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.

Predicting mortality and admission duration for burns patients in Queensland, Australia: a retrospective cohort study.

BACKGROUND: Burn outcomes can be improved by reducing mortality and hospital admission duration. This increases patient quality of life and reduces hospital-associated complications and costs. This study aimed to develop a model with which to predict burns inpatient mortality and admission duration. METHODS: Multiple logistic and linear regression were used to investigate mortality and admission duration by age, total body surface area, sex, delay to presentation, the use of surgery, discharge distance and period. RESULTS: One thousand four hundred and seventy nine patients (747 pre-COVID and 732 during COVID) were admitted between the study dates. Using multiple logistic regression, age and total body surface area predicted mortality LR X2 (5), P < 0.001, pseudo R2  = 0.57. Using multiple linear regression, age, total body surface area and the use of surgery predicted admission duration F (7, 1455) = 161.42, P < 0.001, R2  = 0.44. Sex, delay to presentation, period and discharge distance did not predict mortality or admission duration. CONCLUSIONS: In our institution, mortality was increased by 8.6% for each additional year of age and by 11.3% for each additional percentage total body surface area. Likewise, admission duration was prolonged by 1 day for every 7 years of increased age, by 1 day for each additional percentage total body surface area or by 7 days if surgery was required. These models have been incorporated into a set of prediction tables for mortality and admission duration for use in our institute that can guide patient and family discussions.

Iron status in patients with burn anaemia.

PURPOSE: The iron status of burn patients is poorly understood, limited by difficulty interpreting conventional iron studies in the context of the acute phase response triggered by critical illness. The aim of this study was to evaluate the iron status of patients with burn anaemia using recent post-operative guidelines. METHODOLOGY: This retrospective cohort study utilised data collected from records for adult patients admitted to the Royal Brisbane and Women's Hospital with burns to at least 15% TBSA. Rates of iron deficiency, defined as ferritin< 100 µg/L or ferritin 100-300 µg/L with transferrin saturation< 20%, and low iron availability, defined as transferrin saturation< 20%, were calculated. RESULTS: Of 60 included patients (90% male), 16 (27%) underwent iron studies. 11 (18%) were treated with intravenous iron. Iron studies showed that five (31%) patients had evidence of iron deficiency, and ten out of 12 (83%) had evidence of reduced iron availability. Two patients (40%) with evidence of iron deficiency were not treated with intravenous iron. CONCLUSION: Application of recent guidelines for interpretation of conventional iron studies in patients with inflammatory states may improve the identification of iron deficiency in burn patients. Iron deficiency may be an under-recognised and under-treated contributor to burn anaemia.

Intravenous iron therapy to treat burn anaemia: A retrospective cohort study.

PURPOSE: Intravenous iron is an effective treatment for anaemia in many populations but has not been evaluated in those with burn anaemia. This study aimed to evaluate the efficacy and safety of intravenous iron to manage burn anaemia. METHODOLOGY: This was a retrospective cohort study of patients admitted to the Royal Brisbane and Women's Hospital with burns to at least 15% total body surface area (TBSA). Data collected from patient records included demographics, treatment details, and outcomes including length of stay, blood transfusions, and serum haemoglobin concentrations. Linear mixed effects regression models were used to assess the effect of treatment with intravenous iron on haemoglobin over time. RESULTS: Sixty patients met inclusion criteria, with 11 (18%) treated using intravenous iron. Those treated with intravenous iron had higher TBSA burns (median 39% vs 18%, P = 0.0005), more operations (3 vs 1, P = 0.0012), and more blood transfusions (median 8 units vs 0 units, P = 0.0002). One patient (9%) experienced a minor adverse drug reaction from intravenous iron. When examining the change in modelled haemoglobin levels over the first 14 days following the last major operation, the change in the intravenous iron group (11.22 g/L) was 14.56 g/L greater than the change in the group not receiving intravenous iron (-3.34 g/L, P = 0.0282). CONCLUSION: This exploratory study provides preliminary evidence of benefit and safety of intravenous iron treatment on burn anaemia recovery.

Caravan explosions: a case series of burns patients at the Royal Brisbane and Women's Hospital.

BACKGROUND: Caravan explosions due to gas cylinder explosions or gas leaks are responsible for a small but significantly injured group of burns patients. Those involved in explosions are sometimes assumed to be at risk of primary blast wave injury; however, the likelihood of such injuries is unclear. The aim of this research was to seek evidence of primary blast injury in groups defined by clinicians as having sustained burns in explosive and non-explosive events. METHODS: This is a single-centre case series of patients with caravan-related burns from 2009 to 2019, identified using the burns data registry at the Royal Brisbane and Women's Hospital. Patients were divided into two groups based on the mechanism of injury, with injuries sustained from either a gas bottle explosion (group 1) or from gas ignition (group 2). RESULTS: Twenty-one patients were identified over the 10-year period. The explosion group suffered more extensive burns, with a median % total body surface area of 31% (23.5-43.5) and 9.5% (5-20) in group 1 and group 2, respectively (P = 0.01). There was a numerically longer median hospital and intensive care unit length of stay in group 1. In multivariable analysis, there were no statistically significant predictors of intensive care unit or hospital length of stay. None of the patients appeared to have suffered any of the expected effects of primary blast wave injury. CONCLUSION: Gas bottle explosions in caravans uncommonly, if ever, result in a blast wave of sufficient energy to cause primary blast injury.

Rare case of adhesive large bowel obstruction in acute burn patient: management of open abdomen with ABTHERA ADVANCE™ Open Abdomen Dressing.

Large bowel obstructions (LBO) are rarely caused by adhesions. Surgical management of this condition may require an open approach but closure may not always be possible. There are many temporizing measures in clinical use; however, the ABTHERA ADVANCE™ Open Abdomen Dressing has demonstrated significantly improved outcomes compared to other negative pressure wound therapy dressings. There are few cases in the literature documenting adhesive LBO and none in an acutely unwell burn patient whose abdomen subsequently required the ABTHERA ADVANCE™ Open Abdomen Dressing. We emphasize the importance of considering adhesive LBO as a differential in bowel obstruction and highlight a novel but effective way of managing it in our unique case.