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ORIGINAL ARTICLE
Year : 2014  |  Volume : 27  |  Issue : 2  |  Page : 290-295

Retrospective study of mortality and causes of death in Menofia University Burn Center


Plastic Surgery Department, Faculty of Medicine, Menofia University, Menofia, Egypt

Date of Submission07-May-2013
Date of Acceptance25-Aug-2013
Date of Web Publication26-Sep-2014

Correspondence Address:
Asmaa Mohammed El Mehrat
MBBCh, Shebin Elkom, Menofia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.141678

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  Abstract 

Background
Mortality rates are important outcome parameters after burn injury and can serve as objective endpoints for quality control. Causes of death after severe burn have changed over time, but the exact distribution of causes of death remains unknown.
Objective
The aim of the study was to estimate the mortality rates and determine the causes of death in patients admitted to the Burn Center of the Faculty of Medicine, Menofia University, between 1 January 2006 and 31 June 2010.
Patients and methods
Between January 2006 and June 2010, 516 patients were enrolled. A predesigned questionnaire was used to collect data about percentage of burn, site of burn, and inhalation injury as well as data about age, sex, burnt area, occurrence, and causes of death.
Results
Of the 516 patients included, 96 died, giving an overall mortality rate of 18.6%. The main cause of death was multiorgan failure, which accounted for 48.1% of the mortality cases. Septicemia caused about 27% of deaths, burn shock led to 19.7% of deaths, and other causes were the reason for 5.2% of mortality cases. Comparison of the overall mortality during 2006-2010 with that observed in a previous study conducted in the same unit during 2002-2004 revealed a decrease in rate (24.1-18.6%).
Conclusion and recommendations
Mortality rate among burn patients is influenced by several risk factors such as age, total body surface area involved, and the presence of inhalation injury. The mortality rate from severe burns has decreased but remains high despite improvements in burn care. Early fluid resuscitation, early detection and correction of any laboratory defects, nutritional support, diagnosis and treatment of inhalation injury, and prevention of burn-related infections are recommended in the treatment of acute burn.


How to cite this article:
El Mehrat AM, Ghareeb FM, Keshk TF, El Sheikh YM, Ibrahim AH. Retrospective study of mortality and causes of death in Menofia University Burn Center. Menoufia Med J 2014;27:290-5

How to cite this URL:
El Mehrat AM, Ghareeb FM, Keshk TF, El Sheikh YM, Ibrahim AH. Retrospective study of mortality and causes of death in Menofia University Burn Center. Menoufia Med J [serial online] 2014 [cited 2020 Apr 6];27:290-5. Available from: http://www.mmj.eg.net/text.asp?2014/27/2/290/141678


  Introduction Top


A burn injury is a disastrous trauma that may range from a minor injury to a life-threatening one, making such cases difficult to manage and treat [1]. Several factors influence the outcome among patients, including age, total body surface area (TBSA), depth of burn wound, presence of inhalation injury, previous medical conditions, infections, pneumonia, and septicemia [2].

Causes of death after severe burn have changed over time; in the international literature, multiorgan failure (MOF), acute systemic inflammatory response syndrome (SIRS), and infection are seen as the most important causes, but the exact distribution of causes of death remains unknown [3].

Mortality rates are important outcome parameters after burn, and can serve as objective endpoints for quality control. Furthermore, these rates are used in evaluating new therapeutic interventions and establishing standards of burn survival [4].


  Patients and methods Top


This retrospective study included 516 patients admitted to the Menofia University Burn Center from January 2006 to June 2010. Data of all patients were collected from patient files stored in the Menofia University archive after obtaining approval from the Plastic Surgery Department and medical Ethics Committee.

All data were collected through a predesigned questionnaire, including patients' history (age, sex, cause of burn, pregnancy, and past medical history), physical examination (distribution, percentage, and degree of burn and signs of inhalation injury), laboratory results (complete blood count, liver function tests, renal function tests, electrolyte, and arterial blood gas during the first 48 h and after 1 and 2 weeks), surgical intervention (escharotomy, escharectomy, skin grafts), patient outcome, and cause of death.

Causes of death were analyzed for burn victims admitted and included dysfunction of organ system(s), SIRS, sepsis, and underlying causes. The concept of MOF as the cause of death was defined as dysfunction of more than one organ system responsible for fatal outcome despite organ support. Dysfunction is defined as follows: for the respiratory system, the requirement for mechanical ventilation for more than 72 h; for the cardiovascular system, inotropic dependency to keep mean arterial pressure above 60 mmHg; for the renal system, the use of continuous veno-venous or arterio-venous hemofiltration; for the hepatic system, transaminase level more than 1.5 of normal; and for the hematological system, platelet count below 100 000/ml.

SIRS was defined and diagnosed if the patient showed more than one of the following clinical features:

(1) Body temperature greater than 38.8°C or less than 36.8°C;

(2) Heart rate greater than 90/min;

(3) Respiratory rate greater than 20/min or PaCO 2 lower than 32 mmHg;

(4) White blood cell count greater than 12 000 cells/ml or less than 4000 cells/ml.

Sepsis was defined as the clinical syndrome of a systemic inflammation in response to infection: septic shock, defined as severe arrhythmia, implying persistent bradycardia or tachycardia irregularity without fever or other septic signs despite adequate electric and/or drug therapy; severe hypertension, if on constant readings systolic blood pressure remained greater than 160 mmHg or diastolic blood pressure was consistently greater than 100 mmHg despite adequate drug treatment; other therapy-resistant hypotensive states, defined as other shock states.

The following parameters were examined: age, sex, burn type, circumstances of burn, TBSA, inhalation injury, pre-existing comorbidities, complications during hospital stay, mortality, and hospital stay among survivors for prediction of mortality.

Statistical analysis

Continuous variables were presented as mean and SD. Categorical variables were presented as counts and percentages. Differences among categorical variables were assessed by the two-tailed Fisher's exact test. Differences among continuous variables were assessed by two-tailed unpaired t-test. These statistical analyses were used to assess the relative predictive power of %TBSA burn, age, sex, inhalation injury, pregnancy, comorbid conditions, and cause of burn, as well as different combinations of these variables, as predictors of patient mortality. A P-value less than 0.05 was considered statistically significant.


  Results Top


In the Menofia University Burn Center 516 patients were admitted over 54 months. This study included 283 female (54.8%) and 233 male (45.2%) patients [Figure 1], their ages varying from 6 months to 65 years with a mean age of 23 years. There were 255 patients (49.4%) with burns covering less than 20% of TBSA, 180 patients (34.9%) with burns covering between 20 and 40% of TBSA, and 81 patients (15.7%) with burns covering more than 40% of TBSA [Figure 2].
Figure 1:

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Figure 2:

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The cause of burn was mainly scalding in 338 patients (65.5%), whereas 165 patients (32%) presented with direct flame burn and 13 patients (2.5%) with electrical burn [Figure 3]. There were 112 patients (21.7%) aged less than 15 years, 331 patients (64.1%) aged between 15 years and 45 years, and 73 patients (14.2%) aged above 45 years [Figure 4].
Figure 3:

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Figure 4:

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Inhalation injury was detected in 132 patients (25.6%) [Figure 5], and 80 patients (15.6%) had a past history of diabetes mellitus, hypertension, chronic obstructive pulmonary disease, or hepatic disease.
Figure 5:

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The overall mortality in this study comprised 96 patients (18.6% of cases), as shown in [Figure 6]. There was no significant difference in mortality between male and female patients (17.2 vs. 19.8%). In terms of age the mortality rate was higher in patients younger than 15 years (20.5%) and in patients older than 45 years (32.8%).
Figure 6:

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The different causes of burn had different mortality rates, with electric burn having the highest mortality (76.9%), followed by direct flame (24.8%) and scalding (13.3%).

The percentage of burn showed a significant effect on the mortality rate: no mortality was seen in patients with less than 20% burn, whereas 21.6% mortality was recorded in patients with 20-40% burn and 70.3% in patients with more than 40% burn.

Mortality rate was higher in patients suffering from inhalation injury than in those without inhalation injury (28 vs. 15.3%). There was no significant relation between mortality and the prevalence of past medical history or pregnancy among burn patients.

Electrolyte disturbances at 48 h, after 1 week, and after 2 weeks revealed hypokalemia in 47 patients (9.1%), hyponatremia in 63 patients (12.2%), hypocalcemia in 25 patients (4.8%), and metabolic acidosis in 33 patients (6.4%), and these changes were significantly associated with increased mortality among burn patients. Leukocytosis, falling hemoglobin level, and impaired renal and hepatic functions were associated with significantly increased mortality.

The cause of death varied: MOF in 48.1% of cases, septicemia in 27%, burn shock in 19.7%, and other causes in 5.2% of mortality cases [Figure 7].
Figure 7:

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  Discussion Top


This study was conducted to evaluate the incidence of mortality and causes of death in burn patients in Menofia University Burn Center. The overall mortality calculated in this study was 18.6%. Age of patients was significantly related to mortality, being higher in children (≤14 years) and in patients 45 years or older. Peck [5] had reported that the highest fire-related death rates in children were in infants and in children younger than 4 years of age. Jie and Baoren had studied mortality rates among 5321 patients with burns admitted to a burn unit in China and found that age had been one of the strongest prognostic variables for mortality after burn injury. Very high mortality rates have been observed in elderly patients with burns: up to 45% in burn patients aged 65 years or above [6].

We also found that sex of the patients had no statistically significant effect in our study. Similar results were reported from the Department of Surgery, the University of Iowa College of Medicine, Iowa City, USA: the admissions were spread over a 19-year period with a male : female ratio of 1.8 : 1, but our results are different with a male : female ratio of 1 : 1.2 [7].

The results of the study by Qader conducted in the University of Sulaimani, Iraq, differed from ours. He found a male : female ratio of 1 : 6 (37 males and 223 females) among deceased patients. The predominance of female deaths was observed throughout the study period except in the extreme age groups, in which the male : female ratio was 1 : 1.5 [4].

In our study different types of burns showed different mortality rates: patients with scald burn had a mortality rate of 13.3%, whereas patients with direct flame burn had a mortality of 24.8% and those with electric burn had a mortality rate of about 76.9%. In addition, mortality rate differed according to the percentage of burn: no mortality was observed in patients with mild burn covering less than 20% of TBSA; 21.6% mortality rate was observed in patients with moderate burn covering 20-40% of TBSA; and 70.3% mortality was seen in patients with severe burn covering more than 40% TBSA with significant increase in mortality associated with increased percentage of burn.

Colleges in Ain Shams University Burn Unit had studied the relation between the cause of burn and mortality rate and had reported results similar to ours as they had found that flame burns caused more deaths compared with scalding (64.5 vs. 35.5%) [8].

Another study carried out on a total of 2111 burn patients admitted to the Burn Center in Kuwait had found that, among the predisposing factors responsible for mortality, the TBSA was a critical predictor of burn mortality, with burns covering over 70% of TBSA invariably suggestive of fatal outcome [9].

In this study, patients suffering from inhalation injury showed a mortality rate of about 28%, whereas patients free from inhalation injury had only 15.3% mortality with significant increase in mortality associated with inhalation injury.

Keck et al. [10] had reported that the incidence of inhalation injury in an aged study population was 28% and a significant difference in mortality was observed between patients with inhalation injury (80%) and those without (35%).

A study conducted in Rotterdam Burn Centre, the Netherlands reported that inhalation injury is associated with significant increase in death rate among burn patients [2].

In our study, 15.6% of patients had a past history of illness, such as ischemic heart disease, chronic obstructive pulmonary disease, hypertension, diabetes mellitus, or hepatic diseases, with no significant relation to mortality. Further, 12% of patients had associated injury during treatment in a burn unit, such as pulmonary edema, pulmonary embolism, stroke, paralytic ileus, and psychological troubles, with significant association with mortality.

Mabrouk et al. [8] reported that mortality was higher in patients with previous health problems, particularly diabetics, and in those with cardiovascular issues, which differ with our results; however, they agree with us on the association between pulmonary insult and increased mortality.

In contrast, results reported from Regional Burns Centre, Marseille, France, agree with those from our study that premorbid conditions had no statistically significant influence on mortality [11].

In our study, of 283 female patients admitted to the burn unit only 12 were pregnant (4.4% of female patients). Mortality was seen in 25% of pregnant women (1.1% of all female patients) with no significant relation between pregnancy and mortality because of termination of pregnancy in burn patients.

In a study conducted in Sina Hospital Burn Center, Iran, pregnancy was seen to be associated with increased mortality among burn patients; the most important single predictor of mortality in pregnant women and their fetuses was %TBSA burn, and presence of inhalation injury [12].

The evaluation of electrolyte disturbance and laboratory investigation results and their relation to mortality among burn patients revealed that electrolyte disturbance, including hypokalemia, hyponatremia, hypocalcemia, and pH changes, is significantly associated with increased mortality among burn patients. Leukocytosis and falling hemoglobin level were also associated with increased mortality. Impaired renal and hepatic functions were associated with significantly increased mortality.

In the Department of Burn Surgery, Changhai Hospital, China, reports have revealed that electrolyte disturbance, pH changes, impaired renal function, and leukocytosis are significantly associated with increased mortality, which agrees with our results [13].

A study conducted in the University of California Davis Burn Intensive Care Unit had reported that renal failure is common in critically ill burn patients, and its occurrence is associated with an extremely high mortality rate [14].

In our study the overall mortality rate was 18.6% (96 out of 516 patients) with MOF representing the main cause of death, affecting 50 patients (52.1%). Septicemia affected about 27 patients (28.1%) and burn shock affected about 19 patients (19.8%). Thus, the main cause of death in our burn unit is MOF.

University of Sulaimani Burn Center, Iraq, has reported a mortality rate of 29.4%, and analysis of cause of death revealed that more than half of the deaths (55%) were due to septicemia. Inhalation injury represented 40% of mortality cases and hypovolemic shock was detected in only 5% of cases [4].

In the Rotterdam Burn Centre, the Netherlands, the most frequent cause of death appeared to be MOF (64.9% of cases); 93% of patients had SIRS at the time of death, followed by sepsis in 21.3% [2].

In our study the overall mortality calculated for the period 2006-2010 was 18.6%, compared with 24.1% in a previous study conducted at the same unit (Menofia University Burn Center, Emergency Hospital) during 2002-2004 [15], which reveals an improvement in the treatment protocol and in patient care.


  Conclusion Top


The mortality rate among burn patients is influenced by several risk factors such as age, TBSA involved, and the presence of inhalation injury. Comparison of the overall mortality calculated for the period 2006-2010 with that of a previous study conducted in the same unit during the period 2002-2004 revealed a decrease in mortality (from 24.1 to 18.6%), which indicates an improvement in the treatment protocol and in patient care.


  Acknowledgements Top


Conflicts of interest

None declared.

 
  References Top

1.Miller S, Menekhoff C. Optimizing outcome in the adult and pediatric burn patient [special editorial supplement]. Trauma Rep 2009; 10:2.  Back to cited text no. 1
    
2. Bloemsma G, Dokter J, Boxma H. Mortality and causes of death in a burn centre. Burns 2008; 34:1103.  Back to cited text no. 2
    
3. Pereira C, Murphy K, Herndon D. Review outcome measures in burn care are mortality dead? Burns 2004; 30:761-771.  Back to cited text no. 3
    
4. Qader AR. Burn mortality in Iraq. Burns 2012; 38:772-775.  Back to cited text no. 4
    
5. Peck MD. Epidemiology of burns throughout the world part 1: distribution and risk factors. Burns 2011; 37:1087-1100.  Back to cited text no. 5
    
6. Jie X, Baoren C. Mortality rates among 5321 patients with burns admitted to a burn unit in China. Burns 2003; 29:239-245.  Back to cited text no. 6
    
7. Wibbenmeyer LA, Amelon MJ, Morgan LJ. Predicting survival in an elderly burn patients population. Burns 2001; 27:583-590.  Back to cited text no. 7
    
8. Mabrouk A, Maher A, Nasser S. An epidemiologic study of elderly burn patients in Ain Shams University Burn Unit, Cairo, Egypt. Burns 2003; 29:687-690.  Back to cited text no. 8
    
9. Sharmaa PN, Bang RL, Ghoneim IE. Predicting factors influencing the fatal outcome of burns in Kuwait. Burns 2005; 31:188-192.  Back to cited text no. 9
    
10.Keck M, Lumenta DB, Andel H. Burn treatment in the elderly. Burns 2009; 35:1071-1079.  Back to cited text no. 10
    
11.Lumenta DB, Hautier A, Desouches C. Mortality and morbidity among elderly people with burns - evaluation of data on admission. Burns 2008; 34:965-974.  Back to cited text no. 11
    
12.Maghsoudi H, Samnia R, Garadaghi A. Burns in pregnancy. Burns 2006; 32:246-250.  Back to cited text no. 12
    
13.Wang Y, Tang HT, Xia ZF. Factors affecting survival in adult patients with massive burns. Burns 2010; 36:57-64.  Back to cited text no. 13
    
14.Palmieri T, Lavrentieva A, Greenhalgh DG. Acute kidney injury in critically ill burn patients. Risk factors, progression and impact on mortality. Burns 2010; 36:205-211.  Back to cited text no. 14
    
15.Saber AF, Ghareeb FM, Keshk TF, El-Kased AF. 2005 Prediction and risk factors of mortality in burn patients in Menofia University Burn Center [thesis]. Egypt: Faculty of Medicine, Menofia University.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]


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