The predictive validity of the Functional Assessment for Burns - Critical Care (FAB-CC) score for discharge outcomes in major burns.

INTRODUCTION: Physical function scoring of burn ICU patients is recommended but currently validated scores are lacking. OBJECTIVE: To evaluate the predictive validity of the FAB -CC for burn ICU patients' discharge outcome. METHODS: All patients underwent daily exercise and FAB -CC screen if they were stable. Two FAB-CC scores were performed; FAB-CC1 on the first day the patient passed the FAB-CC screen, FAB-CC2 within 48 h before ICU discharge. Hospital discharge outcome was defined as transfer for further inpatient rehabilitation or home with social care versus home with no social care. 76 patients' data were entered into the analyses. We used multiple logistic regression analysis to identify variables that predict discharge outcome. RESULTS: Increasing patient age (p = 0.001), duration of ventilation (p = 0.0003), ICU Length of stay (LOS) (p = 0.0001), total hospital LOS (p < 0.0001), presence of cardiopulmonary disease (p = 0.008), neurological disorder (p = 0.0003) and psychiatric illness (p = 0.003) are positively associated with transfer for inpatient rehabilitation or home with social care. Increasing FAB-CC1 (p < 0.0001) and FAB -CC2 (p = 0.0001) are negatively associated with transfer for inpatient rehabilitation or home with social care. The most predictive model for discharge outcome combined the variables patient age, FAB-CC1, FAB-CC2 and psychiatric illness. Patient age (p = 0.01), FAB-CC1 (p = 0.02) and psychiatric illness (p = 0.009) independently predict discharge outcome. CONCLUSIONS: FAB-CC2 is associated with, and FAB-CC1 has predictive validity for, patient hospital discharge outcome. These findings, in conjunction with our earlier work, confirm clinical utility of the FAB-CC for burns ICU patients.

Increasing the utility of the Functional Assessment for Burns Score: Not just for major burns.

The Functional Assessment for Burns (FAB) score is established as an objective measure of physical function that predicts discharge outcome in adult patients with major burn. However, its validity in patients with minor and moderate burn is unknown. This is a multi-centre evaluation of the predictive validity of the FAB score for discharge outcome in adult inpatients with minor and moderate burns. FAB assessments were undertaken within 48 h of admission to (FAB 1), and within 48 h of discharge (FAB 2) from burn wards in 115 patients. Median age was 45 years and median burn size 4%. There were significant improvements in the patients' FAB scores (p<0.0001), 98 patients were discharged home (no social care) and 17 patients discharged to further inpatient rehabilitation or home with social care. FAB 1 score (≤ 14) is strongly associated with discharge to inpatient rehabilitation or home with social care (p=0.0001) and as such can be used to facilitate early discharge planning. FAB 2 (≤ 30) independently predicts discharge outcome to inpatient rehabilitation or home with social care (p<0.0001), increasing its utility to patients with minor and moderate burns.

The utility of microalbuminuria measurements in pediatric burn injuries in critical care.

PURPOSE: Microalbuminuria, as measured by urinary albumin-creatinine ratios (ACRs), has been shown to be a marker of systemic inflammation and an indicator of the potential severity of trauma and critical illness. Severe pediatric burns represent the best model in which to investigate the clinical utility of microalbuminuria. This study aims to ascertain whether ACR measurements have any role in predicting the severity or the intensive care requirements in the critically unwell pediatric burn population. MATERIALS AND METHODS: A retrospective observational study was undertaken within a regional burn center with a dedicated 8-bed burn intensive care unit (ICU). This looked at 8 years of consecutive pediatric burns requiring intensive care support-a total of 63 patients after exclusions. Daily urinary ACR measurements were acquired from all patients. RESULTS: All patients had greater than or equal to 1 ACR measurement out with the reference range, and only 8% (5/63) presented to the ICU with a normal ACR. The median day for the peak ACR measurement was day 4. The relative lack of mortalities (3/63) precluded adequate correlations between ACR and outcomes. Peak and mean ACR values correlate well with length of ICU stay, and the peak ACR also correlates with total length of hospital stay and severity of burn injury as measured by total body surface area burnt and number of organ systems requiring support. No significant differences were found when the patients were stratified by age. The peak ACR measurement was found to be independently predictive of the length of the ICU stay. As such, we have created a predictive model to prove that an ACR that remains less than 12 mg/mmol is predicative of an ICU stay of less than or equal to 7 days. CONCLUSIONS: The clinical utilities of ACR measurements are demonstrated by their correlation with the severity of injury, length of ICU stay, and requirements for multiple organ support. Albumin-creatinine ratios raised over certain thresholds highlight to the clinician the need for closer observation and the potential deterioration of patients.

Physical functional outcome assessment of patients with major burns admitted to a UK Burn Intensive Care Unit.

Determining the discharge outcome of burn patients can be challenging and therefore a validated objective measure of functional independence would assist with this process. We developed the Functional Assessment for Burns (FAB) score to measure burn patients' functional independence. FAB scores were taken on discharge from ICU (FAB 1) and on discharge from inpatient burn care (FAB 2) in 56 patients meeting the American Burn Association criteria for major burn. We retrospectively analysed prospectively collected data to measure the progress of patients' physical functional outcomes and to evaluate the predictive validity of the FAB score for discharge outcome. Mean age was 38.6 years and median burn size 35%. Significant improvements were made in the physical functional outcomes between FAB 1 and FAB 2 scores (p<0.0001). 48 patients were discharged home, 8 of these with social care. 8 patients were transferred to another hospital for further inpatient rehabilitation. FAB 1 score (≤ 9) is strongly associated with discharge outcome (p<0.006) and as such can be used to facilitate early discharge planning. FAB 2 score (≤ 26) independently predicts discharge outcome (p<0.0001) and therefore is a valid outcome measure to determine discharge outcome of burn patients.

Cough strength, secretions and extubation outcome in burn patients who have passed a spontaneous breathing trial.

The aim of this study was to develop a clinical prediction model to inform decisions about the timing of extubation in burn patients who have passed a spontaneous breathing trial (SBT). Rapid shallow breathing index, voluntary cough peak flow (CPF) and endotracheal secretions were measured after each patient had passed a SBT and just prior to extubation. We used multiple logistic regression analysis to identify variables that predict extubation outcome. Seventeen patients failed their first trials of extubation (14%). CPF and endotracheal secretions are strongly associated with extubation outcome (p<0.0001). Patients with CPF ≤60 L/min are 9 times as likely to fail extubation as those with CPF >60 L/min (risk ratio=9.1). Patients with abundant endotracheal secretions are 8 times as likely to fail extubation compared to those with no, mild and moderate endotracheal secretions (risk ratio=8). Our clinical prediction model combining CPF and endotracheal secretions has strong predictive capacity for extubation outcome (area under receiver operating characteristic curve=0.96, 95% confidence interval 0.91-0.99) and therefore may be useful to predict which patients will succeed or fail extubation after passing a SBT.

The incidence and outcome of extubation failure in burn intensive care patients.

To identify the incidence and outcome of extubation failure in patients with burn. Retrospective cohort study in a tertiary burn intensive care unit. A review of the casenotes of 132 consecutive adult patients with burn admitted between 2001 and 2005, and requiring mechanical ventilation for >24 hours, was undertaken. Sixty-seven patients underwent extubation and entered data analyses. Extubation failure was defined as reintubation within 48 hours. The outcomes of interest were incidence and cause of extubation failure, duration of mechanical ventilation (DMV), length of stay (LOS), and mortality. The patients who succeeded and failed extubation were similar in terms of age, sex, burn size (P = .3), and incidence of inhalation injury (P = .1). Of 67 planned extubations, 20 (30%) failed. DMV (22.5 vs. 4 days; P < .001), intensive care LOS (1.20 vs. 0.41 days/% burn; P < .001), and hospital LOS (1.90 vs. 1.18 days/ % burn; P < .003) were significantly longer in reintubated patients when compared with those who extubated successfully. Extubation outcome, burn size, and age provided the best predictive model for patient outcome (P = .02), but extubation outcome was the only predictor that operated individually (P = .05). The aetiology of extubation failure in 15 (75%) patients was poor pulmonary toilet. The incidence of extubation failure in this homogenous population of patients with burn is higher than general intensive care patients (30% vs. 4-23%). The DMV, lengths of intensive care, and hospital stay are significantly longer in patients who failed extubation. In addition to burn size and age, extubation outcome is an important predictor of intensive care mortality. The indication for reintubation in most patients is poor airway clearance.

Evaluation of the spontaneous breathing trial in burn intensive care patients.

BACKGROUND: The extubation failure rate in our burn patients is 30%. OBJECTIVE: To evaluate the influence of the 30 min spontaneous breathing trial on extubation outcome in burn patients. METHODS: A prospective, observational study in a burn intensive care unit. All adult patients requiring mechanical ventilation for >24h and meeting the inclusion criteria underwent a 30 min spontaneous breathing trial (SBT). Extubation was undertaken after a successful SBT. RESULTS: Of 49 planned extubations, 9 failed (18%), much lower than the 30% extubation failure rate identified prior to the implementation of the SBT. The duration of ventilation was significantly shorter (p=0.04) in the patients who passed a SBT and those who failed extubation were significantly older (p=0.003). The logistic regression analysis identified that age independently predicted extubation outcome. Patients who failed extubation, after a successful SBT, had a significantly longer duration of ventilation (p=0.0001) and ITU length of stay (p=0.001). CONCLUSIONS: The incidence of extubation failure was much lower and the duration of ventilation significantly shorter in patients who were extubated after a successful SBT. These findings support the use of the SBT in burn patients. Age independently predicts extubation outcome in burn patients who have passed a SBT.