Threshold age and burn size associated with poor outcomes in the elderly after burn injury

doi:10.1016/j.burns.2015.12.008

Burns

Volume 42, Issue 2, March 2016, Pages 276-281

https://doi.org/10.1016/j.burns.2015.12.008 Get rights and content

Highlights

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In elderly, risk of death increased linearly with increasing age.
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LD50 decreases from 45% TBSA to 25% TBSA from the age of 55 years to the age of 70 years.
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Despite modern burn care protocols outcome remains poor in elderly patients.

Abstract

Elderly burn care represents a vast challenge. The elderly are one of the most susceptible populations to burn injuries, but also one of the fastest growing demographics, indicating a substantial increase in patient numbers in the near future. Despite the need and importance of elderly burn care, survival of elderly burn patients is poor. Additionally, little is known about the responses of elderly patients after burn. One central question that has not been answered is what age defines an elderly patient. The current study was conducted to determine whether there is a cut-off age for elderly burn patients that is correlated with an increased risk for mortality and to determine the burn size in modern burn care that is associated with increased mortality. To answer these questions, we applied appropriate statistical analyses to the Ross Tilley Burn Centre and the Inflammatory and Host Response to Injury databases. We could not find a clear cut-off age that differentiates or predicts between survival and death. Risk of death increased linearly with increasing age. Additionally, we found that the LD50 decreases from 45% total body surface area (TBSA) to 25% TBSA from the age of 55 years to the age of 70 years, indicating that even small burns lead to poor outcome in the elderly. We therefore concluded that age is not an ideal to predictor of burn outcome, but we strongly suggest that burn care providers be aware that if an elderly patient sustains even a 25% TBSA burn, the risk of mortality is 50% despite the implementation of modern protocolized burn care.

Introduction

A severe burn is an injury that affects every organ system, leading to significant morbidity and mortality [1], [2]. It has been shown that outcomes after burn are linked to age [3]. The best outcomes can be found in children, followed by adults and lastly, the elderly [3], [4]. While significant advances in outcomes have been made in children and adults [5], there have been minimal improvements in the outcomes for elderly burn patients with small burn which is recently reported in a historical cohort study [3]. The LD50 burn size in elderly has remained almost the same, at around 35% TBSA burn, over the last few decades. In general, the elderly have a thinning of the skin [6], decreased sensation, decreased metabolic resources and capacity [7], mental alterations, pre-existing medical conditions and other contributing factors [8], [9], [10]. The failure of their immune system to fight off burn infections along with altered inflammatory and immune responses [11] contribute to worsened outcomes after burn.

There is an ongoing effort to determine why the elderly have such poor outcomes on a cellular and mechanistic level; however, there are several essential questions that have not been addressed or well-defined. First, when is an elderly patient considered elderly? The definition of when a human becomes an elderly is not entirely clear. The World Health Organization (WHO) and the National Institutes of Health (NIH) have defined ‘elderly’ as 65 years or older (www.who.int/healthinfo/survey/ageingdefnolder/en/), but there is ongoing discussion about the age that defines an individual as elderly, varying from 55 to 75 years [12]. It is currently not clear what age can be defined as elderly in burn patients; therefore, the first aim of this study was to determine whether there is a cut off age for elderly burn patients. Second, we aimed to determine the minimum burn size that is associated with increased mortality. We tried to define elderly cut-off age by using the increase in mortality as an indicator for it. To do this, we looked at two databases: the Ross Tilley Burn Centre database and the Inflammation and Host Response to Injury (Glue Grant; https://www.gluegrant.org) database and compared their cut-off age and cut-off burn size. We hypothesized that elderly burn patients would have a cut-off age that is clearly associated with burn size and mortality. We further hypothesized that a particular burn size would be associated with increased morbidity and mortality after burn.

Section snippets

Patients

In this study, two existing databases were used to examine the cut-off age for elderly after burn and the cut-off burn size associated with increased morbidity and mortality. The first database was that of a single ABA-verified burn center, Ross Tilley Burn Centre (RTBC) at Sunnybrook Health Sciences Centre (SHSC). Research Ethics Board (REB) at Sunnybrook approved this study (# 003-2011). Patients from January 2006 to October 2014 with TBSA ≥20 and removing those cases that were futile (died

Results

A total of 1457 patients were enrolled from the RTBC database and 573 patients from the Glue Grant database. In order to compare the two patient populations, we focused on burns over 20% TBSA and excluded pediatric burn patients, resulting in 235 patients from RTBC and 347 from the Glue Grant. Patient characteristics are presented in Table 1. Patients in the Glue Grant cohort were younger (40 years old vs. 48.0 years) and had a higher TBSA (42.1% vs.34.4%) compared to the RTBC patients. Both

Discussion

Over the last few decades, changes in the care of burned children and adults have significantly improved outcomes; however, these improvements have not been reflected in the elderly. The LD50 burn size has remained steady in this population at 35% TBSA burn over the last 2–3 decades [4], [18]. This lack of progress is of great concern in light of the substantially growing elderly population. In this study, we aimed to determine the LD50 as well as an age cut-off to predict the age at which

Source of funding

This study was supported by – Canadian Institutes of Health Research # 123336. CFI Leader's Opportunity Fund: Project # 25407 NIH RO1 GM087285-01.

Conflict of interest

There is no conflict of interest.

Acknowledgements

The authors would like to acknowledge the participants of the Inflammation and Host Response to injury project:

Celeste C. Finnerty, PhD; Henry V. Baker, PhD; M. Cecilia Lopez, MSc; Richard L. Gamelli, MD; Nicole S. Gibran, MD; Matthew B. Klein, MD; Brett Arnoldo, MD; Ronald G. Tompkins, MD; David N. Herndon, MD; Ulysses G.J. Balis, MD; Paul E. Bankey, MD, PhD; Timothy R. Billiar, MD; Bernard H. Brownstein, PhD; Steven E. Calvano, PhD; David G. Camp II, PhD; Irshad H. Chaudry, PhD; J. Perren

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Threshold age and burn size associated with poor outcomes in the elderly after burn injury

Highlights

Abstract

Introduction

Section snippets

Patients

Results

Discussion

Source of funding

Conflict of interest

Acknowledgements

Burns

J Am Coll Surg

Lancet

Burns

Dermatol Clin

Pathophysiologic response to severe burn injury

Ann Surg

Long-term persistance of the pathophysiologic response to severe burn injury

PLoS ONE

Inflammatory response in the elderly

Curr Opin Clin Nutr Metab Care

Influence of comorbidities and age on outcome following burn injury in older adults

J Burn Care Res