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.

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.

Hydroxocobalamin is not associated with methemoglobinemia in patients with inhalation injury and suspected cyanide toxicity and a proposed algorithm for hydroxocobalamin administration.

BACKGROUND: Cyanide poisoning poses a significant threat to burn patients exposed to smoke in residential or workplace fires, leading to central nervous system dysfunction, hemodynamic instability, cardiovascular collapse, and death. Prompt administration of an effective antidote is critical. Hydroxocobalamin, a form of vitamin B12, is the gold standard treatment for cyanide toxicity, by binding to cyanide molecules and converting them into non-toxic cyanocobalamin that is eliminated by the kidneys. This mechanism is distinct from previous cyanide antidotes, which induce the formation of methemoglobin to bind to cyanide. Recent case studies have reported elevated methemoglobin levels after hydroxocobalamin administration, raising concerns regarding its safety. The current study investigates smoke inhalation patients treated with hydroxocobalamin at a single institution Burn Unit in hopes of enhancing our understanding of the complexities surrounding cyanide antidote therapy. METHODS: After Institutional Board Approval, a retrospective cohort study was conducted. Our sample comprised burn patients with inhalation injury admitted to a single institution from 2013 to 2023 and treated with hydroxocobalamin for suspected cyanide toxicity. We also analyzed a matched control cohort of similar patients with inhalation injury not treated with hydroxocobalamin. We analyzed changes and peaks in methemoglobin levels, lactate levels, blood urea nitrogen (BUN) and creatinine, ventilator days, % total body surface area (TBSA), various types of medications and dressings, and mortality. Statistical analyses included t-tests, chi-square, linear and logistic regressions, and correlation analysis. RESULTS: In the study, 36 patients with suspected inhalation injury were treated with hydroxocobalamin at the Los Angeles General (LAG) Burn Unit from 2013 to 2023, who were matched to 32 control patients with inhalation injury who were not treated with hydroxocobalamin. Demographic and baseline characteristics showed no statistically significant differences between the groups, including age, gender, BMI, and %TBSA. No significant differences were found in initial, final, peak, or change in methemoglobin levels. The study also revealed no significant disparities in initial lactate levels, mortality, kidney function tests, ventilator days, surgeries, or use of medications/treatments (e.g., Silvadene dressings, Vitamin C) between the two groups. When controlling for covariates, multiple linear regression analysis (age, gender, and %TBSA) indicated that hydroxocobalamin administration was not significantly associated with changes in methemoglobin or mortality. Increased %TBSA, however, was linked to elevated lactate levels. CONCLUSIONS: Our investigation sought to assess the potential risks associated with hydroxocobalamin administration in burn patients with concomitant inhalation injury. Contrary to our initial hypothesis, we found no statistically significant differences in methemoglobinemia, lactate levels, mortality, or kidney function. The influence of other factors, such as methemoglobinemia-inducing drugs or hydroxocobalamin's interference with co-oximetry, adds complexity. Although elevated methemoglobin levels were observed in some cases, their clinical significance was limited. However, this study's limitations, particularly the rarity of inhalation injury cases with concern for cyanide toxicity, warrant consideration. Further research is required to comprehensively elucidate the impact of hydroxocobalamin administration on burn patients' outcomes.

Frequency, complications, and mortality of inhalation injury in burn patients: A systematic review and meta-analysis protocol.

INTRODUCTION: Burns are tissue traumas caused by energy transfer and occur with a variable inflammatory response. The consequences of burns represent a public health problem worldwide. Inhalation injury (II) is a severity factor when associated with burn, leading to a worse prognosis. Its treatment is complex and often involves invasive mechanical ventilation (IMV). The primary purpose of this study will be to assess the evidence regarding the frequency and mortality of II in burn patients. The secondary purposes will be to assess the evidence regarding the association between IIs and respiratory complications (pneumonia, airway obstruction, acute respiratory failure, acute respiratory distress syndrome), need for IMV and complications in other organ systems, and highlight factors associated with IIs in burn patients and prognostic factors associated with acute respiratory failure, need for IMV and mortality of II in burn patients. METHODS: This is a systematic literature review and meta-analysis, according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). PubMed/MEDLINE, Embase, LILACS/VHL, Scopus, Web of Science, and CINAHL databases will be consulted without language restrictions and publication date. Studies presenting incomplete data and patients under 19 years of age will be excluded. Data will be synthesized through continuous (mean and standard deviation) and dichotomous (relative risk) variables and the total number of participants. The means, sample sizes, standard deviations from the mean, and relative risks will be entered into the Review Manager web analysis software (The Cochrane Collaboration). DISCUSSION: Despite the extensive experience managing IIs in burn patients, they still represent an important cause of morbidity and mortality. Diagnosis and accurate measurement of its damage are complex, and therapies are essentially based on supportive measures. Considering the challenge, their impact, and their potential severity, IIs represent a promising area for research, needing further studies to understand and contribute to its better evolution. The protocol of this review is registered on the International prospective register of systematic reviews platform of the Center for Revisions and Disclosure of the University of York, United Kingdom (https://www.crd.york.ac.uk/prospero), under number RD42022343944.

New Treatment Modality for Burn Injury-Related Acute Respiratory Distress Syndrome: High-Flow Nasal Oxygen Therapy in Major Burns.

Pulmonary insufficiency is the primary cause of death in cases of major burns accompanied by inhalation damage. It is important to consider the impact on the face and neck in flame burns. Early implementation of bronchial hygiene measures and oxygenation treatment in inhalation injury can reduce mortality. This case series presents the effects of high-flow nasal oxygen (HFNO) application on patient outcomes in major burns and inhalation injury. This report discusses 3 different patients. One patient, a 29-year-old male with 35% TBSA burns, received HFNO treatment for inhalation injury on the sixth day after the trauma. After 72 hours of HFNO application, the patient's pulmonary symptoms improved. The second patient had 60% TBSA burns and developed respiratory distress symptoms on the fifth day after the trauma. After 7 days of HFNO application, all symptoms and findings of acute respiratory distress syndrome (ARDS) were resolved. HFNO has been used for the treatment of ARDS related to major burn (60% of burned TBSA) in a 28-year-old patient, and improvement was achieved. The use of HFNO in pulmonary insufficiency among burn patients has not been reported previously. This series of patient cases demonstrates the successful application of HFNO in treating inhalation injury and burn-related ARDS. However, further clinical studies are necessary to increase its clinical utilization.

Kerosene condenses in the trachea following inhalation.

PURPOSE: We have investigated the absorption dynamics of petroleum fuel components from the analytical results of autopsy samples. METHODS: Post-mortem samples of the severely burned case, including femoral blood, intratracheal contents (mucus) and intratracheal gas-phase samples were collected, and analysed by gas chromatography-mass spectrometer with head-space solid-phase microextraction. RESULTS: The composition of flammable substances in the tracheal gas phase differed slightly from that in mucus. CONCLUSION: High-boiling point components are retained in the trachea, whereas relatively lower-boiling point components are detected predominantly in the tracheal gas phase and blood.

The impact of infection on length of stay in adult burns: A scoping review.

BACKGROUND: The disruption to the immune system and profound metabolic response to burn injury gives rise to a unique susceptibility to infection. Indeed, infection is one of the most frequently encountered post-burns complications placing significant burden on patients and healthcare system. Advancements in burn care have led to marked improvements in burn-related mortality and morbidity; however, scarce hospital resources hamper adequate burn-related care, and patient length of stay (LOS) in hospital is an important drain on such resources. The aim of this review was to assess and evaluate the existing literature relating to the impact of infections on LOS in hospitalised, adult burn patients. METHODS: Electronic searches were performed in Medline and Embase. Eligible studies were those reporting on LOS and infection in adult burn populations. Articles published before 2000 were excluded to ensure that the analysis was focused on contemporary literature that reflects current, clinical management of burn patients. RESULTS: Nineteen studies (54,397 burn patients) were included in the review. All studies were retrospective, with the majority undertaken in North America (14 studies). The mean age range was 38-67 years and the majority of patients were male. Inhalation injury was recorded in eleven studies. The most common types of infection included pneumonia, blood stream infections (BSI) and burn wound infections. Overall, there was a trend towards a positive association between infection and LOS. CONCLUSION: The results of this scoping review provide an overview of the existing literature on the relationship between infection and LOS in adult burn populations. However, significant gaps remain in knowledge which call for further high-quality research. Standardised definitions for the collection of infection data and the use of burns specific infection control guidelines are also critical to understanding and improving patient outcomes.

An Appraisal of Pharmacotherapy-Pertinent Literature Published in 2021 and 2022 for Clinicians Caring for Patients With Thermal or Inhalation Injury.

Studies focusing on pharmacotherapy interventions to aid patients after thermal injury are a minor focus in burn injury-centered studies and published across a wide array of journals, which challenges those with limited resources to keep their knowledge current. This review is a renewal of previous years' work to facilitate extraction and review of the most recent pharmacotherapy-centric studies in patients with thermal and inhalation injury. Twenty-three geographically dispersed, board-certified pharmacists participated in the review. A Medical Subject Heading-based, filtered search returned 2336 manuscripts over the previous 2-year period. After manual review, 98 (4%) manuscripts were determined to have a potential impact on current pharmacotherapy practice. The top 10 scored manuscripts are discussed. Only 17% of those reviewed were assessed to likely have little effect on current practice. The overall impact of the current cohort was higher than previous editions of this review, which is encouraging. There remains a need for investment in well-designed, high-impact, pharmacotherapy-pertinent research for patients sustaining thermal or inhalation injuries.

Intubación orotraqueal en el trauma por quemaduras en Uruguay: rol de la intubación profiláctica / Orotracheal intubation in burn trauma in Uruguay: the role of prophylactic intubation / Intubação orotraqueal no trauma por queimaduras no Uruguai: papel da intubação profilática

Introducción: La Intubación orotraqueal (IOT) profiláctica en pacientes con sospecha de Injuria Inhalatoria (II) es una práctica clínica extendida en nuestro país. La misma puede estar asociada a complicaciones y a un aumento de los costos asistenciales. Objetivo: caracterizar a la población de pacientes que ingresaron con IOT al Centro Nacional de Quemados, determinar la incidencia de Intubación orotraqueal no necesaria (IOTNN) así como las complicaciones vinculadas a la misma. Método: Estudio retrospectivo, observacional, analítico. Se incluyeron todos los pacientes con quemadura térmica ingresados al CENAQUE con vía aérea artificial entre enero de 2015 y julio 2023. Se determinaron características demográficas, circunstancias de la injuria, lugar y técnico que realizo la IOT, porcentaje de superficie corporal total quemada (SCTQ), scores de severidad, días de ARM, estado al alta y diagnóstico de II por fibrobroncoscopía. Se analizaron las complicaciones asociadas a la IOT y ARM. Dichas variables fueron contrastadas entre el grupo extubado exitosamente en las primeras 48 horas (IOTNN) y aquellos extubados luego de las 48 horas (IOTP). Resultados: Se incluyeron 562 pacientes. La incidencia de IOTNN fue 41,7% e II 46,7%. Se observaron diferencias significativas entre IOTNN y IOTP para edad [34 (24-48) versus 45 (30-62); p <0,001, para SCTQ [4% (1-11) versus 20% (6-36); p <0,001], ABSI [4 (3-5) versus 7 (5-9) p<0,001], Rev. Baux [48 (33-62) versus 77 (60-99), p <0,001], incidencia de II (32% versus 56,6%, p <0,001). La aspiración de VA (30% versus 20,2% p 0,018), extubación durante el traslado (2% versus 0% p 0,043) e incidencia de NA (Neumonía aspirativa) y NAVP (neumonía asociada a la ventilación mecánica precoz) (56,3% versus 15% p <0,001) fueron mayores en el grupo IOTP. Conclusiones: La IOTNN en los pacientes con quemaduras es frecuente en nuestro medio y se asocia a complicaciones. La misma es realizada por médicos sin formación en el manejo de la vía aérea.

Introduction: Prophylactic Orotracheal Intubation (OTI) in patients with suspected Inhalation Injury (II) is a widespread clinical practice in our country. It can be associated with complications and increased healthcare costs. Objective: To characterize the population of patients admitted with OTI to the National Burn Center, determine the incidence of unnecessary Orotracheal Intubation (UOTI), and the associated complications. Method: Retrospective, observational, analytical study. All patients with thermal burns admitted to the National Burn Center (CENAQUE) with an artificial airway between January 2015 and July 2023 were included. Demographic characteristics, injury circumstances, location, and technician performing the OTI, percentage of total body surface area burned (TBSA), severity scores, days on mechanical ventilation, discharge status, and diagnosis of II by fibrobronchoscopy were determined. Complications associated with OTI and mechanical ventilation were analyzed. These variables were compared between the group extubated successfully within the first 48 hours (UOTI) and those extubated after 48 hours (necessary OTI, NOTI). Results: 562 patients were included. The incidence of UOTI was 41,7% and II 46,7%. Significant differences were observed between UOTI and NOTI in age [34 (24-48) versus 45 (30-62); p <0.001], TBSA [4% (1-11) versus 20% (6-36); p <0,001], ABSI [4 (3-5) versus 7 (5-9) p<0,001], Baux score [48 (33-62) versus 77 (60-99), p <0,001], incidence of II (32% versus 56.6%, p <0,001). Aspiration of the airway (30% versus 20,2% p 0,018), extubation during transport (2% versus 0% p 0,043), and incidence of aspiration pneumonia (AP) and early ventilator-associated pneumonia (VAP) (56,3% versus 15% p <0,001) were higher in the NOTI group. Conclusions: UOTI in burn patients is frequent in our setting and is associated with complications. It is performed by physicians without training in airway management.

Introdução: A intubação orotraqueal (IOT) profilática em pacientes com suspeita de lesão por inalação (LI) é uma prática clínica difundida em nosso país. Esta prática pode estar associada a complicações e ao aumento dos custos assistenciais. Objetivo: Caracterizar a população de pacientes que ingressaram com IOT no Centro Nacional de Queimados, determinar a incidência de intubação orotraqueal desnecessária (IOTD) e as complicações associadas. Método: Estudo retrospectivo, observacional, analítico. Foram incluídos todos os pacientes com queimadura térmica admitidos no CENAQUE com via aérea artificial entre janeiro de 2015 e julho de 2023. Foram determinadas características demográficas, circunstâncias da lesão, local e técnico que realizou a IOT, porcentagem da superfície corporal total queimada (SCTQ), escores de gravidade, dias de ventilação mecânica, estado na alta e diagnóstico de LI por fibrobroncoscopia. Complicações associadas à IOT e à ventilação mecânica foram analisadas. Essas variáveis foram comparadas entre o grupo extubado com sucesso nas primeiras 48 horas (IOTD) e aqueles extubados após 48 horas (IOTP). Resultados: Foram incluídos 562 pacientes. A incidência de IOTD foi de 41,7% e LI de 46,7%. Diferenças significativas foram observadas entre IOTD e IOTP em relação à idade [34 (24-48) versus 45 (30-62); p <0,001], SCTQ [4% (1-11) versus 20% (6-36); p <0,001], ABSI [4 (3-5) versus 7 (5-9) p<0,001], índice de Baux [48 (33-62) versus 77 (60-99), p <0,001], incidência de LI (32% versus 56,6%, p <0,001). A aspiração de via aérea (30% versus 20,2% p 0,018), extubação durante o transporte (2% versus 0% p 0,043) e incidência de pneumonia aspirativa (PA) e pneumonia associada à ventilação mecânica precoce (NAVM) (56,3% versus 15% p <0,001) foram maiores no grupo IOTP. Conclusões: A IOTD em pacientes com queimaduras é frequente em nosso meio e está associada a complicações. A mesma é realizada por médicos sem formação no manejo da via aérea.

[Advances on the application of physical airway clearance techniques in the treatment of inhalation injury].

Although the treatment of patients with burns combined with inhalation injury has achieved great success, from the perspective of epidemiology, inhalation injury is still the most common cause of death in mass burns. Such patients often suffered burns of large total body surface area, which is difficult to treat, with airway management as one of the core links. Physical airway clearance technique (ACT) acts on a patient's respiratory system by physical means, to discharge secretions and foreign bodies in the airway, achieve airway clearance, and improve gas exchange. In addition, the technique can prevent or alleviate many complications, thereby improving the clinical outcome of patients with inhalation injury. This article reviews the application of physical ACT in the field of inhalation injury, and to provide decision-making basis for clinical medical staff to choose physical ACT corresponding to the patient's condition.

Insignificant Difference in Early Post-injury Gene Expression Between Patients with Burns Only and Those with Inhalation Injury: A Bioinformatics Analysis.

Airway obstruction is fatal but common among burn patients in the early period after inhalation injury, during which most tracheotomies are performed within 48 h post-injury. Inflammation is common in laryngoscopy; however, the related gene expression has rarely been studied. In this study, we obtained the data of healthy control and patient samples collected within 8-48 hours post-injury from the Gene Expression Omnibus database and classified them into 10 inhalation-injury patients, 6 burn-only, and 10 healthy controls. Differential gene expression was identified between the patient groups; however, principal component analysis and cluster analysis indicated a similarity between groups. Furthermore, enrichment analysis, Kyoto Encyclopedia of Genes and Genomes, and gene set enrichment analyses showed no significant differences in immune regulation and cell adjustment between the patient groups; but differences were shown when comparing either patient group to the healthy control group, including prominent regulation in inflammatory cells, infection, and cell adjustment. Thus, the gene expression in inhalation injury and burn-only patients does not significantly differ in the early period after injury, especially in inflammation, indicating the absence of specific diagnostic markers or anti-inflammatory treatment in inhalation injury patients, with the potential to identify more subtle differences. Further research is warranted.

Protection of laryngeal mucosa and function in laryngeal burns by heat absorption of perilaryngeal tissue.

OBJECTIVE: The laryngeal tissue carries most of the heat during inhalation injury. This study aims to explore the heat transfer process and the severity of injury inside laryngeal tissue by horizontally studying the temperature rise process at various anatomical layers of the larynx and observing the thermal damage in various parts of the upper respiratory tract. METHODS: The 12 healthy adult beagles were randomly divided into four groups, and inhaled room temperature air (control group), dry hot air of 80 °C (group I), 160 °C (group II), and 320 °C (group III) for 20 min, respectively. The temperature changes of the glottic mucosal surface, the inner surface of the thyroid cartilage, the external surface of the thyroid cartilage, and subcutaneous tissue were measured every minute. All animals were immediately sacrificed after injury, and pathological changes in various parts of laryngeal tissue were observed and evaluated under a microscope. RESULTS: After inhaling hot air of 80 °C, 160 °C and 320 °C, the increase of laryngeal temperature in each group was ΔT = 3.57 ± 0.25 °C, 7.83 ± 0.15 °C, 11.93 ± 0.21 °C. The tissue temperature was approximately uniformly distributed, and the difference was not statistically significant. The average laryngeal temperature-time curve showed that the laryngeal tissue temperature in group I and group II showed a trend of "first decrease and then increase", except that the temperature of group III directly increased with time. The prominent pathological changes after thermal burns mainly concluded necrosis of epithelial cells, loss of the mucosal layer, atrophy of submucosal glands, vasodilatation, erythrocytes exudation, and degeneration of chondrocytes. Mild degeneration of cartilage and muscle layers was also observed in mild thermal injury. Pathological scores indicated that the pathological severity of laryngeal burns increased significantly with the increase of temperature, and all layers of laryngeal tissue were seriously damaged by 320 °C hot air. CONCLUSIONS: The high efficiency of tissue heat conduction enabled the larynx to quickly transfer heat to the laryngeal periphery, and the heat-bearing capacity of perilaryngeal tissue has a certain degree of protective effect on laryngeal mucosa and function in mild to moderate inhalation injury. The laryngeal temperature distribution was in accordance with the pathological severity, and the pathological changes of laryngeal burns provided a theoretical basis for the early clinical manifestations and treatment of inhalation injury.

Inhalation Injury: Which Providers Can Assess the Need for Intubation?

Previous studies have suggested that many burn patients undergo unnecessary intubation due to concern for inhalation injury. We hypothesized that burn surgeons would intubate burn patients at a lower rate than non-burn acute care surgeons (ACSs). We performed a retrospective cohort study of all patients admitted to an American Burn Association-verified burn center who presented emergently following burn injury from June 2015 to December 2021. Patients excluded include polytrauma patients, isolated friction burns, and patients intubated prior to hospital arrival. Our primary outcome was intubation rates between burn and non-burn ACSs. 388 patients met inclusion criteria. 240 (62%) patients were evaluated by a burn provider and 148 (38%) were evaluated by a non-burn provider; the groups were well-matched. In total, 73 (19%) of patients underwent intubation. There was no difference in the rate of emergent intubation, diagnosis of inhalation injury on bronchoscopy, time to extubation, or incidence of extubation within 48 hours between burn and non-burn ACSs. We found no difference between burn and non-burn ACSs in the airway evaluation and management of burn patients. Surgical providers with acute care surgery backgrounds and Advanced Trauma Life Support training are well-equipped for initial airway management in burn patients. Further studies should seek to compare other types of provider groups to identify opportunities for intervention and education in preventing unnecessary intubations.

Machine learning approach for predicting inhalation injury in patients with burns.

BACKGROUND: The coronavirus disease pandemic has had a tangible impact on bronchoscopy for burn inpatients due to isolation and triage measures. We utilised the machine-learning approach to identify risk factors for predicting mild and severe inhalation injury and whether patients with burns experienced inhalation injury. We also examined the ability of two dichotomous models to predict clinical outcomes including mortality, pneumonia, and duration of hospitalisation. METHODS: A retrospective 14-year single-centre dataset of 341 intubated patients with burns with suspected inhalation injury was established. The medical data on day one of admission and bronchoscopy-diagnosed inhalation injury grade were compiled using a gradient boosting-based machine-learning algorithm to create two prediction models: model 1, mild vs. severe inhalation injury; and model 2, no inhalation injury vs. inhalation injury. RESULTS: The area under the curve (AUC) for model 1 was 0·883, indicating excellent discrimination. The AUC for model 2 was 0·862, indicating acceptable discrimination. In model 1, the incidence of pneumonia (P < 0·001) and mortality rate (P < 0·001), but not duration of hospitalisation (P = 0·1052), were significantly higher in patients with severe inhalation injury. In model 2, the incidence of pneumonia (P < 0·001), mortality (P < 0·001), and duration of hospitalisation (P = 0·021) were significantly higher in patients with inhalation injury. CONCLUSIONS: We developed the first machine-learning tool for differentiating between mild and severe inhalation injury, and the absence/presence of inhalation injury in patients with burns, which is helpful when bronchoscopy is not available immediately. The dichotomous classification predicted by both models was associated with the clinical outcomes.

Delayed Tracheoesophageal Fistula and Refractory Respiratory Failure Caused by Inhalation Burns and Emergency Venovenous ECMO to Facilitate Its Management: A Case Report.

Acquired tracheoesophageal fistulae are uncommon in burn patients but can occur as a complication of inhalation injury. We report a case of a 30-yr-old male patient presenting after suffering from inhalation and 25% total body surface area burns. On postburns day 14, he developed a massive tracheoesophageal fistula causing refractory acute respiratory failure. Veno-venous extracorporeal membrane (VV ECMO) oxygenation was initiated without systemic anticoagulation via bi-femoral cannulation under transthoracic echocardiography guidance. He underwent successful 5-hr apnoeic ventilation-assisted surgical repair of the fistula via a right posterolateral thoracotomy. ECMO was discontinued after 36 hr, and he was discharged to the ward after 33 d in the intensive care unit. Inhalation burn injury can cause a delayed life-threatening tracheoesophageal fistula. Surgical repair can be successfully performed for this condition. VV- ECMO can be used to facilitate prolonged apnoeic surgery and to manage refractory respiratory failure due to this condition.

Acute kidney injury in burns in the intensive care unit: A retrospective research.

BACKGROUND: Acute kidney injury (AKI) is one of the common complications, associated with high mortality and morbidity in patients with burn injuries. This study aimed to determine the frequency of AKI development, its affective factors, and mortality rates according to kidney disease improving global outcomes (KDIGO) criteria in the burn patients. METHODS: The study included patients who are hospitalized for at least 48 h and aged >18 years, whereas patients with a renal transplant, chronic renal failure, undergoing hemodialysis, <18 years of age, with a glomerular filtration rate of <15 on admission, and toxic epidermal necrolysis was excluded from the study. KDIGO criteria were used to evaluate the occurrence of AKI. Burn mech-anism, total body surface area, inhalation injury respiratory tract burn, fluid replacement at 72 h with Parkland Formula, mechanical ventilator support, inotrope/vasopressor support, intensive care unit, lenght of stay, mortality, abbreviated burn severity index (ABSI), acute physiology, and chronic health evaluation II (APACHE II) ve Sequential organ failure assessment (SOFA) were recorded. RESULTS: A total of 48 patients were included in our study, of which 26 (54.2%) developed AKI (+), whereas 22 (45.8%) did not (-). The mean total burn surface area was 47.30% in the AKI (+) group and 19.88% in the AKI (-) group. Mean scores of ABSI, II (APACHE II), and SOFA, the mechanical ventilation and inotrope/vasopressor support and the presence of sepsis were significantly higher in the AKI (+). No mortality was determined in the AKI (-) group, whereas 34.6% in the AKI (+) group which was significantly high. CONCLUSION: AKI was related to high morbidity and mortality in patients with burns. Using KDIGOs, classification in daily fol-low-up is useful in early diagnosis.

Multiplexed Human Gene Expression Analysis Reveals a Central Role of the TLR/mTOR/PPARγ and NFkB Axes in Burn and Inhalation Injury-Induced Changes in Systemic Immunometabolism and Long-Term Patient Outcomes.

Burn patients are subject to significant acute immune and metabolic dysfunction. Concomitant inhalation injury increases mortality by 20%. In order to identify specific immune and metabolic signaling pathways in burn (B), inhalation (I), and combined burn-inhalation (BI) injury, unbiased nanoString multiplex technology was used to investigate gene expression within peripheral blood mononuclear cells (PBMCs) from burn patients, with and without inhalation injury. PBMCs were collected from 36 injured patients and 12 healthy, non-burned controls within 72 h of injury. mRNA was isolated and hybridized with probes for 1342 genes related to general immunology and cellular metabolism. From these specific gene patterns, specific cellular perturbations and signaling pathways were inferred using robust bioinformatic tools. In both B and BI injuries, elements of mTOR, PPARγ, TLR, and NF-kB signaling pathways were significantly altered within PBMC after injury compared to PBMC from the healthy control group. Using linear regression modeling, (1) DEPTOR, LAMTOR5, PPARγ, and RPTOR significantly correlated with patient BMI; (2) RPTOR significantly correlated with patient length of stay, and (3) MRC1 significantly correlated with the eventual risk of patient mortality. Identification of mediators of this immunometabolic response that can act as biomarkers and/or therapeutic targets could ultimately aid the management of burn patients.

Mortality prediction models for severe burn patients: Which one is the best?

BACKGROUND: For prediction of mortality and clinical course, various scoring systems had been developed. We choose four well known burn specific scoring systems and a general scoring system that using in Intensive Care Units. The primary outcome of this study was evaluate the predictive performances of this models and define the optimal one for our patient population. METHODS: Variables analyzed were age, gender, burn type, total burned surface area (TBSA), total partial thickness burn area, total full thickness burn area, inhalation injuries, mechanical ventilation supports, blood products usage, total scores of Abbreviated Burn Severity Index (ABSI), revised Baux, Belgian Outcome in Burn Injury, Fatality by Longevity, Acute Physiology and Chronic Health Eval-uation II (APACHE II) score, Measured Extent of burn and Sex (FLAMES) and APACHE II, and their relations with mortality. RESULTS: In our study, a statistically significant relationship was found with mortality between age, TBSA, full thickness burn percent-age, inhalation injury, burn type, and it was similar to literature. Female gender was found to be a significant risk factor for mortality. CONCLUSION: We compared several burn mortality scoring systems and their predictional mortality rates. ABSI scores of patients for estimated mortality rates were similar to our mortality rate. Consequently, it was thought that ABSI was included all mortality-re-lated parameters.