanical ventilation were assessed for acute respiratory distress syndrome (ARDS), inhalation injury, sepsis, ventilator-associated pneumonia (VAP), ventilator-induced lung injury (VILI), using conventional criteria, together with measurements of cardiovascular variables and viscoelastic properties of the lung including extravascular lung water.

Nine patients developed ARDS within 6 days of injury. ARDS was characterized by a large reduction in the PEEP-adjusted PaO2:FiO2 ratio, pulmonary compliance, and increased extra vascular lung water together with increased renal dysfunction rates. Seven patients fulfilled the criteria for inhalation injury. They also had decreased PaO2:FiO2 ratios. There was an increase in extra vascular lung water and a decrease in compliance measures though not to the same extent as in the ARDS group. White blood cell counts dropped from (mean) 21.4 x 10exp9 /l (95% CI 15.3-27.5) in day 1 to 4.3 x 10exp9 /l (2.2-6.5) on day 3, and lower values tended to correlate with the development of ARDS. Sepsis occurred before onset of ARDS in only three cases. One patient fulfilled the criteria for VAP, but none was thought to have VILI.

We found that respiratory dysfunction after burns is multifactorial, and ARDS and inhalation injury are most important. The early onset of ARDS, together with the changes in white blood cell count and organ dysfunction, favours a syndrome in which respiratory distress is induced by an inflammatory process mediated by the effect of the burn rather than being secondary to sepsis. The power of these conclusions is, however, hampered by the small number of patients in this study.    

Keyword
Burns, Inflammation, Leukocytes, Organ dysfunction, Permeability, Viscoelastic properties
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-43096 (URN)10.1016/j.burns.2007.10.007 (DOI)71559 (Local ID)71559 (Archive number)71559 (OAI)
Available from: 2009-10-10 Created: 2009-10-10 Last updated: 2017-12-13Bibliographically approved
2. Acute kidney injury is common, parallels organ dysfunction or failure, and carries appreciable mortality in patients with major burns: a prospective exploratory cohort study
Open this publication in new window or tab >>Acute kidney injury is common, parallels organ dysfunction or failure, and carries appreciable mortality in patients with major burns: a prospective exploratory cohort study
2008 (English)In: Critical Care, ISSN 1364-8535, E-ISSN 1466-609X, Vol. 12, no R124Article in journal (Refereed) Published
Abstract [en]

Introduction: The purpose of this study was to determine the incidence, time course, and outcome of acute kidney injury after major burns and to evaluate the impact of possible predisposing factors ( age, gender, and depth and extent of injury) and the relation to other dysfunctioning organs and sepsis.

Method: We performed an explorative cohort study on patients with a TBSA% (percentage burned of total body surface area) of 20% or more who were admitted to a national burn centre. Acute kidney injury was classified according to the international consensus classification of RIFLE ( Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease). Prospectively collected clinical and laboratory data were used for assessing organ dysfunction, systemic inflammatory response, and sepsis.

Results: The incidence of acute kidney injury among major burns was 0.11 per 100,000 people per year. Of 127 patients, 31 (24%) developed acute kidney injury (12% Risk, 8% Injury, and 5% Failure). Mean age was 40.6 years (95% confidence interval [CI] 36.7 to 44.5), TBSA% was 38.6% (95% CI 35.5% to 41.6%), and 25% were women. Mortality was 14% and increased with increasing RIFLE class (7% normal, 13% Risk, 40% Injury, and 83% Failure). Renal dysfunction occurred within 7 days in 55% of the patients and recovered among all survivors. Age, TBSA%, and extent of full thickness burns were higher among the patients who developed acute kidney injury. Pulmonary dysfunction and systemic inflammatory response syndrome were present in all of the patients with acute kidney injury and developed before the acute kidney injury. Sepsis was a possible aggravating factor in acute kidney injury in 48%. Extensive deep burns (25% or more full thickness burn) increased the risk for developing acute kidney injury early (risk ratio 2.25).

Conclusions: Acute kidney injury is common, develops soon after the burn, and parallels other dysfunctioning organs. Although acute kidney injury recovered in all survivors, in higher acute kidney injury groups, together with cardiovascular dysfunction, it correlated with mortality.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-16218 (URN)10.1186/cc7032 (DOI)
Available from: 2009-02-27 Created: 2009-01-09 Last updated: 2017-12-14Bibliographically approved
3. Mortality After Thermal Injury: No Sex-Related Difference
Open this publication in new window or tab >>Mortality After Thermal Injury: No Sex-Related Difference
2011 (English)In: JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE, ISSN 0022-5282, Vol. 70, no 4, 959-964 p.Article in journal (Refereed) Published
Abstract [en]

Background: Young women have been reported to be more likely to survive than men after severe trauma. Girls also have less inflammation and hypermetabolism after major burns. Yet burned women have been found to have a twofold greater risk of death than men. Our aim was to find out if there is a sex-related difference in mortality after thermal injury, particularly in the age group between 16 years and 49 years, when hormonal differences would be most influential. Methods: All patients admitted to the Linkoping University Hospital Burn Unit with thermal injuries during the years 1993-2008 were included and the variables percentage burned total body surface area (TBSA%), age, type of burn, mechanical ventilation, and year were included in a multiple regression (Poisson log) model. Results: Of 1,119 patients with thermal injury, 792 (71%) were men. Crude mortality was 5% among men, and 8% among women (p = 0.04). After adjustment for age and TBSA%, there was no correlation between mortality and sex, in any age group. Eight men and four women died in the group of young adults (16-49 years) in which TBSA% correlated with mortality (p andlt; 0.01) but age did not. Mortality was 14% (32 of 221) among the men and 23% (23 of 102) of women in the group of older adults (50 years and older), and both age and TBSA% correlated with mortality (p andlt; 0.001). Conclusions: There is no relevant sex-related difference in survival after thermal injury. The conclusion is, however, tempered by the few deaths, particularly among younger adults.

Place, publisher, year, edition, pages
LIPPINCOTT WILLIAMS and WILKINS, 530 WALNUT ST, PHILADELPHIA, PA 19106-3621 USA, 2011
Keyword
Burns, Outcome, Dimorphism, Age, Total body surface area
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-67966 (URN)10.1097/TA.0b013e3181e59dbe (DOI)000289558700039 ()
Available from: 2011-05-04 Created: 2011-05-04 Last updated: 2012-03-25
4. Incidence of early burn-induced effects on liver functionas reflected by the plasma disappearance rate of indocyanine green: a prospective descriptive cohort study
Open this publication in new window or tab >>Incidence of early burn-induced effects on liver functionas reflected by the plasma disappearance rate of indocyanine green: a prospective descriptive cohort study
2012 (English)In: Burns, ISSN 0305-4179, E-ISSN 1879-1409, Vol. 38, no 2, 214-224 p.Article in journal (Refereed) Published
Abstract [en]

Organ dysfunction and failure are important for burned patients as they increase morbidity and mortality. Recent evidence has suggested that organ injuries are occurring earlier after burns, and are more common, than previously thought. In this study we have assessed the extent to which liver function, assessed by the plasma disappearance rate of indocyanine green (PDRICG), is affected in patients with severe burns. This is a prospective, descriptive exploratory study at a national burn centre. Consecutive adult patients with a total burned body surface area (TBSA%) of 20% or more, were examined prospectively by dynamic (PDRICG) and static liver function tests (plasma: bilirubin concentration, prothrombin complex, and alanine aminotransferase and alkaline phosphatase activities). Early liver dysfunction was common, as assessed by both dynamic (7 of 17) and static liver function tests (6-17 of 17). A regression model showed that changes in PDRICG were associated with age, TBSA%, plasma bilirubin concentration, plasma C-reactive protein concentration, and cardiac index. Persistent and advanced hepatic dysfunction was associated with mortality. The PDRICG seems to give a comprehensive assessment of liver function after major burns. Hepatic dysfunction seems to be as common as dysfunction in other organs. We interpret the recorded effects on liver function as part of a multiple organ dysfunction syndrome, primarily induced by the burn itself. However, this needs to be further investigated.

Place, publisher, year, edition, pages
Elsevier, 2012
Keyword
Burns, organ dysfunction, hepatic dysfunction, plasma disappearance rate of indocyanine green, age, cardiac index, sepsis
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-70059 (URN)10.1016/j.burns.2011.08.017 (DOI)000301621500010 ()
Note

On the day of the defence date the status of this article was "Manuscript".

Funding agencies|Department of Hand and Plastic Surgery, Linkoping University Hospital||PULSION Medical Systems AG, Munich, Germany||

Available from: 2011-08-17 Created: 2011-08-17 Last updated: 2017-12-08Bibliographically approved

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