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The impact and validity of the Berlin criteria on burn-induced ARDS: Examining mortality rates, and inhalation injury influences. A single center observational cohort study.
Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Hand and Plastic Surgery.ORCID iD: 0000-0002-5903-2918
Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Hand and Plastic Surgery.
Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Hand and Plastic Surgery.ORCID iD: 0000-0002-2500-728X
Linköping University, Department of Health, Medicine and Caring Sciences. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Diagnostics, Department of Radiology in Linköping.
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2024 (English)In: Burns, ISSN 0305-4179, E-ISSN 1879-1409, article id S0305-4179(24)00149-9Article in journal (Refereed) Epub ahead of print
Abstract [en]

BACKGROUND: As several recent studies have shown low mortality rates in burn injury induced ARDS early (≤7 days) after the burn, the Berlin criteria for the ARDS diagnosis in this setting may be disputed. Related to this issue, the present study investigated the incidence, trajectory and risk factors of early Acute Respiratory Distress Syndrome (ARDS) and outcome in burn patients, as per the Berlin criteria, along with the concurrent prevalence and influence of inhalation injury, and ventilator-acquired pneumonia (VAP).

METHODS: Over a 2.5-year period, burn patients with Total Burn Surface Area (TBSA) exceeding 10% admitted to a national burn center were included. The subgroup of interest comprised patients with more than 48 h of ventilatory support. This group was assessed for ARDS, inhalation injury, and VAP.

RESULTS: Out of 292 admissions, 62 sustained burns > 10% TBSA. Of these, 28 (45%) underwent ventilatory support for over 48 h, almost all, 24 out of 28, meeting the criteria for ARDS early, within 7 days post-injury and with a PaO2/FiO2 (PF) ratio nadir at day 5. The mortality rate for this early ARDS group was under 10%, regardless of PF ratios (mean TBSA% 34,8%). Patients with concurrent inhalation injury and early ARDS showed significantly lower PF ratios (p < 0.001), and higher SOFA scores (p = 0.004) but without impact on mortality. Organ failure, indicated by SOFA scores, peaked early (day 3) and declined in the first week, mirroring PF ratio trends (p < 0.001).

CONCLUSIONS: The low mortality associated with early ARDS in burn patients in this study challenges the Berlin criteria's for the early ARDS diagnosis, which for its validity relies on that higher mortality is linked to worsening PF ratios. The finding suggests alternative mechanisms, leading to the early ARDS diagnosis, such as the significant impact of inhalation injury on early PF ratios and organ failure, as seen in this study. The concurrence of early organ failure with declining PF ratios, supports, as expected, the hypothesis of trauma-induced inflammation/multi-organ failure mechanisms contributing to early ARDS. The study highlights the complexity in differentiating between the contributions of inhalation injury to early ARDS and the related organ dysfunction early in the burn care trajectory. The Berlin criteria for the ARDS diagnosis may not be fully applicable in the burn care setting, where the low mortality significantly deviates from that described in the original Berlin ARDS criteria publication but is as expected when considering the actual not very extensive burn injury sizes/Baux scores as in the present study.

Place, publisher, year, edition, pages
Elsevier, 2024. article id S0305-4179(24)00149-9
Keywords [en]
ARDS, Burns, Inhalation injury, Mortality ventilatory acquired pneumonia
National Category
Anesthesiology and Intensive Care
Identifiers
URN: urn:nbn:se:liu:diva-203817DOI: 10.1016/j.burns.2024.05.005PubMedID: 38777667OAI: oai:DiVA.org:liu-203817DiVA, id: diva2:1861194
Note

Funding agencies: The Carnegie Foundation, Stockholm, Sweden. King Gustaf the Vth and Queen Victoria Foundation, Stockholm and King Gustaf foundation, “Frimurarestiftelsen” Stockholm Sweden. Linköping University Hospital and Linköping University, Linköping Sweden.

Available from: 2024-05-27 Created: 2024-05-27 Last updated: 2024-05-28

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Sjöberg, FolkeElmasry, MoustafaAbdelrahman, IslamNyberg, GustenSteinvall, Ingrid

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Division of Surgery, Orthopedics and OncologyFaculty of Medicine and Health SciencesDepartment of Hand and Plastic SurgeryDepartment of Health, Medicine and Caring SciencesDepartment of Radiology in Linköping
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