Characteristics and outcome of acute respiratory distress syndrome among severe burn patients

Nội dung text: Characteristics and outcome of acute respiratory distress syndrome among severe burn patients

1. Journal of military pharmaco-medicine n o7-2017 CHARACTERISTICS AND OUTCOME OF ACUTE RESPIRATORY DISTRESS SYNDROME AMONG SEVERE BURN PATIENTS Tran Dinh Hung*; Dong Khac Hung**; Nguyen Nhu Lam* SUMMARY Objectives: To determine clinical and paraclinical manifestations and outcome of severe burn patient with acute respiratory distress syndrome. Subjects and methods: A prospective study was conducted on 66 severe burn patients with acute respiratory distress syndrome (ARDS), treated at Burn Intesive care Unit, National Institute of Burns from 11 - 2013 to 10 - 2016. Diagnosis of ARDS was based on the Berlin criteria in 2012. Clinical and paraclinical manifestations of the patients at ARDS onset until discharged or death were recorded and analyzed. Results: Over a half (53.03%) of ARDS cases developed during the first week post burn. Most of cases were classified as moderate and severe levels (72.72% and 25.75%, respectively). Common characteristics were mental disorder (86.36%), fever, leukocytosis (54.55%), dyspnea, tachypnea, diffuse rales, cyanosis, tachycardia, chest pain and dry cough. Fully bilateral alveolar infiltrate on chest radiograph was recorded in 40.91% of cases. Plasma cytokine levels (IL1-β, IL-6, IL-8, IL-10 and TNF-α) increased significantly since admission and prolonged. Overall mortality rate was 61.12% with the main cause of multiple organ failure (56%). Conclusion: ARDS was a serious complication post burn with typical acute pulmonary abnormalities, significantly prolong raising plasma cytokines levels and high mortality rate due to multiple organ failure. * Keywords: Burn; Acute respiratory distress syndrome; Characters. INTRODUCTION introduced at Berlin meeting to overcome Acute respiratory distress syndrome limitation of 1994 AECC definition and to which was first described by Ashbaugh et al make easier for diagnosing and classifying in 1967 characterized by acute onset, ARDS [10]. severe hypoxemia with bilateral infiltrate ARDS is one of common syndromes and non-hydrostatic pulmonary edema in intensive care unit. ARDS can lead to [1]. In 1994, a formal definition and multiple organ failure and has high classification of ARDS was reported mortality up to 40 - 80%. Previous studies by the American-European Consensus reported that about 200,000 cases of Conference committee on ARDS (AECC) ARDS per year in the United States, [3]. The definition has been widely applied leading to significant patient morbidity and to define patient with ARDS therapeutic health care burden. In many burn centers, trials. Despite the simplicity of this definition, some clinical limitations are recognized. ARDS is still a leading cause of death in In 2012, a new definition of ARDS was patients with severe burns. * Natio nal Institute of Burn ** Vietnam Military Medical University Corresponding author: Tran Dinh Hung (hung73vb@yahoo.com.vn) Date received: 10/06/2017 Date accepted: 11/08/2017 89
2. Journal of military pharmaco-medicine N o7-2017 Currently, in Vietnam, there are not treated at Burn Intensive Care Unit, many reports about ARDS complication in National Institute of Burns from 11 - 2013 burn patients. The aims of this study are to 10 - 2016 with selected criteria: admission to: Investigate clinical and subclinical within 48 hours post burn, aged from 16 characteristics and outcome of ARDS to 60, burn surface area ≥ 15% of total body among severe burn patients. surface area (TBSA), without concomitant trauma or peexisting morbidities. Berlin SUBJECTS AND METHOD definition was used to determine the A prospective study was conducted on development of as well as severity of 66 severe burn patients with ARDS, ARDS as described at table 1 [7]. Table 1: The severity of ARDS (Berlin 2012). Oxygenation Radiological Severity Timing* abnormalities Origin of edema (PaO 2/FiO 2) Mild Acute 200 < P/F < 300 Chest bilateral Respiratory failure opacities not fully explained Moderate Acute 100 < P/F < 200 by cardiac failure Severe Acute P/F < 100 or fluid overload (*: Within 1 week of a known clinical insult or new/worsening respiratory symptoms) Inhalation injury was diagnosed by the IL-10 and TNF-α were determined at circumstance of burn injury (closed 3 times: admission, ARDS onset and space), clinical manifestations (facial burn, 3 days thereafter by ELISA method soot in mouth or pharynx, hoarseness and (DAR-800, Diagnostic Automation InC, carbonaceous) and confirmation by the US) at Pathophysiological Department, flexible bronchoscopy performed during Military Medical University. Clinical and the first 3 days of admission. Once ARDS paraclinical manifestations of patients diagnosed, lung protective mechanical were recorded and monitored until ventilation as ARDS networt protocol was discharge or death. Stata intercool 11.0 implemented [11]. Blood gas was tested 3 software was used to analyze the data times a day and as demanded. Serum and a p value ≤ 0.05 was seen as levels of cytokines including IL1-β, IL-6, IL-8, significant. RESULTS Table 2: Demographic criteria of patients (n = 66). Criteria Mean value Min - max Age (year) 39.18 ± 11.11 18 - 59 Burn surface area (%) 54.82 ± 17.85 18 - 92 Full thickness burn area (%) 26.83 ± 15.49 0 - 65 90
3. Journal of military pharmaco-medicine n o7-2017 Apacher II 16.80 ± 4.07 9 - 26 Prognostic burn index (PBI) 93.26 ± 21.93 51.5 - 139 Inhalation injury; n (%) 33 (50) Male/female 52/14 (78.79%) The mean of age was 39.18 years. Male was predominant with the mean of total burn surface area was 54.82% and 26.83% of full-thickness area. Inhalation injury was diagnosed in 33 patients (50%) with prognostic burn index (PBI) of 93.26 and admission Apacher II score of 16.8. Table 3: Onset time and severity of ARDS. Criteria n % < 7 35 53.03 Onset time post burn (day) 7 - 14 24 36.36 > 14 07 10.61 Mild 01 1.52 Severity of ARDS Moderate 48 72.73 Severe 17 25.75 Over a half of ARDS cases (53.03%) developed during the 1 st week post burn with average of 8.50 ± 4.61 days, ranging from 2 rd day to 27 th day. According to Berlin 2012 definition, 72.73% of patients were classified as moderate, 25.75% was severe and only one case was mild ARDS. Table 4: Clinical characteristics of patients at ARDS onset (n = 66). Criteria n % Mean ≤ 38 03 4.55 Body temparature ( 0C) 38.1 - 39 48 72.73 38.86 ± 0.46 > 39 15 22.72 15 04 9.09 Glasgow score 10 - 14 38 86.36 12.57 ± 1.55 (n = 44)* 6 - 9 02 4.55 Heart rate < 120 01 1.52 133.35 ± 11.75 (beat/min) ≥ 120 65 98.48 < 65 01 1.55 MAP** 65 - 70 05 7.58 87.17 ± 11.60 (mmHg) > 70 59 90.87 Respiratory rate (beat/min) 25 - 29 2 4.55 (n = 44)* 30 - 45 40 90.9 36.82 ± 5.03 > 45 2 4.55 91
4. Journal of military pharmaco-medicine N o7-2017 < 80 2 3.03 SpO 2 (%) 80 - 90 40 60.61 88.42 ± 5.59 91 - 100 24 36.36 Diffuse rales 41 62.12 Cyanosis 42 63.64 Chest pain and dry cough (n = 44)* 44 100 (*: Only for patients without mechanical ventilation; **: MAP: Mean arterial blood pressure) All 66 patients were in the severe situation with tachypnea (30.14 ± 2.26 breath/minute), fever, low SPO 2 82%, diffuse rales (62.12%), cyanosis (63.64%), dry cough and chest pain. In addition, most patients suffered from mild mental disorder with Glasgow score of 12.57 ± 1.55. Table 5: Arterial blood gas and chest radiography at ARDS onset (n = 66). Parameters n % Mean value < 70 47 71.21 PaO 2 (mmHg) 70 - 90 11 16.67 62.5 ± 2.31 > 90 8 12.12 < 95 49 74.24 SaO 2 (%) 88.77 ± 7.79 ≥ 95 17 25.76 < 2 30 45.46 Lactat (mmol/L) 2 - 3 20 30.30 2.43 ± 0.14 > 3 16 24.24 Bilateral infiltrate on chest Partial 39 59.09 radiograph Full 27 40.91 Table 5 revealed criteria of arterial blood gas at the time of meeting ARDS criteria, most of patients had disorder of blood gas in term of low level of PaO 2 (PaO 2 < 70 mmHg in 71.21% of cases) with mean value for all patients was of 62.5 ± 2.31 mmHg and slightly increased lactic acidosis (2.43 ± 0.14 mmol/L). Result of initial chest radiography showed 27 cases (40.91%) has fully bilateral alveolar infiltrate. Table 6: Hematology parameter at time point of ARDS (n = 66). Parameter n % X ± SD ˂ 60 1 1.52 70 - 90 30 45.45 Hemoglobin (g/L) 98.89 ± 3.45 91- 119 26 39.39 ≥ 120 9 13.64 92
5. Journal of military pharmaco-medicine n o7-2017 ˂ 4 2 3.03 White blood cells (G/L) 4 - 9 28 42.42 12.01 ± 0.73 > 9 36 54.55 ˂ 70 14 21.21 Platelets (G/L) 187.44 ± 16.16 ≥ 70 52 78.79 At the time point of ARD, leukocytosis was recorded in over a half of cases (36 patients, accounting for 54.55%) and there were 2 cases with leucopenia. In addition, 46.97% of patients suffered from severe anemia and 78.79% significantly reduced counted platelet. Table 7: Concentrations of plasma cytokines. Cytokine (pg/mL) Normal value* Admission ARDS onset 3rd day post ARDS IL-1β < 3.2 586.57 ± 32.42 594.25 ± 47.36 601.09 ± 42.21 IL-6 < 10 462.56 ± 177.01 653.03 ± 143.04 348.86 ± 72.78 IL-8 29.30 503.19 ± 167.13 379.49 ± 204.96 398.19 ± 157.57 IL-10 12.6 33.45 ± 9.65 27.34 ± 7.22 18.25 ± 5.56 TNF-α 30 67.74 ± 10.46 44.74 ± 3.83 68.40 ± 11.62 (* Kliener G et al, 2013) [8]) As can be seen from table 7, plasma cytokine levels of at admission, at the time point of ARDS and 3 days after ARDS diagnosed all much greater than normally physiological values. There was no difference between plasma cytokine levels when comparing time to time. Table 8: Mortality, time and causes of death. Outcomes n % Mild 0 0 Mortality according to ARDS severity Moderate 31 64.38 Severe 10 58.82 Total 41 62.12 < 7 days 29 70.73 Times of death 7 - 14 days 10 24.39 (from ARDS onset) > 14 days 2 4.88 Multiple organ failure 23 56.10 Causes of death Refractory septic shock 16 39.02 Refractory respiratory failure 2 4.88 Forty one cases accounting for 62.12% did not survive. Main causes of death were multiple organ failure (56.10%), followed by refractory septic shock (39.02%). Most death occurred during the first week since ARDS onset (70.73%). 93
6. Journal of military pharmaco-medicine N o7-2017 DISCUSSION usually underwent metal disorder. These Despite substantial progress in characteristics are same to our records. understanding ARDS pathophysiology, At time ARDS was diagnosed, most ARDS remains a major clinical problem patients suffered from mild mental and mortality is still high. During the past disorder with Glasgow ranged from 10 to decades, outcome of burn patients has 14 (86.36%), fever (72.73%), tachypnea improved as a results of better with low SpO2 as well as arterial blood management of burn shock, more gas values and bilateral infiltrate on chest effective topical antimicrobials used, radiograph. Patients may also suffered better systemic antibiotics, earlier from anemia, leucocytosis and excision, and alternative measures for thrombocytopenia. This finding was wound closure. However, ARDS has accordant with the results of Hodgson C.L recently been claimed to be important in et al (2011) [6]. respiratory dysfunction in burns and Inflammatory reaction plays an studies have indicated ARDS is still one important role in pathological mechanism of leading complications causing death of ARDS. In severe burn patients, it has among burn patients. According to been proven that significantly inflammatory previous studies, the incidence of ARDS response along with burn severity leading in burn patients is about 20 - 56% to complications including sepsis, septic depending on burn severity. Recently, in shock, ARDS and MOF. Our study 2014, a prospective study of ARDS showed that both inflammatory and characteristics in burned military anti-inflammatory cytokines increased casualties by using the Berlin definition considerably right after admission and showed that prevalence of ARDS was prolonged even 3 days after ARDS 32.6% [1]. Most studies have an onset. This can be explained by severe agreement that the onset of ARDS was burn, with large extent of burn injuries, around 6 to 7 days post burn. In our especially with concominant inhalation study, the time point of ARDS was during injuries in our studied patients. the first week post burn (53.03%). As Study by Bhadade et al in 2011 Berlin classification, most ARDS cases in revealed that mortality rate of ARDS was our study was moderate and severe, 57% and up to 88% when ARDS these results were accordant with those of combined with severe sepsis [4]. other reports. Recently, Villar et al reviewed ARDS According to Hansen-Flaschen J and studies since 2000 for all patients Siegel M.D (2010), common clinical categories, concluded that despite the symptoms of patients with ARDS were use of lung protective mechanical dyspnea, tachypnea, cyanosis, dry cough, ventilation, the mortality rate of ARDS chest pain and tachycardia [5]. In patients was still greater than 40% [12]. addition, at onset time of ARDS, patients For burn patients, works by Dancey et al 94
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