Elsevier

Burns

Volume 36, Issue 8, December 2010, Pages 1263-1270
Burns

Extravascular lung water index as a sign of developing sepsis in burns

https://doi.org/10.1016/j.burns.2010.04.006Get rights and content

Abstract

Sepsis and multiple organ failure remain the leading cause of mortality and morbidity in burns. The aim of our study was to analyse the predictive value of extravascular lung water index (EVLWI) in the development of severe septic complications and mortality.

The records of 28 patients with total burned surface area >20% were analysed (EVLWI, procalcitonin (PCT), intrathoracic blood volume index (ITBVI), positive end-expiratory pressure (PEEP), Baltimore Sepsis Scale (BaSS)). Diagnosis of infection (day 0) was based on consensus conference of the American Burn Association.

EVLWI correlated with PCT (r = 0.597), and PEEP (r = 0.501) on day 0 and with BaSS (r = 0.524) and MODS (r = 0.513) from day 1. EVLWI was elevated (p < 0.05) from one day before diagnosis of infection, PCT was higher (p < 0.05) from day 0 only. ROC analysis for EVLWI on day −1 and for PCT on day 0 showed similar areas under curve (0.760; 0.766). EVLWI >9 ml kg−1 on day −1 predicted sepsis (89% sensitivity, 72% specificity). After antibiotic treatment EVLWI remained high in non-survivors, decreased in survivors, whereas PCT decreased in both groups.

Our data suggest that EVLWI is an early warning sign of developing infection and its continuous elevation can predict poor prognosis in burns.

Introduction

Burned patients are susceptible to infections because of the anti-inflammatory processes caused by trauma [1], [2], [3], [4]. Despite improvements in burn wound care and intensive therapy, sepsis and consequent multiple organ failure (MOF) remain the major causes of death in patients suffering from severe thermal injury [5], [6]. Burned patients show signs of systemic inflammatory response syndrome (SIRS) without bacterial infection making early detection of sepsis difficult. Sepsis is usually diagnosed from clinical signs [7]. Early and adequate administration of antibiotics may improve patients’ survival [8], [9], [10]. Based on the Surviving Sepsis Campaign, administration of the first dose of antibiotics is necessary within 1 h following diagnosis.

Due to existing SIRS the haemodynamic profile of burn injury in septic patients is very similar to the non-septic profile, characterized by high cardiac index (CI) and low systemic vascular resistance index (SVRI). By using transpulmonary thermodilution extravascular lung water index (EVLWI) can be calculated and monitored. It has been shown that inhalation injury and fluid resuscitation per se rarely influence EVLWI alone [11], [12], [13], although an elevated EVLWI can often be detected during the treatment of burned patients in the intensive care unit (ICU). According to Tranbaugh et al. elevated EVLWI may be a sign of developing bacterial sepsis in burned patients [11]. Yang et al. showed that EVLWI has a prognostic value in critically ill patient suffering from septic shock. EVLWI >14 ml kg−1 has been associated with a significantly higher in-hospital mortality [14].

Procalcitonin (PCT) is a useful marker of bacterial infection in septic patients [15] and a helpful parameter for the detection of developing sepsis in burned patients [6]. According to Nylen et al. it may be an indicator of the severity of inhalation injury [16]. In a study by von Heimburg et al. a cut-off value higher than 3 ng ml−1 was found as a reliable indicator for bacterial or fungal infection [17] with values over 10 ng ml−1 associated with life-threatening infections. However, Housinger et al. and Neely et al. conclude that PCT is less sensitive than platelet count or CRP in the early detection of sepsis in burned children [18], [19]. No reports have found a correlation between total burned body surface area (TBSA) and PCT values measured on admission however, a significant correlation has been proven between the peak value of PCT and TBSA [17].

The aim of our retrospective study was to analyse EVLWI changes in association with the clinical diagnosis of sepsis, PCT level, Baltimore Sepsis Scale (BaSS) [20] Multiple Organ Dysfunction Score (MODS) [21] and Sequential Organ Failure Assessment (SOFA) [22] to assess whether EVLWI elevation is superior to other markers for the prediction and early diagnosis of the onset of sepsis in burned patients.

Section snippets

Patients

Data from 98 patients admitted to our tertiary intensive care unit between January 2006 and April 2009 with burns affecting more than 20% of the body surface area were analysed. Inclusion criteria were the development of sepsis during treatment, minimum of six days survival from the beginning of study period and the use of transpulmonary thermodilution haemodynamic monitoring (PiCCO, Pulsion Medical Systems AG, Munich, Germany). Exclusion criterion was the presence of any obvious bacterial

Results

This retrospective study included 28 subjects (6 women, 22 men) (Fig. 1). Median age was 52 years (IQR 25–64), median TBSA 37% (IQR 30–49). Nineteen died during their intensive care stay while 9 survived the injury.

Demographic and haemodynamic parameters on admission are summarized in Table 1. Table 2 shows a summary of the measured and calculated parameters on days 1 and 2 following admission. Albumin level was significantly higher in the survivor group on admission. Initial MODS, SOFA, and

Discussion

As sepsis remains the major cause of mortality in burned patients, it needs early diagnosis and specific treatment. Patients suffering from thermal injury are constantly and chronically exposed to microorganism invasion due to extensive skin damage. The gastrointestinal tract is another focus of infection due to impaired circulation in the resuscitation phase of burn injury. Standard criteria for infection and sepsis cannot be used in burned patients due to existing SIRS without bacterial

Conflict of interest

We have no financial or personal relationships with other people or Organizations (e.g., employment, consultancies, stock ownership, honoraria, paid expert testimony, patent applications/registrations, and grants or other funding) that could inappropriately influence our work.

Acknowledgement

This work was supported by PTE ÁOK KA no: 2009/34039-29 grant.

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