The Critical Care effect on the outcome of burn patients with multi-organ failure (MOF).
Critical Care evolution in India
Over the past 50 years, India has witnessed significant advancements in healthcare, leading to an increase in the average life span from 21 to 63 years (Shailesh Bihari et al., winter 2006/2007). This progress is attributed to improved public health measures and the delivery of quality acute care in hospitals. In the earlier years, India's focus was primarily on addressing basic issues like malnutrition and infections, relegating critical care, considered expensive to a secondary position. However, the country's recent economic growth has resulted in a burgeoning middle class with the means to access modern and specialized care. Despite this, critical care medicine, akin to Western practices, remains concentrated in large metropolitan areas in India. Critical care in India took root in the late 1960s with the establishment of coronary care units in Mumbai. The first such unit began at King Edward Memorial Hospital in 1968.? Dr. Farokh E. Udwadia pioneered respiratory care units in Mumbai during the 1970s, shedding light on the essential need for critical care services. Despite primitive technology, early intensive care units were manned by dedicated personnel. The 1980s marked a significant leap forward, as corporate hospitals with both Indian and overseas investors improved infrastructure and care standards. Consultants returning from international training, particularly in the UK, US, and Australia, played a crucial role in advancing critical care. In 1992, these consultants formed the Indian Society of Critical Care Medicine (ISCCM), now a prominent representative body with over 2,500 members and 16 city branches across India. (Shailesh Bihari et al., winter 2006/2007)
Burns
The tissue and skin injury caused mainly by heat, radiation, electricity, friction, or chemicals are known as Burns. Thermal burns result from hot liquids, hot solids, or flames. Worldwide, burn-related mortalities reach approximately 180,000 annually, occurs predominantly in low- and middle-income nations, particularly within WHO African and Southeast Asia regions (organization, 13 OCTOBER 2023).Nonfatal burns show notable morbidity, long hospital stays, disfigurement, disability, social rejection. Burns stand among the leading causes of disability-adjusted life years (DALYs) lost in low- and middle-income countries. Hospitalization trends show shorter stays, and there is an increasing proportion of burns being treated in specialized burn centres. (organization, 13 OCTOBER 2023)
Multiple Organ Dysfunction Syndrome (MODS) is a progressive condition that manifests in acutely unwell patients, often associated with severe burns. It exists along with Systemic Inflammatory Response Syndrome (SIRS). Few factors such as burn wounds >20% total body surface area, advanced age, male gender, sepsis, hypoperfusion, and under-resuscitation increases the risk of MODS. About 48-50% of the patients involved in burn injuries are confirmed with MODS. The burn wound or lungs are common sites for infection triggering MODS, leading to organ damage and failure. Prevention of sepsis from burn wound infection is crucial, emphasizing immediate debridement, wound closure, early enteral nutrition, and weaning from the ventilator. MODS in severely burned patients can occur early due to hypoperfusion or late due to sepsis, often beginning in the renal or pulmonary system and progressing systematically. (Gerd G Gauglitz and Felicia N Williams, 2022). Major burn victims face a heightened risk of pneumonia, particularly ventilator-associated pneumonia (VAP), contributing significantly to morbidity and mortality despite recent advancements in critical care unit and burns surgery. Several mechanisms contribute to pneumonia development in severely burnt individuals. Inhalational injuries commonly lead to pulmonary complications, but even in the absence of direct lung injury, burn patients experience increased pulmonary issues. Due to altered ventilation and reduced lung expansion, atelectasis and hypostatic pneumonia are quite frequent, especially with chest or abdominal burn patients. All those patients are prone to aspiration, emphasizing the importance of respiratory physiotherapy, including regular airway suctioning and sputum expectoration, to maintain the respiratory function. Prolonged ventilation increases the risk of VAP, further elevating the likelihood of multi-organ failure (MOF). Overall, addressing respiratory complications is crucial in the comprehensive care of major burn victims. (Rogers et al., 2012). Specific organ failures occur in early and late clinical sequences, with mortality increasing with the number of failed organ systems, reaching nearly 100% when three or more systems fail.
?Epidemiology And Prevalence
Worldwide, burns account for approximately more than 8 million disability-adjusted life-years (DALYs), disproportionately impacting low- and middle-income countries (LMICs). (Vikash Ranjan keshri, 2021)
South Asia experiences an increased incidence of burns during the Diwali festive season, particularly in India, where in 2019, over 23,000 fire-related deaths occurred, representing 20% of the global mortality burden.
Burn survivors often face financial distress, vocational challenges, and social exclusion, due to global burden of diseases.
In India alone, around 7 million burn incidents occur annually, contributing significantly to the global burn burden.???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
Worldwide, burns cause more than 7.1 million injuries, nearly 18 million DALYs lost, and over 265,000 deaths annually. (Vikash Ranjan keshri, 2021)
A cross-sectional study in Karnataka, India, revealed that females (58.61%) were more affected, with most injuries occurring at home (97.5%). (Thittamaranahalli Muguregowda Honnegowda, 2018)
Flame injuries constituted 80.1% of burns in females, while electrical injuries were significantly higher in males (9.8%).
Clothing-related ignition was a common cause of burn injuries, with variations in total burn surface area (TBSA) between genders.
Pseudomonas aeruginosa, Klebsiella pneumoniae, and Escherichia coli were the most frequent bacterial growths.
The rate of fatality case was 29.3%, with a higher recovery rate among males (60.7%) compared to females (45.89%) (Thittamaranahalli Muguregowda Honnegowda, 2018)
?Risk Factors (organization, 13 OCTOBER 2023)
1. Certain occupations that involve increased exposure to fire pose a higher risk of burns.
2. Poverty, overcrowding, and inadequate safety measures contribute to a heightened risk of burns.
3. household activities by the young girls, particularly involve taking care of small kids and cooking food, increases their vulnerability to burns.
4. Some medical conditions such as epilepsy, peripheral neuropathy, and physical or cognitive impairment individuals suffer a high risk of burns.
5. For non-electric domestic appliances using kerosene (paraffin) as a fuel source is a high risk of burn
6. Due to inappropriate safety measures for liquefied petroleum gas and electricity further contribute to the overall risk of burns. (organization, 13 OCTOBER 2023)
?Condition Of Burns In India
?(Coppa, june18,2019)
India bears a disproportionately high burden of burn-related deaths, then any other country globally, with more than twice the annual fatalities. Women are significantly more prone to self-inflicted burns and face a higher likelihood of mortality from such injuries.
Stanford emergency medicine physician and researcher, Dr. Jennifer Newberry, collaborates on a study addressing burn-related challenges in India. (A Newberry1, 2015) Published in BMJ, the research emphasizes the urgent requirement for gender-associated violence support services and enhanced mental health, particularly for all the females in India. The study, focused on pre-hospital care, reveals a concerning gender disparity in burn-related fatalities. While most patients receive prompt critical treatments, a subgroup of women, often victims of non-accidental burns, experiences a staggering 90% mortality rate, compared to the overall rate of 65%. Factors contributing to this gender-based issue include extensive burns, motivations like self-immolation for various reasons, and prevalent gender-based violence. Burn survivors often face financial distress, vocational challenges, and social exclusion, emphasizing the multifaceted impact of burn injuries. In India, women (age 15-49 years) bear a burden of burns that is threefold greater than that experienced by men. Gender-based inequities contribute to this disparity, with women experiencing differential risks linked to unsafe cooking practices, suicides, and domestic violence, including dowry-related conflicts. Addressing burn prevention necessitates a focus on gender-based considerations. (Vikash Ranjan keshri, 2021). The severity of burns highlights the imperative for improved emergency services and comprehensive preventative measures, addressing both physical and mental health aspects to combat the burn epidemic in India.(Coppa, june18,2019)
The role of Critical Care in changing outcomes for patients with Burns.
Criteria for ICU admission
The American Burn Association (ABA) provides notifications for determining the need for specialized care in dedicated burn centres. (Datta et al., 2022). Severe burn injury patients, require critical care support and monitoring, should be considered for burn-care ICU admission. This comprises adult individuals with involvement of over 20% total body surface are (TBSA), excluding first-degree burns. For children under 14 years and the elderly over 60 years, the threshold is more than 10% TBSA. Additional criteria for admission to the intensive care unit (ICU) include inhalation injury supported by airway management, altered mental status or shock, circumferential burns impacting respiration or limb perfusion, impending or established compartment syndrome, and signs of organ dysfunction or concurrent major trauma. (Datta et al., 2022)
?Strategy
The Advanced Burn Life Support (ABLS) protocol serves as a particular approach for the assessment and for managing the burn patients: (Datta et al., 2022)
?1.Air and cervical spine
The assessment begins with a thorough evaluation of the airway and cervical spine, emphasizing securement if necessary
?2.Breathing and ventilation
Priority is given to assessing breathing, with a focus on identifying potential causes of acute respiratory distress, such as open and tension pneumothorax, or haemothorax, in a requirement of immediate decompression
?3.Circulatory assessment
In cases of hypotension or shock, obtaining two wide-bore peripheral IV lines is crucial, with caution against IV access in burnt limbs where circulation may be compromised
?4.Neurological assessment
?Following circulatory stability, a neurological assessment is conducted, paying particular attention to potential causes of altered mental status
?5.Environmental control and full body exposure
considering the risk of hypothermia, burn patients are exposed in a warm environment, with removal of adherent materials and irrigation of chemical burns with room temperature water
?AMPLET history
A detailed secondary survey involves obtaining an AMPLET history (Allergy, Medine, Previous medical history, Last meal, Events leading to presentation, and history of tetanus immunization)
Burn area assessment
Wallace’s Rule of 9 and the Lund and Browder Chart are employed to estimate burn surface area and depth. The palm method is used for scattered burns (Datta et al., 2022)
?*Special considerations
Awareness of complications such as carbon monoxide (CO) or cyanide (CN) poisoning in closed-space burns and recognizing unique challenges in high-voltage electrical burns, including the risk of arrhythmias, limb compartment syndrome, and rhabdomyolysis.(Datta et al., 2022)
Treatment In ICU
?1.Fluid resuscitation in burn patients
?Choice of Fluids: (Datta et al., 2022)
-Normal saline may lead to hyperchloremic metabolic acidosis in burn patients. A balanced solution named Ringer's lactate (RL), that can potentially cause hyponatremia. A new balanced crystalloid with sodium concentrations nearer to plasma are recommended.? (Datta et al., 2022)
Fluid Resuscitation Guidelines:
Initial IV fluid rate at 10 ml/kg/h. Resuscitation volume got calculated using formulas after assessment of burn area. ABA recommends adults with 2 ml/kg/%TBSA and children with 3 ml/kg/%TBSA.(Datta et al., 2022)
Administration Protocol:
Administering half of the calculated fluid over the initial 8 Hours and dispensing the remaining half over the subsequent 16 hours, with the fluid rate adjusted based on individual requirement.
Monitoring:
Urine output (adults-0.5-1 ml/kg/h, children-1-1.5 ml/kg/h) used as an measurable criteria of fluid resuscitation sufficiency. Close monitoring through urinary catheterization.
Role of Colloids:
Colloids may reduce resuscitation volume, but potential complications, including tissue edema and delayed wound healing, limit their use. Albumin supplementation considered after the initial 24 hours in specific cases.
Blood Transfusions:
Haemoconcentration noted initially, and blood transfusions may be harmful. Elevated haematocrit normalizes with early fluid resuscitation. Routine transfusion triggers applied based on general criteria for critically ill patients. (Datta et al., 2022)
?2.Nutrition management in burn patients
?Early Initiation: Essential for overcoming hyper catabolism, preventing stress ulcers, reducing infections.
Timing of Enteral Nutrition: within the first six to 12 hours of injury.
Dietary Recommendations:
-Low-Fat Diet: 15-35% of total calories from lipids.
- Diet of high carbohydrate: Reduces muscle protein degradation.
-Glutamine: Recommended for up to two weeks; may reduce gut permeability.
-Vitamin C: High doses stabilize endothelium, reducing capillary leak. (Datta et al., 2022)
?3.Prevention of ventilator associated pneumonia (VAP)
?Ventilator-associated pneumonia (VAP) poses a significant threat to critically ill burn patients, contributing to morbidity and mortality (Sen et al., 2016). To mitigate this risk, a VAP prevention bundle was implemented and evaluated through a retrospective chart review. The study focused on mechanically ventilated adult burn patients before and after implementation of a VAP prevention bundle. Parameters as total body surface area (TBSA), age of the person, male or female, diagnosis of inhalation injury, injury mechanism, comorbidities, length of mechanical ventilation, hospital stay, VAP development, discharge status, and mortality. Burn patients with VAP exhibited larger burn injuries, a higher prevalence of inhalation injuries, prolonged mechanical ventilation, and extended stays in the intensive care unit (ICU) and hospital. Mortality rates were significantly higher in patients with VAP. In 2010, a VAP prevention bundle was introduced and diligently overseen by a nurse champion, achieving a compliance rate exceeding 95%. By 2012, regardless of patient characteristics, the VAP prevention bundles demonstrated a remarkable reduction in the risk of developing VAP. Burn patients, especially those with inhalation injuries and extensive burn injuries, face an elevated risk of VAP. Implementation of VAP prevention bundles are associated with a proper reduction in the incidence and risk of VAP in burn patients.? (Sen et al., 2016)
PREVENTIVE MEASURES
1.Flame height control in the domestic environment
2 Promote the use of safer cooking equipment and educate on potential hazards.
3.Temperature Control in Hot Water Taps to prevent scalds.
4.Promote fire safety education and installation of safety systems.
5. Implement and comply with industrial safety regulations.
6.Should not smoke in bed and use child-resistant lighters, fire -resistant aprons
?Improved Outcomes
?In India, the extended and costly treatment required for burn patients often results in significant financial burdens. The introduction of the Ayushman Bharat scheme, specifically the Pradhan Mantri Jan Arogya Yojana (PMJAY) in 2018, marked a significant step towards public-financed health insurance. The call is made to make burn services universally free at the point of care across the country. The goal is to make burn care more accessible and financially protective for all individuals in need across India. (Vikash Ranjan Kesari, 2021)
Changing Trends in Burn ICU Management
This retrospective study (1987–2016) investigates shifts in burn ICU outcomes, indications, and case-mix. Key findings include an overall decrease in mortality to 7%, with a notable 15% reduction in major burn mortality. The major burn group declined by 36%, while the inhalation injury and watchful waiting groups increased. Mechanical ventilation rose by 14% in major burns and reached 40% in the watchful waiting group. Despite improved survival, the study underscores potential risks associated with increased mechanical ventilation, emphasizing the need for heightened awareness of its consequences. (Gigengack et al., 2019)??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????Global Trends in Burn Patient Mortality and ICU Care
Over the past decades, global mortality rates for burn victims, especially those admitted to the intensive care unit (ICU), have consistently decreased. Reported rates vary, with the American National Burn Repository citing 3.2%, and regional variations ranging from 10.9% in Australia and New Zealand to 58.2% in Brazil.
Hypovolemic shock is a common cause of death within the initial 48 hours post-burn, with subsequent respiratory complications becoming predominant. Research advancements, particularly in intensive and burn care, contribute to evolving treatment strategies. (Gigengack et al., 2019)
A study by Mackie et al. highlights a significant rise in burn patients receiving mechanical ventilation upon ICU admission, linked to aggressive airway management policies. This shift suggests a move toward a preventative or observational ICU approach, challenging traditional indications like resuscitation or inhalation injury. The study's objectives are to assess improvements in burn ICU outcomes over time.
Trends in Burn ICU Care and Mortality
A retrospective study at Maasstad Hospital, Rotterdam, spanning 1987-2016, analysed outcomes for 1141 burn ICU patients. Mortality decreased from 23% (1987-1996) to 9% (2007-2016), with significant case-mix changes—fewer major burn cases, more inhalation injuries, and increased watchful waiting admissions. The 7% mortality in the last decade reflects improvements, primarily in major burn cases. However, a shift towards inhalation injuries and watchful waiting suggests evolving ICU practices. The study highlights a changing landscape in burn ICU care and decreasing mortality, influenced by altered case-mix dynamics. (Gigengack et al., 2019)
REFERENCES
?A NEWBERRY1, C. B. B., HTTP:A PIRROTTA1, MICHELE BARRY3, GOVINDARAJU VENKATA RAMANA RAO4, SWAMINATHA V MAHADEVAN1, MATTHEW C STREHLOW1 2015. Timely access to care for patients with critical burns in India: a prehospital prospective observational study BMJ.
COPPA, S. june18,2019. Burns in India:Emergency care improving, but patients often too injured to benefit [Online]. Stanford Medicine Scopeblog. Available: https://scopeblog.stanford.edu/2019/06/18/burns-in-india-emergency-care-improving-but-patients-often-too-injured-to-benefit/ [Accessed 2023].
DATTA, P. K., ROY CHOWDHURY, S., ARAVINDAN, A., SAHA, S. & RAPAKA, S. 2022. Medical and Surgical Care of Critical Burn Patients: A Comprehensive Review of Current Evidence and Practice. Cureus, 14, e31550.
GERD G GAUGLITZ, M., MD & FELICIA N WILLIAMS, M. 2022. Overview of complications of severe burn injury [Online]. uptodate. Available: https://medilib.ir/uptodate/show/87444#rid5 [Accessed 19/11/2023].
GIGENGACK, R. K., VAN BAAR, M. E., CLEFFKEN, B. I., DOKTER, J. & VAN DER VLIES, C. H. 2019. Burn intensive care treatment over the last 30 years: Improved survival and shift in case-mix. Burns, 45, 1057-1065.
ORGANIZATION, W. H. 13 OCTOBER 2023. BURNS. WORLD HEALTH ORGANISATION.
ROGERS, A. D., ARGENT, A. C. & RODE, H. 2012. Review article: ventilator-associated pneumonia in major burns. Ann Burns Fire Disasters, 25, 135-9.
SEN, S., JOHNSTON, C., GREENHALGH, D. & PALMIERI, T. 2016. Ventilator-Associated Pneumonia Prevention Bundle Significantly Reduces the Risk of Ventilator-Associated Pneumonia in Critically Ill Burn Patients. J Burn Care Res, 37, 166-71.
SHAILESH BIHARI, M., JAIN, N. & N.RAMAKRISHNAN, D. winter 2006/2007. critical care in India [Online]. ICU Management & Practice. Available: https://healthmanagement.org/c/icu/issuearticle/critical-care-in-india [Accessed 19/11/2023].
SHRESTHA, M. 2023. burn prevention [Online]. physiopedia. Available: https://www.physio-pedia.com/Burn_Prevention#cite_note-7 [Accessed 2023].
THITTAMARANAHALLI MUGUREGOWDA HONNEGOWDA, P. K., PADMANABHA UDUPA, PRAGNA RAO 2018. Epidemiological study of burn patients hospitalised at a burns centre, Manipal. INTERNATIONAL WOUND JOURNAL.
VIKASH RANJAN KESHRI, J. J. 2021. burns in Indis:a call for health policy. The Lancet Public Health.
?