b u r n s 4 5 ( 2 0 1 9 ) 1 0 5 7 – 1 0 6 5 Available online at www.sciencedirect.com ScienceDirect jo urnal homepage: www.elsevier.com/locate/burns Burn intensive care treatment over the last 30 years: Improved survival and shift in case-mix a,b, c,d a,e Rolf K. Gigengack *, Margriet E. van Baar , Berry I. Cleffken , a a,c,f Jan Dokter , Cornelis H. van der Vlies a Department of Trauma and Burn Surgery, Maasstad Hospital, Maasstadweg 21, 3079 DZ Rotterdam, The Netherlands b Department of Anesthesiology, Amsterdam UMC, Location VU Medical Center, Boelelaan 1117, 1081HV Amsterdam, The Netherlands c Association of Dutch Burn Centers, Maasstad Hospital, Maasstadweg 21, 3079 DZ Rotterdam, The Netherlands d Department of Public Health, Erasmus MC, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands e Department of Intensive Care Medicine, Maasstad Hospital, Maasstadweg 21, 3079 DZ Rotterdam, The Netherlands f Trauma Research Unit Department of Surgery, Erasmus MC, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands a r t i c l e i n f o a b s t r a c t Article history: Purpose: Mortality in burn intensive care unit (ICU) has been decreasing and treatment Accepted 7 February 2019 appears to be changing. The aims of this study: (1) examine outcome in burn patients, (2) examine changes in ICU indication and (3) explore the influence of a changing case-mix. Methods: Retrospective study in patients admitted to ICU (1987–2016). Four groups were specified: major burns (15% TBSA), inhalation injury with small injury (<15% TBSA, < Keywords: inhalation injury), watchful waiting ( 15% TBSA, without inhalation injury), tender loving care (patients withheld from treatment). Logistic regression was performed to evaluate the Intensive care relation between case-mix and outcome. Burn injury Treatment Results: Overall mortality decreased to 7%. Mortality of major burns decreased by 15%. The major burn group decreased by 36%. The inhalation injury and watchful waiting group Inhalation injury Mortality increased by 9% and 21%. The percentage of ventilated patients increased by 14% in the major burn group. 40% of patients were ventilated in the watchful waiting group. Length of stay Conclusions: After correction for case-mix, survival improved, mainly in the major burn group. Case-mix shifted towards inhalation injury and watchful waiting. Growth of the watchful waiting group is not necessarily harmful. However, the increase of mechanical ventilation could be. We suggest raising awareness for risks and consequences of mechanical ventilation. © 2019 Elsevier Ltd and ISBI. All rights reserved. Abbreviations: %TBSA, percentage of total body surface area; ABA, American Burn Association; ATLS, advanced trauma life support; BICU, burn intensive care unit; EMSB, European Management of Severe Burns; ICU, intensive care unit; ISBI, International Society of Burn Injuries; LOS, length of stay; LOS ICU, length of stay intensive care unit; RBAUX, revised BAUX-score; SDD, selective digestive decontamination; TBSA, total body surface area; TLC, tender loving care. * Corresponding author at: Department of Trauma and Burn Surgery, Maasstadweg 21, 3079 DZ Rotterdam, The Netherlands. E-mail addresses: [email protected] (R.K. Gigengack), [email protected] (M.E. van Baar), [email protected] (B.I. Cleffken), [email protected] (J. Dokter), [email protected] (C.H. van der Vlies). https://doi.org/10.1016/j.burns.2019.02.005 0305-4179/© 2019 Elsevier Ltd and ISBI. All rights reserved. 1058 b u r n s 4 5 ( 2 0 1 9 ) 1 0 5 7 – 1 0 6 5 for intensive care treatment. Indications for intensive care 1. Introduction treatment were: 15% percentage of total body surface affected by burn injury (%TBSA) leading to resuscitation or The mortality of burn victims, including patients admitted to the need for support of vital functions (i.e. mechanical the intensive care unit (ICU), has been steadily declining ventilation or circulatory support). Exclusion criteria were: throughout the world over the last decades [1–3]. The American admittance for reconstructive surgery, re-admission, delayed National Burn Repository of 2015 reported an overall mortality intensive care treatment (>24h) and intensive care admittance rate of 3.2% [4]. Dokter et al. found a similar overall mortality for non-burn related injury. rate in the Netherlands [5]. The reported mortality of burn patients admitted to an intensive care unit differs between 2.3. Data collection geographical regions. The mortality ranged from 10.9% in Australia and New Zealand [6] to 58.2% in Brazil [7]. The database contains extensive data including the nature of The most common cause of death in the first 48h after burn the trauma, details about the burns (i.e. %TBSA burned, BAUX- injury is hypovolemic shock. After this period, respiratory score, revised BAUX-score (RBAUX), inhalation injury) and complications are the most common causes of death in burn intensive care treatment (i.e. ventilator days, length of stay victims [3,5]. Research and knowledge about intensive care (LOS), antibiotics use). The treating burn care professionals and burn care is expanding and provides new insights in the clinically diagnosed inhalation injury. To examine trends over best treatment strategy for burn patients [8–10]. time, a 30-year period was divided in three decades: 1987–1996, Mackie et al. showed a substantial increase in the number 1997–2006 and 2007–2016. Furthermore, four treatment groups of burn patients receiving mechanical ventilation at admission were defined based on the type of ICU indication: (1) major on the intensive care unit (from 38% to 76%). Furthermore, an burn trauma group, (2) inhalation Injury with small burn increase from 9% to 57% (1987–1996 vs. 1997–2006) was found in trauma group, (3) watchful waiting group, (4) tender loving care patients with a suspicion of inhalation injury [11]. These group. developments seems to be related to aggressive airway management policies of the Advanced Trauma Life Support 2.4. Treatment groups (ATLS) and the guidelines of the European Management of Severe Burns (EMSB), American Burn Association (ABA) and the International Society of Burn Injuries (ISBI) [11–14]. The (1) Major burn group: all patients in the major burn group had threshold for intubation is low, wherein the maintenance of a TBSA burned 15% with or without inhalation injury. vital organ function plays an important role. This development Patients were resuscitated using the Parkland formula. The can have negative consequences as mechanical ventilation is administered volume was adjusted based on diuresis with associated with morbidity and mortality [8]. a target of 0,5ml/kg/h. Hypertonic sodium bicarbonate The results of Mackie et al. and the emphasis on aggressive solution was used for resuscitation (Sodium 202mmol/ml, airway management suggest a shift towards a new intensive Chloride 145mmol/ml, Bicarbonate 57mmol/ml, ethyl- care indication aimed at prevention or observation instead of enediaminetetraacetic acid 50mg/ml). After 12h an albu- the classical indications of resuscitation or inhalation injury. min infusion was started [9]. The aims of this study are to (1) examine whether the (2) Inhalation injury with small burn trauma group: all outcome of patients admitted to the burn intensive care unit patients in this group had inhalation injury with or without improved over the last decades, (2) examine whether the small burn trauma (<15% TBSA burned). Due to smaller indication for admittance to a burn intensive care unit is burns, these patients were not resuscitated using the shifting and to (3) explore whether changes in outcome are Parkland formula. influenced by changes in case-mix. (3) Watchful waiting group: patients in this group had small burns (<15% TBSA burned) and were not diagnosed with inhalation injury. Indications included the suspicion of 2. Methods (but not proven) inhalation injury and the risk of swelling of the face and neck and thereby threatening the airway. 2.1. Design (4) Tender loving care (TLC) group: these patients were refrained from active treatment and received palliative A retrospectively study was performed with data extracted treatment at admittance at the burn intensive care unit due from a database prospectively collected by burn care profes- to an expected poor outcome. The decision for tender sionals. The Institutional Review Board of Maasstad Hospital, loving care was weighed for each individual case by an Rotterdam, approved the study (L2018030). The primary experienced team of burn care professionals based on age, outcome measure was mortality. Secondary outcomes includ- %TBSA burned, location of the burn injury and medical ed hospital and ICU length of stay. history of the patient. All patients died of irreversible shock as resuscitation was withheld. 2.2. Population Since 1994, in all groups (except group 4) selective digestive All patients admitted to the burn care unit at the Maasstad decontamination (SDD) was started in patients with 20% Hospital from January 1987 to December 2016 were eligible for TBSA burned or in patients expected to need respiratory inclusion. Inclusion criteria were: 18 years and an indication support for >48h [15]. All patients in group 1–3 received b u r n s 4 5 ( 2 0 1 9 ) 1 0 5 7 – 1 0 6 5 1059 standardized intensive care treatment in case of organ failure and had no significant effect on the decrease in mortality. The (i.e. mechanical ventilation, renal replacement therapy, etc.) percentage of patients on mechanical ventilation increased All burns were initially treated with cerium silver sulphadia- from 44% in the first decade to 58% in the last. While this zine or silver sulphadiazine. Wound dressings were changed increased, the days on mechanical ventilation decreased daily [16]. significantly. In the last decade, patients in the major burn group had more severe burns compared to the inhalation 2.5. Statistical analysis injury group and watchful waiting group indicated by a higher %TBSA, BAUX-score and percentage of full thickness burns.