|Year : 2018 | Volume
| Issue : 1 | Page : 225-228
Serum albumin and base deficit as prognostic factors for mortality in major burn patients
Mohamed A Megahed1, Shawky S M. Gad2, Rana H El-Helbawy3, Mohamed M Mansour4
1 Department of Plastic Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Department of Chest, Faculty of Medicine, Menoufia University, Menoufia, Egypt
4 Department of Plastic Surgery, Ahmed Maher Teaching Hospital, Cairo, Egypt
|Date of Submission||25-Dec-2016|
|Date of Acceptance||11-Mar-2017|
|Date of Web Publication||14-Jun-2018|
Mohamed M Mansour
Source of Support: None, Conflict of Interest: None
The objective of this study was to assess serum albumin and base deficit as prognostic factors for mortality in major burn patients.
Hypoalbuminemia is a common clinical deficiency in burn patients and is associated with complications related to increased extravascular fluid, including edema, abnormal healing, and susceptibility to sepsis. Base deficit is routinely calculated on blood gas analysis, and it provides the best estimate of the degree of tissue anoxia and shock at the whole body level, particularly in hemorrhagic shock. A rising base deficit indicates increasing metabolic acidosis, and may stratify mortality in patients after major trauma. Some prognostic scales do not include biochemical parameters, whereas others consider them together with comorbidities. The purpose of this study was to determine whether serum albumin and base deficit can predict mortality in burn patients.
Patients and methods
This study included 42 patients. All patients were admitted to the burn ICU at Menoufia University Hospital. Serum albumin and base deficit were estimated in patients at admission, after 3 days, and after 1 week.
The mean of serum albumin on admission was 3.33 ± 0.44 g/dl, after 3 days it was 2.85 ± 0.54 g/dl, and after 1 week it was 2.46 ± 0.67 g/dl, and the mean of base deficit was 5.75 ± 2.40, 5.24 ± 2.05, and 5.45 ± 2.76, respectively. These results were significant (P < 0.001).
Statistically, serum albumin and base deficit can be used as prognostic factors for mortality, and colloid therapy should be continued for the first week, not only for the first 3 days.
Keywords: albumin, base deficit, burns, level of severity of injury, mortality
|How to cite this article:|
Megahed MA, M. Gad SS, El-Helbawy RH, Mansour MM. Serum albumin and base deficit as prognostic factors for mortality in major burn patients. Menoufia Med J 2018;31:225-8
|How to cite this URL:|
Megahed MA, M. Gad SS, El-Helbawy RH, Mansour MM. Serum albumin and base deficit as prognostic factors for mortality in major burn patients. Menoufia Med J [serial online] 2018 [cited 2020 Feb 27];31:225-8. Available from: http://www.mmj.eg.net/text.asp?2018/31/1/225/234253
| Introduction|| |
Hypoalbuminemia is common in critically ill patients, particularly in burn patients . Even when burns cover less than 10% of the body surface, important metabolic changes occur. Burns produce hypermetabolic and hypercatabolic responses, which are related to the extent and depth of the injuries .
Burns affecting more than 20% of the body surface cause a major loss of extracellular fluids, thereby inducing shock by increasing vascular permeability and reducing plasma albumin from the wound exudations .
Hypoalbuminemia also causes complications related to increasing extravascular fluids, including edema, abnormalities in healing, and increased susceptibility to sepsis .
Burns cause cellular hypoxia and this leads to accumulation of acids – for example, lactic acid and pyruvic acid – and metabolic acidosis characterized by a fall in blood bicarbonate concentration (where the normal level of bicarbonate is 22–26 mEq/l) ,.
Base deficit (BD) is defined as a decrease in total concentration of bicarbonate. It is considered as an indication of metabolic acidosis .
Metabolic acidosis is defined as a BD of more than 4–5 mEq/l. It is managed by treatment of the underlying cause and administering sodium bicarbonate (NaHCO3) only if the pH is less than 7.30 and with BD is more than 7. Calculation of the dose of bicarbonate (mEq) given for correction is as follows : base deficit × 0.2 × body weight (kg).
| Patients and Methods|| |
All patients or their relatives gave written informed consent before inclusion into the study. This study included 42 patients admitted to the burn ICU at Menoufia University Hospital. Patients with associated injuries or with past history of medical diseases were excluded from the study. Patients had major burns with the following criteria: total body surface area (TBSA) burned more than 25% in adults or more than 20% at extremes of age, full-thickness burns more than 10%, burns involving face and or neck, inhalation burns, associated trauma, and burns in patients with serious pre-existing medical disorders.
Causes of burn varied; a total of 20 patients presented with direct flame burn, 19 patients presented with scald, and three patients presented with electrical burn.
Age of the patients varied from 3 months to 61 years, with a mean age of 22 years.
The variables examined were age, sex, TBSA, and laboratory test results, such as albumin and ABGs at admission to the burn unit, after 3 days, and after 1 week. The calculation of TBSA was based on the 'rule of nines'.
Continuous variables were presented as mean and SD; categorical variables were presented as counts and percentages. Differences of categorical variables were assessed by the two-tailed Fisher exact test (t-test). Differences between continuous variables were assessed by two-tailed unpaired t-test. These statistical analyses were used to assess the relative predictive power of %TBSA of burn, age, sex, inhalation injury, pregnancy, and cause of burn as predictors of patient mortality. A P value less than 0.05 was considered statistically significant. Microsoft Excel 2007 (Microsoft, Redmond, Washington, USA) and SPSS for Windows (version 17; SPSS Inc., Chicago, Illinois, USA) were used for data processing and statistical analysis.
| Results|| |
Among 19 (45.2%) patients aged between 0 and 15 years, five of them died; among 16 (38.1%) patients aged between 15 and 45 years, three of them died; and among seven (16.7%) patients aged more than 45 years, one of them died. P value less than 0.05 indicates that age is a significant variable in prediction of mortality [Table 1].
[Table 2] shows that sex was used as a predictor of mortality, whereas TBSA and inhalation burns were significant predictors (P < 0.01).
|Table 2: Sex, total body surface area, and inhalation injury in the studied patients|
Click here to view
[Table 3] shows the comparison between the surviving patients and those who died according to albumin. Serum albumin at days 1, 3, and 7 was significantly higher in the surviving groups. Therefore, serum albumin level may become a reference for prediction of mortality in burn patients. Low serum albumin, especially on admission, predicts a high mortality rate.
|Table 3: Comparison between the surviving and dead patients according to albumin|
Click here to view
[Table 4] shows that BD was highly significantly increased in patients who died, and can be used as a predictor of outcome at days 1, 3, and 7.
|Table 4: Comparison between surviving and dead patients according to base deficit|
Click here to view
| Discussion|| |
The mortality rate in different age groups was 55.6, 33.3, and 11.1% [Table 1].
These results are in agreement with those of Arizona Burn Center, USA, which reported that the highest fire-related death rates in children occur in infants and children less than 4 years of age. Death rates begin to rise again after the age of 15 years . In another study, mortality rates were studied among 5321 patients with burns admitted to a burn unit in China. Age has been one of the strongest prognostic variables for mortality after burn injury . In the elderly with burns, up to 45% mortality was reported in patients aged at least 65 years. Also these results are in agreement with the results of the Department of Surgery, the University of Iowa College of Medicine, Iowa City, USA, where the mortality rate was 30.2% in 308 patients of at least 60 years of age .
In this study, 21 were female and 21 were male. Mortality rate varied from 33.3% in females to 66.7% in males, with no statistically significant difference between the two groups [Table 2].
The sex of the patients in Menoufia University burn unit is statistically not significant, and these results are in agreement with the results of the Department of Surgery, the University of Iowa College of Medicine: the admission was spread over a 19-year-period with a male to female ratio of 1.8: 1 . University of Sulaimani, Iraq, found that the male/female ratio in dead patients was 1: 6 (37 male and 223 female). The predominance of female deaths was observed throughout the study period except in the extremes of age where the male/female ratio was 1: 1.5 .
There is a significant increase in mortality associated with increased percentage of burn [Table 2]. Another study also reported that there is a statistically significant association between mortality rate and increased body surface area burned, with obvious increase in mortality rate in burns at least 70% TBSA . Another study carried out on a total of 2111 burn patients admitted at 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 over 70% TBSA invariably suggestive of fatal outcome .
In this study, patients suffering from inhalation injury showed a mortality rate of about 88.9% of patients, whereas other patients had only 9.1% mortality, with a significant increase of mortality associated with inhalation injury [Table 2]. Another study had reported that mortality in patients with inhalation injury was 80%, whereas in patients without inhalation injury 35% mortality was observed .
Albumin level may be used as an indicator of mortality. Albumin level of 3.0 ± 0.12 g/l had fatal outcome and patients who improved had a mean value of 3.42 ± 0.45 g/l. Therefore, albumin level less than or equal to 2.46 g/dl indicates bad prognosis and high mortality [Table 3]. These results were in agreement with those of Aguayo-Becerra et al. , who stated that patients with albumin levels of 2 g/dl had a mortality risk of 80%, with 84% sensitivity and 83% specificity.
BD also may be used as an indicator of mortality. A BD of 9.069 ± 1.30 mEq/l had bad prognosis, and patients with a mean BD of 4.84 ± 1.73 mEq/l improved. Therefore, a BD of at least 5.75 indicates bad prognosis with a high mortality [Table 4].
Pediatric Trauma Center of University of Florida Health Science Center, Florida, USA, reported similar results: a high initial BD in injured children predicts a higher incidence of complications and a less favorable outcome .
Department of Surgery, Division of Burn, Trauma and Critical Care, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA, analyzed arterial BD as a marker for shock at each of the 24-h (n = 81) and 48-h (n = 75) time points after injury. The median BD was 1.1 mEq/l (0.8–4.7 mEq/l) at the 24-h time point and 1.1 mEq/l (2.9–1.1 mEq/l) after 48 h. Few patients had evidence of shock (BD ≥6 mEq/l) at the 24-h, 12 of 81 (15%), or 48-h, two of 75 (3%), time point. Patients who died (22%) had greater BD at both 24- and 48-h time points. After controlling for the effects of inhalation injury, full-thickness burn size, and age, a base of deficit of at least 6 mEq/l at 24 h was associated with death. A BD of at least 6 mEq/l at 48 h was not associated with mortality .
| Conclusion|| |
BD and serum albumin in patients with major burns on admission, after 3 days, and after 1 week are good prognostic factors. Continuation of fluid therapy (colloid administration) up to 1 week – not only 3 days – is recommended, as correction of hypoalbuminemia can increase patient survival.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Cartwright M. The metabolic response to stress: a case of complex nutrition support managment. Crit Care Nur Clin North Am 2004; 16
Budagov RS, Ul'ianova LP. Some consequences of systemic inflammatory response in the pathogenesis of aggravation of outcomes of combined radiation and thermal injuries. Radiats Biol Radioecol 2005; 45
Lehnhardt M, Jafari HJ, Druecke D, Steinstraeser L, Steinau HU, Klatte W, et al.
qualitative and quantitative analysis of protein loss in human burn wounds. Burns 2005; 31
Zimmermann WE. Acidosis in severe burns. Early treatment of severe burns. Ann N
Y Acad Sci 1968; 150
Kraut JA, Kurtz I. Use of base in treatment of severe organic acidosis and critical care physicians: results of an online survey. Clin Exp Nephrol 2006; 10
Habermann TM, Ghosh A. Mayo Clinic Internal Medicine Concise Textbook
ed. USA: CRC Press; 2007. pp. 599–914.
Peck MD. Epidemiology of burns throughout the world part 1: distribution and risk factors. Burns 2011; 37
Jie X, Baoren C. Mortality rates among 5321 patients with burns admitted to a burn unit in China: 1980-1988. Burns 2003; 29
Wibbenmeyer LA, Amelon MJ, Morgan LJ, Robinson BK, Chang PX, Kealey GP, et al.
Predicting survival in an elderly burn patients population. Burns 2001; 27
Qader AR. Burn mortality in Iraq. Burns 2012; 38
Sharmaa PN, Bang RL, Ghoneim IE, Bang S, Sharma P, Ebrahim MK. Predicting factors influencing the fatal outcome of burns in Kuwait. Burns 2005; 31
Keck M, Lumenta DB, Andel H, Kamolz LP, Frey M. Burn treatment in the elderly. Burns 2009; 35
Aguayo-Becerra OA, Torres-Garibay C, Macîas-Amezcua MD, Fuentes-Orozco C, Chávez-Tostado MD, Andalón-Dueñas E, et al.
Serum albumin level as a risk factor for mortality in burn patients. Clinics 2013; 68
Peterson DL, Schinco MA, Kerwin AJ, Griffen MM, Pieper P, Tepas JJ. Initial base deficit as a prognosticator of outcome in the pediatric trauma population. Am Surg 2004; 70
Fitzwater J, Purdue GF, Hunt JL, Keefe GE. The risk factors and time course of sepsis and organ dysfunction after burn trauma. Burns 2003; 29
[Table 1], [Table 2], [Table 3], [Table 4]