Do standard burn mortality formulae work on a population of severely burned children and adults?

doi:10.1016/j.burns.2015.03.017

Burns

Volume 41, Issue 5, August 2015, Pages 935-945

https://doi.org/10.1016/j.burns.2015.03.017 Get rights and content

Highlights

•
Common burn severity scores are more discriminatory than the general APACHEII.
•
The Ryan Score performs well in the critically ill burn patient population.
•
Revised Baux is well-calibrated in the severely burned adult population.
•
ABSI and pediatric Baux exceedingly overestimate mortality in severely burned.
•
We advise against the over generalized use of mortality formulae.

Abstract

Accurate prediction of mortality following burns is useful as an audit tool, and for providing treatment plan and resource allocation criteria. Common burn formulae (Ryan Score, Abbreviated Burn Severity Index (ABSI), classic and revised Baux) have not been compared with the standard Acute Physiology and Chronic Health Evaluation II (APACHEII) or re-validated in a severely (≥20% total burn surface area) burned population. Furthermore, the revised Baux (R-Baux) has been externally validated thoroughly only once and the pediatric Baux (P-Baux) has yet to be. Using 522 severely burned patients, we show that burn formulae (ABSI, Baux, revised Baux) outperform APACHEII among adults (AUROC increase p < 0.001 adults; p > 0.5 children). The Ryan Score performs well especially among the most at-risk populations (estimated mortality [90% CI] original versus current study: 33% [26–41%] versus 30.18% [24.25–36.86%] for Ryan Score 2; 87% [78–93%] versus 66.48% [51.31–78.87%] for Ryan Score 3). The R-Baux shows accurate discrimination (AUROC 0.908 [0.869–0.947]) and is well-calibrated. However, the ABSI and P-Baux, although showing high measures of discrimination (AUROC 0.826 [0.737–0.916] and 0.848 [0.758–0.938]) in children), exceedingly overestimates mortality, indicating poor calibration. We highlight challenges in designing and employing scores that are applicable to a wide range of populations.

Section snippets

Background

Burn is a significant global public health concern and is one of the major causes of trauma-related mortality worldwide [1]. The prediction of mortality following burn is advantageous to evaluate processes of care, to analyze and standardize populations for research purposes, and for its potential to provide criteria for triage and information to clinicians, patients and their families considering care plans. For the latter uses, accuracy and statistical validity of the formulae are crucial,

Study design/patient and definition outcome

This study was performed by means of the secondary use of 573 patient clinical data from the Inflammation and the Host Response to Injury Study (“Glue Grant”), a prospective, longitudinal study which enrolled burn patients with minimum 20% total burn surface area (TBSA) at six US institutions between 2003 and 2009. Permission for this secondary use of the de-identified data was obtained from the Massachusetts General Hospital Institutional Review Board. Among a total of 573 patients, 522

Patient demographics, baseline characteristics and outcome

Among the dataset of 522 patients with severe burns, excluding electrical burns, who arrived at the hospital within 96 h since injury, have spent at least one day in the ICU and having complete clinical report (Supplementary Figure 1), 333 (63.3%) are adults (≥16 years old) and 189 (36.7%) are children (<16 years old). A total of 77 patients were considered to have experienced death due to burn trauma in our study, as described (Supplementary Figure 2). Among the adult population, 63 (18.9%)

Discussion

We performed a comprehensive analysis evaluating various baseline characteristics and clinical score performance for mortality prediction in a unique population of severely burned adult and pediatric patients (≥20% TBSA and high prevalence of full-thickness burns). Prior mortality score prediction studies have focused primarily on patients with mean or median TBSA similar to or below the minimum of our current study base. Although the population analyzed in this current study is derived from

Future studies or limitations

The study successfully identified significant risk factors of burn trauma-related death, assessed the performance of general versus burn-specific score methods and re-validated the Ryan Score, ABSI, revised R-Baux, P-Baux Scores in the severely burned patient population. In our dataset, the number of children was much smaller compared to that of adults and thus future studies would enroll a larger number of pediatric study subjects. Moreover, especially given the severity of burn, some patients

Conclusion

Our study of mortality prediction in severely burned patients demonstrates that burn-specific mortality formulae outperform the general APACHEII formula. Furthermore, we demonstrate that the categorical TBSA, age and inhalation injury indicators, as established by the Ryan Score are relevant risk factors. Our re-validation of ABSI finds that it grossly underestimates the probability of survival among both adults and children in our study. The R-Baux model for adults has descent discrimination

Acknowledgements

This work was supported by the US Army Medical Research Acquisition Act of US Department of Defense, Congressionally Directed Medical Research Programs (CDMRP), Defense Medical Research and Development Program (DMRDP) Basic Research Award, W81XWH-10-DMRDP-BRA to LGR. AT was supported by the Shriners Hospitals Research Fellowship #84293. The investigators acknowledge the contribution of the Inflammation and the Host Response to Injury Large-Scale Collaborative Project Award 5U54GM062119 from the

References (34)

M.D. Peck
Epidemiology of burns throughout the world. Part I: Distribution and risk factors
Burns
(2011)
N. Brusselaers et al.
Assessment of mortality prediction models in a Ghanaian burn population
Burns
(2013)
A. Hussain et al.
Predicting survival in thermal injury: a systematic review of methodology of composite prediction models
Burns
(2013)
S. Baux et al.
Burns in the elderly
Burns
(1989)
J. Tobiasen et al.
The abbreviated burn severity index
Ann Emerg Med
(1982)
A.E. Berndtson et al.
Estimating severity of burn in children: Pediatric Risk of Mortality (PRISM) score versus Abbreviated Burn Severity Index (ABSI)
Burns
(2013)
N.A. Forster et al.
30 years later – does the ABSI need revision?
Burns
(2011)
G. Germann et al.
The impact of risk factors and pre-existing conditions on the mortality of burn patients and the precision of predictive admission-scoring systems
Burns
(1997)
G. Gravante et al.
Analysis of prognostic indexes and other parameters to predict the length of hospitalization in thermally burned patients
Burns
(2007)
D.K. Seo et al.
Epidemiological trends and risk factors in major burns patients in South Korea: a 10-year experience
Burns
(2015)

A. Hussain et al.

Accuracy of commercial reporting systems to monitor quality of care in burns

Burns

(2014)

G.T. Lionelli et al.

A three decade analysis of factors affecting burn mortality in the elderly

Burns

(2005)

P. Mahar et al.

Clinical factors affecting mortality in elderly burn patients admitted to a burns service

Burns

(2008)

L.A. Wibbenmeyer et al.

Predicting survival in an elderly burn patient population

Burns

(2001)

R. Galeiras et al.

A model for predicting mortality among critically ill burn victims

Burns

(2009)

G.E. O’Keefe et al.

An evaluation of risk factors for mortality after burn trauma and the identification of gender-dependent differences in outcomes

J Am Coll Surg

(2001)

A.M. Ghanem et al.

Body Mass Index (BMI) and mortality in patients with severe burns: is there a tilt point at which obesity influences outcome?

Burns

(2011)

Cited by (29)

Predictive value of lactate dehydrogenase combined with the abbreviated burn severity index for acute kidney injury and mortality in severe burn patients
2023, Burns
Extensive burns are devastating trauma. This study aimed to explore the predictive value of early lactate dehydrogenase (LDH) level, the abbreviated burn severity index (ABSI) and their combination on acute kidney injury (AKI) and mortality after severe burns.
194 severe burn patients (TBSA ≥ 30%) were included. After multivariate analyses, early LDH value (first 24 h after admission) was an independent risk factor for early AKI (OR=1.095, CI,1.025–1.169,p = 0.007) and AKI (OR=1.452, CI,1.131–1.864, p = 0.003) in severe burn patients and was still a significant risk factor for mortality (OR=1.059, CI,1.006–1.115，p = 0.03). In ROC analysis, after combining LDH and ABSI, the AUC values were 0.925 for AKI, 0.926 for stage 3 AKI, and 0.904 for mortality. Based on cut-off values, patients were divided into different risk groups. The cumulative incidence of AKI (within 5 days, 30 days) and survival rate (within 60 days) were analyzed by the Kaplan-Meier method. The mortality, AKI incidence, and AKI staging showed a significant upward trend with the increasing risk level (P < 0.001).
Early LDH level is an independent risk factor for early AKI and AKI. LDH combined with ABSI can better predict mortality and AKI than single indicators.
Aspartate transaminase/alanine transaminase (De Ritis ratio) predicts survival in major burn patients
2022, Burns
Citation Excerpt :
If a simple and inexpensive routine test was available which can quickly and correctly distinguish high mortality risk from low mortality risk, it would guide the treatment and establish expectations. Several commonly used burn patient-specific formulae are available, including the Ryan Score, Abbreviated Burn Severity Index (ABSI) and the classic and revised Baux Scores [1], which use commonly measured variables such as age, total burned surface area (TBSA), and inhalation injury to predict mortality. But these formulae are never combined with physiological and biochemical variables.
Although treatment of burn patients has significantly improved in recent decades, major burns remain fatal. Therefore, the evaluation of the death risk of the patients with extensive burns is very important. The ratio between the serum levels of aspartate transaminase and alanine transaminase (De Ritis ratio) was an independent predictor of poor outcomes in patients with acute ischemic stroke, cardiac surgery, non-metastatic renal cell carcinoma, and upper urinary tract urothelial carcinoma. Our aim was to determine whether the ratio between the serum levels of AST and ALT (De Ritis ratio) was useful to assess prognosis in extensively burned patients.
We conducted a single-center cohort study at the Burns Department of Changhai Hospital. This retrospective observational analysis was performed based on the clinical data of major burn patients admitted between May 1, 2005 and April 30, 2018. Univariate and multivariate logistic regression analyses were performed on variables such as age, sex, total body surface area (TBSA), De Ritis ratio, and serum albumin level, which may affect mortality in major burn patients. We assessed their diagnostic value and found the cut-off value by receiver operative characteristic (ROC) curve analysis. We used the Kaplan–Meier curve to display the impact of the De Ritis ratio and serum albumin level on survival in burn patients.
A total of 351 patients with extensive burns were included in the study. The cohort predominantly consisted of males (74.64%), and most of the patients (78.35%) had been burned by a flame. Age, TBSA, inhalation, and the De Ritis ratio were found to be independent risk factors for the 30-days mortality of major burn patients, while age, TBSA, inhalation, and the De Ritis ratio were independent risk factors for 90-day mortality. Further, the De Ritis ratio was a better mortality predictor than serum albumin in severely burned patients, whose area under ROC for 30-day and 90-day mortality was 0.771 (95% confidence intervals [CI], 0.708–0.835) and 0.750 (95% CI, 0.683, 0.818).
The De Ritis ratio was useful as a prognostic indicator for major burn patients, which can be conveniently obtained through blood examination. Regardless of whether the prediction was for 30-day or 90-day mortality, the accuracy remained high. Moreover, compared to serum albumin level, the De Ritis ratio was superior in assessing the prognosis of extensively burned patients.
Clinical outcome and comparison of burn injury scoring systems in burn patient in Indonesia
2021, African Journal of Emergency Medicine
Citation Excerpt :
The region under the curve (AUC) was used to identify the model and was much more accurate in the distinction between survivors (false positives) and deceased (true positive). An area >0.9 indicated high accuracy, 0.7–0.9 moderate accuracy, 0.5–0.7 low accuracy, and 0.5 indicated discrimination of chance [19]. Statistical significance was defined as a p value<0.05.
The purpose of this study was to explore and compare the performance of four burn injury scoring systems in Indonesia. In a retrospective study, data of all burn patients admitted to the emergency centre (EC) were collected. The following clinical outcome and four burn injury scoring systems were used to assess each patient: Abbreviated Burn Severity Index (ABSI), Belgian Outcome in Burn Injury (BOBI), the Ryan model, and revised Baux Score.
From April 2017 to April 2018, clinical outcome and burn injury score for every admitted patient were calculated to evaluate burn prognosis. Demographic information, ABSI score, full-thickness total body surface area (TBSA), overall TBSA, hospital stay, and inhalation injury were noted for analysis. Discriminative ability and goodness-of-fit of the prediction models were determined by receiver operating characteristic curve analysis and Hosmer–Lemeshow tests.
We included 72 patients (mean age: 40.79 ± 16.30 years, average TBSA: 23.59% ± 24.84). Only 1 (1.4%) of them was diagnosed with inhalation injury. Mortality rate was 25%. Deceased patients had significantly higher mean age, %TBSA, and number of inhalation injuries. The ABSI model with sensitivity was 81.6, specificity was 92.5, accuracy was 87.3 and under the Receiver Operator Characteristics curve (AUC) was 0.93 (SE = 0.03).
The best estimation of predicted mortality was obtained with the ABSI model.
Development of dynamic cell and organotypic skin models, for the investigation of a novel visco-elastic burns treatment using molecular and cellular approaches
2020, Burns
Citation Excerpt :
In such events, appropriate and comprehensive primary care is essential while effective and rapid triage, stabilisation, and transfer provide optimal outcomes. However outcomes for severely burned patients, particularly children or the elderly, who cannot be transferred for burn care, are poor [27–31]. Despite advances, concerns for the success, time and cost of treatment, inability to restore functionality of the skin, and the high rates of complications related to severe burn wounds remain [32].
Burn injuries are a major cause of morbidity and mortality worldwide. Despite advances in therapeutic strategies for the management of patients with severe burns, the sequelae are pathophysiologically profound, up to the systemic and metabolic levels. Management of patients with a severe burn injury is a long-term, complex process, with treatment dependent on the degree and location of the burn and total body surface area (TBSA) affected. In adverse conditions with limited resources, efficient triage, stabilisation, and rapid transfer to a specialised intensive care burn centre is necessary to provide optimal outcomes. This initial lag time and the form of primary treatment initiated, from injury to specialist care, is crucial for the burn patient. This study aims to investigate the efficacy of a novel visco-elastic burn dressing with a proprietary bio-stimulatory marine mineral complex (MXC) as a primary care treatment to initiate a healthy healing process prior to specialist care.
A new versatile emergency burn dressing saturated in a >90% translucent water-based, sterile, oil-free gel and carrying a unique bio-stimulatory marine mineral complex (MXC) was developed. This dressing was tested using LabSkin as a burn model platform. LabSkin a novel cellular 3D-dermal organotypic full thickness human skin equivalent, incorporating fully-differentiated dermal and epidermal components that functionally models skin. Cell and molecular analysis was carried out by in vitro Real-Time Cellular Analysis (RTCA), thermal analysis, and focused transcriptomic array profiling for quantitative gene expression analysis, interrogating both wound healing and fibrosis/scarring molecular pathways. In vivo analysis was also performed to assess the bio-mechanical and physiological effects of this novel dressing on human skin.
This hybrid emergency burn dressing (EBD) with MXC was hypoallergenic, and improved the barrier function of skin resulting in increased hydration up to 24 h. It was demonstrated to effectively initiate cooling upon application, limiting the continuous burn effect and preventing local tissue from damage and necrosis. xCELLigence RTCA® on primary human dermal cells (keratinocyte, fibroblast and micro-vascular endothelial) demonstrated improved cellular function with respect to tensegrity, migration, proliferation and cell-cell contact (barrier formation) [1]. Quantitative gene profiling supported the physiological and cellular function finding. A beneficial quid pro quo regulation of genes involved in wound healing and fibrosis formation was observed at 24 and 48 h time points.
Utilisation of this EBD + MXC as a primary treatment is an effective and easily applicable treatment in cases of burn injury, proving both a cooling and hydrating environment for the wound. It regulates inflammation and promotes healing in preparation for specialised secondary burn wound management. Moreover, it promotes a healthy remodelling phenotype that may potentially mitigate scarring. Based on our findings, this EBD + MXC is ideal for use in all pre-hospital, pre-surgical and resource limited settings.
The ABSI is dead, long live the ABSI - reliable prediction of survival in burns with a modified Abbreviated Burn Severity Index
2020, Burns
The Abbreviated Burn Severity Index (ABSI) is a widely used and simple score to predict mortality after burn injuries. On the one hand, significant improvements in intensive care management and surgical treatment result in an increased survival rate. On the other hand, the aging population might lead to an increased injury-related mortality rate. Therefore, the question arises whether the ABSI still accurately predicts survival.
Data of 14,984 patients from the German Burn Registry from 2015 to 2018 were analyzed to re-evaluate the variables included in the ABSI, identify discrepancies between the predicted age-related probability of survival and the actual survival rate. Descriptive statistics, univariate analysis and binary logistic regression were used to test the variable impact and to establish a modified score.
The original ABSI does not accurately predict the survival in the present cohort. In particular, univariate analysis identified age, total body surface area burned, full thickness burn and inhalation injury as significant impactors on survival. Moreover, sex could not be confirmed as significant and was, therefore, excluded from the modified score. The assumption of a linear relation between age and mortality was not correct. We developed a new age scale representing the actual existing relationship. The resulting modified score was significantly more accurate in predicting the probability of survival for all burn score categories.
The ABSI does not accurately predict probability of survival. Mortality is overestimated in severely burned patients. A modified version was developed that was significantly more accurate in predicting the probability of survival in this cohort.
Palliation, end-of-life care and burns; concepts, decision-making and communication – A narrative review
2020, African Journal of Emergency Medicine
Citation Excerpt :
And lastly, the use of burn mortality scores to guide futility decisions has not been explored in the literature. There is little to choose between the various scores, with different scores performing better in different populations [30–35]. In HICs death after a paediatric burn is a rare event, even after burns over 80% TBSA.
Palliative care is the turn from cure as the priority of care to symptom relief and comfort care. Although very little is published in the burn literature on palliative care, guidelines can be gleaned from the general literature on palliative care, particularly for acute surgical and critical care patients. Palliative care may be started because of futility, on request of the patient, or because of limited resources. The SPIKES acronym is a useful guide to avoid errors in communication with terminal patients and their relatives.

View all citing articles on Scopus

View full text

Do standard burn mortality formulae work on a population of severely burned children and adults?

Highlights

Abstract

Section snippets

Background

Study design/patient and definition outcome

Patient demographics, baseline characteristics and outcome

Discussion

Future studies or limitations

Conclusion

Acknowledgements

Burns

Burns

Burns

Burns

Ann Emerg Med

Burns

Burns

Burns

Burns

Burns

Burns

Burns

Burns

Burns

Burns

J Am Coll Surg

Burns