Using acute kidney injury severity and scoring systems to predict outcome in patients with burn injury

Acute kidney injury (AKI) is a frequent complication of severe burn injury and is associated with mortality. The definition of AKI was modified by the Kidney Disease Improving Global Outcomes Group in 2012. So far, no study has compared the outcome accuracy of the new AKI staging guidelines with that of the complex score system. Hence, we compared the accuracy of these approaches in predicting mortality. Methods: This was a post hoc analysis of prospectively collected data from an intensive care burn unit in a tertiary care university hospital. Patients admitted to this unit from July 2004 to December 2006 were enrolled. Demographic, clinical, and laboratory data and prognostic risk scores were used as predictors of mortality. Results: A total of 145 adult patients with a mean age of 41.9 years were studied. Thirty-five patients (24.1%) died during the hospital course. Among the prognostic risk models, the Acute Physiology and Chronic Health Evaluation III system exhibited the strongest discriminative power and the AKI staging system also predicted mortality well (areas under the receiver operating characteristic curve: 0.889 vs. 0.835). Multivariate logistic regression analysis identified total burn surface area, ventilator use, AKI, and toxic epidermal necrolysis as independent risk factors for mortality. Conclusion: Our results revealed that AKI stage has considerable discriminative power for predicting mortality. Compared with other prognostic models, AKI stage is easier to use to assess outcome in patients with severe burn injury

Acquisition and clearance of multidrug resistant Acinetobacter baumannii on healthy young adults concurrently burned in a dust explosion in Taiwan: the implication for antimicrobial stewardship

Abstract Background Information is limited about the effect of restricted carbapenem use on clearance of multi-drug resistant Acinetobacter baumannii (MDRAB). We sought to determine the time effect of antibiotic exposure on multi-drug resistant Acinetobacter baumannii (MDRAB) acquisition and clearance. Methods We conducted a retrospective observational study at the intensive care units of a tertiary medical center. Forty-two of a cohort of previously healthy young adults who were concurrently burned by a dust explosion was included. Cases consisted of those from whom MDRAB was isolated during hospitalization. Controls consisted of patients from whom MDRAB was not isolated in the same period. Use of antimicrobial agents was compared based on days of therapy per 1,000 patient-days (DOT/1,000PD). A 2-state Markov multi-state model was used to estimate the risk of acquisition and clearance of MDRAB. Results MDRAB was discovered in 9/42 (21.4%) individuals. The cases had significantly higher use of carbapenem (652 DOT/1,000PD vs. 385 DOT/1,000PD, P < 0.001) before MDRAB isolation. For the cases, clearance of MDRAB was associated with lower use of carbapenem (469 DOT/1,000PD vs. 708 DOT/1,000PD, P = 0.003) and higher use of non-carbapenem beta-lactam (612 DOT/1,000PD vs. 246 DOT/1,000PD, P <0.001). In multi-state model, each additional DOT of carbapenem increased the hazard of acquiring MDRAB (hazard ratio (HR), 1.08; 95% confidence interval (CI) 1.01–1.16) and each additional DOT of non-carbapenem beta-lactam increased the protection of clearing MDRAB (HR, 1.25; 95% CI 1.07–1.46). Conclusions Both acquisition and clearance of MDRAB were related to antibiotic exposure in a homogeneous population. Our findings suggest that early discontinuation of carbapenem could be an effective measure in antibiotic stewardship for the control of MDRAB spreading

Hyperphosphatemia is associated with high mortality in severe burns

<div><p>Introduction</p><p>Phosphate level is often deranged during acute illness, regardless of the presence of kidney injury or not. A few studies described that hypophosphatemia may associated with outcome in patients admitted to the burn unit, but the literatures for hyperphosphatemia is limited. Our study aims to evaluate if hyperphosphatemia, one of the sign of severe tissue damage or kidney injury, will associate with mortality of patients with severe burns.</p><p>Materials and methods</p><p>The study was a post hoc analysis of prospectively collected data from patients admitted to the burn unit between September 2006 and December 2011. Patients were stratified into normophosphatemic or hyperphosphatemic group by baseline plasma phosphate level. The primary endpoint is 90-day mortality.</p><p>Results</p><p>Total 301 patients were included (hyperphosphatemia: n = 52; normophosphatemia: n = 249). The hyperphosphatemic group had lower Glasgow Coma Scale, mean arterial blood pressure, hemoglobin level, albumin, and higher TBSA of burns, APACHE II score, ABSI score, Acute kidney injury (AKI), and creatinine. The 90-day mortality was higher in the hyperphosphatemic group than in the normal group (53.8% vs 18.1%, <i>P</i> < .001) and this difference was still significant when adjusting for several confounding factors (hazard ratio, 2.05; 95% CI, 1.17–3.59). Multivariable Cox analysis showed risk factors of mortality included TBSA of burns, hyperphosphatemia, reduced urine output, and APACHE II score.</p><p>Conclusions</p><p>Our study found in addition to TBSA of burns and inhalation injury, baseline hyperphosphatemia in patients with severe burns is also associated with higher mortality.</p></div

Factors associated with ninety-day mortality (model 5–1 in Table 3).

<p>Factors associated with ninety-day mortality (model 5–1 in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0190978#pone.0190978.t003" target="_blank">Table 3</a>).</p

Individual values of serum phosphate levels at baseline and the third day.

<p>(Comparison was made using a paired sample <i>t</i> test).</p

Baseline characteristics of the patients according to serum phosphate.

<p>Baseline characteristics of the patients according to serum phosphate.</p

Burning characteristics of the patients according to serum phosphate.

<p>Burning characteristics of the patients according to serum phosphate.</p

Kaplan–Meier survival curves of 90-day mortality in patients surviving more than 3 days based on different trends of plasma phosphate level.

<p>The survival rate was lower in the High → High group versus the Normal → Normal group (<i>P</i> < 0.001); the survival rates were lower in the Normal → High group and High → Normal group than in the Normal → Normal group (<i>P</i> = 0.003; <i>P</i> = 0.035). Other comparisons were not significant (<i>P</i> > 0.0083).</p