with burnsEvaluation of data on admission

b u rn s 3 4 ( 2 0 0 8 ) 9 6 5 9 7 4

avai lab le at www.sc iencedi rec t .com

.e lD.B. Lumenta a,b,*, A. Hautier a, C. Desouches a, J. Gouvernet c,R. Giorgi c, J.-C. Manelli a, G. Magalon a

aRegional Burns Centre, La Conception, Public University Hospital, F-13385 Marseille, FrancebDivision for Plastic and Reconstructive Surgery, Medical University Vienna, Vienna, Austriac LERTIM, Medical Faculty, University Aix-Marseille, F-13385 Marseille, France

1. Introduction

The age group of 65 years and older represents the fastest

growing segment of populations in the USA and Europe.

The age distribution pattern, formerly building a triangular

pyramid, will become a cylinder-like structure in 20 years.

People aged 65 years will make up about one-third of thepopulation in theWesternworld by 2025 [1]. This development

must be taken into account; it is reported that this cohort is

more prone to burns [2], and burnsunits should prepare for the

a r t i c l e i n f o

Article history:

Accepted 5 December 2007

Keywords:

Burns

Comorbidity

Aged, 80 and above

Mortality

Morbidity

Diabetes

Inhalation Injury

Length of Stay

a b s t r a c t

People aged 65 years represent a growing population within burns units in the Westernworld. In 2001, this group was reported to rise to 20% of such admissions. We reviewed the

records of 265 burn cases with complete admission and discharge histories, from January

1990 to December 2003 in an A-level regional burns centre.

The predictive value of age, gender, total body surface area burned (TBSA), inhalation

trauma (IT), premorbid conditions and currently used burn scores (Baux, ABSI, Ryan) for

haemodynamic or respiratory complications, mortality and morbidity were analysed.

Additionally a subset of patients with diabetes mellitus and >30% total body surface area

burned were reviewed.

About 16% of all admissions with burns were 65 years of age, with a mortality rate of30.6% (81/265). Only gender and premorbid conditions did not influence mortality. Haemo-

dynamic and respiratory complications were significantly related to TBSA, presence of I and

any of the three scores (all p < 0.001). Among survivors (184/265), the median duration of

hospital stay was 26.0 days. Factors contributing to a significantly increased length of stay

were, in decreasing order, total body surface area burned, high levels of burn scores,

inhalation trauma, flame injury and certain premorbid conditions (cardiovascular disease,

alcoholism). About 77.7% of all patients were discharged either to a rehabilitation centre or

back to their previous form of housing.

This study showed that among burned people aged 65 years a good outcome asevaluated on discharge can be achieved. Studies pooling different centres results are

needed to improve the significance of conclusions drawn from these data.

# 2007 Elsevier Ltd and ISBI. All rights reserved.

* Corresponding author at: Division for Plastic and Reconstructive Surgery, Medical University Vienna, Vienna, Austria. Tel.: +43 1 404000.E-mail address: david.lumenta@meduniwien.ac.at (D.B. Lumenta).

0305-4179/$34.00 # 2007 Elsevier Ltd and ISBI. All rights reserved.Mortality and morbidity among elderly peoplejournal homepage: wwwdoi:10.1016/j.burns.2007.12.004sev ier .com/ locate /burns

Parameters from each case were collected prospectively on

a standardised institutional patient record database. Incom-

s

p

d

w

s

infused until pH was normal. Burn victims with myolysis or

b u r n s 3 4 ( 2 0 0 8 ) 9 6 5 9 7 4966plete datasets and individuals who developed toxic epidermal

necrolysis were excluded from the study.

2.2. Treatment

During the study period, the standard treatment regimen was

not subjected to major changes. Resuscitation protocol

consisted of oxygen supply via a nasal cannula, intubation

or tracheotomy (as appropriate); rapid fluid administration

with crystalloid solutions during the first 24 h, using central

and/or peripheral lines, according to urinary output and

haematocrit; and, if needed, albumin infusions after the first

day, according to plasmaalbumin levels. Arterial lines, urinary

and gastric tubes were placed as required.

Burns were initially covered with silver sulfadiazine and

were evaluated immediately on admission, at 24 and 48 h

thereafter. Immediate incisional decompression via eschar-

iotomy or fasciectomywas performed for deep circular burns

involving neck, extremities or trunk. No prophylactic

antibiotic therapy was administered. Further surgery was

not performed until haemodynamic stability was estab-

lished, and patients usually underwent operation between

days 5 and 7 after burn (data not shown). After necrosect-

omy, areas were either covered primarily with homologousadmission of a growing number of elderly people in the future.

Therefore it is not surprising that studies dealing with this

group have become popular, with particular regard to cost

analysis [3,4], outcome prediction [5] and premorbid condi-

tions [69]. However, the most relevant factors increasing the

risks among this group for mortality and length of stay (LoS)

remain age, total body surface area burned (TBSA) [9], and

sometimes inhalation trauma [1012]. The main hypotheses

for an increased risk among older individuals commonly

invoke comorbidities, slower reactions, bedridden conditions

and decreased mental status [6,13,14].

Age is an accepted parameter that has readily been

integrated into current burn scores such as the Baux,

Abbreviated Burn Severity Index (ABSI) and Ryan scores,

and is known to contribute to increased mortality [1518]. In

order to examine the influence of the above factors on

outcome among burned people aged 65 years, it is necessaryfor this entity to be examined separately. The present study

aims to evaluate the contribution of these parameters on

admission to mortality and morbidity (e.g. LoS, modes of

discharge), analyse the power of existing burn scores and

examine possible associations of premorbid conditions with

commonly encountered respiratory or haemodynamic com-

plications.

2. Materials and methods

2.1. Patient selection

A total of 265 burned people aged 65 years, were admitted toour burns centre from January 1990 to December 2003.skin grafts and secondarily with autologous meshed skin

grafts, or were primarily covered with autologous meshedhaemolysis received standard bicarbonate for urine alkalisa-

tion. Individuals with haemoglobin levels below 8 mg/dl

received erythrocyte concentrate transfusions.

As soon as the patients condition allowed (respiratory

support, graft take, bathing frequency, monitoring require-

ments), transfer to the minor burns sector of the same centre

was arranged in order to improve the psychological context

and to provide additional social support.

Treatment was not withheld from any of the patients on

account of burn severity or premorbid conditions.

2.3. Grouping and definitions

Patients were divided into four age groups: 6569, 7079, 8089

and90 years-of-age. We analysed criteria influencing overallsurvival, taking a closer look at premorbid conditions as well

as the occurrence of haemodynamic and respiratory compli-

cations. We then evaluated among survivors the same

parameters and their contribution to LoS.

The following parameters were examined: age, gender,

burn type, circumstances of burn, TBSA, IT, pre-existing

comorbidities, complications during in-hospital stay, mortal-

ity and LoS among survivors. We determined the burn scores

adapted fromRyan, Tobiasen (ABSI) andBaux to compare their

predictions for our patient collective [15,17,20].

Premorbid conditions were divided into the following

subgroups (Table 1): hypertension (HTN), cardiovascular

disease (CVD), cardiac disease (CARDIAC), diabetes mellitus

(DIAB), respiratory (RESP), neurological (NEURO), digestive

tract (DIG), renal (RENAL), psychiatric (PSY), chronic alcohol

abuse-related (ALC) disorders, allergic (ALLERG), neoplastic

(TUMOUR) and all other conditions (OTHER) not listed above.

Heart-related diseases were split into three subgroups:

hypertension, cardiovascular disease and other cardiac ill-

nesses. Chronic alcohol abuse was defined as daily alcohol

intake of 60 g and above, and people in this group required

additional therapy in order to overcome alcohol withdrawal

symptoms [20].

Criteria for a haemodynamic complication was met, if one

of the following conditions applied:

septic shock, defined as recommended by the ACCP/SCCM

[21];

severe arrhythmia, implying persistent bradycardic or

tachycardic irregularity without fever or other septic signs

despite adequate electric and/or drug therapy;

severe hypertension, if on constant readings systolic blood

pressureremained>160 mmHgordiastolicbloodpressurewas

consistently >100 mmHg despite adequate drug treatment;copy if necessary.

For control of severe acidosis, bicarbonate solution waseneep second- and third-degree burns of the head and neck as

ell as in particular circumstances (e.g. fire in enclosed

vironment), and was confirmed using fibre-optic broncho-kin grafts. Operated body surface area did not exceed 20%

er session.

Inhalation trauma (IT) was suspected in the presence ofother therapy-resistant hypotensive states, defined as other

shock states.

admissions in our burns centre between January 1990 and

Table 1 Premorbid conditions: subgroups and definitions

Subgroup Abbreviation Description

Hypertension HTN High blood pressure

Cardiovascular CVD Coronary heart disease, diseases of the arteries

Cardiac CARDIAC Congestive heart failure, chronic arrhythmias, ventricular dysfunction,

heart valve and other myocardial diseases

Diabetes DIAB Diabetes mellitus types I and II

Respiratory RESP Bronchial, pulmonary and pleural diseases

Neurological NEURO Central/peripheral nerve system and neuromuscular disorders

Digestive tract DIG Illnesses of the upper and lower digestive tract including pancreatic and

liver diseases

Renal RENAL Renal and urinary output-related diseases

Psychiatric PSY Mental/psychiatric disease

Alcoholism ALC Chronic alcohol abuse

Allergies ALLERG Allergic diseases

Neoplastic TUMOUR Cancer and other neoplastic diseases regardless of origin or histological

grading

Other OTHER All others not classified above

b u rn s 3 4 ( 2 0 0 8 ) 9 6 5 9 7 4 967Respiratory complications were classified according to the

modeof ventilation; thefirst grouphadnoadditional treatment

(NONE), the second underwent oral or nasal intubation with or

without later tracheotomyandartificial ventilation (WITH), and

the third group additionally required a positive end-expiratory

pressure (PEEP) >10 cmH2O and an inspiratory fraction of

oxygen (FiO2) > 0.6 (PLUS).

2.4. Statistical analysis

To comparedeath and survivalweused for quantitative values

(age, TBSA, etc.) the MannWhitney test, and for qualitative

variables (gender, type of burn, etc.) chi-squared or Fishers

exact testing. For analysis of the correlation of age, TBSA, the

different scores and the LoS, the MannWhitney or the

KruskalWallis test were used. For univariate analysis, p-

values below 0.05 were considered significant. Multivariate

analysis was performed in order to identify independent

variables formortality, defined as death in hospital, LoS (using

a logarithmic transformation), haemodynamic and respira-Fig. 1 Aetiology and circumstances of burn admissions of peo

2003.December 2003. Most thermal injuries among the elderly

occurred in a domestic environment (78.1%, 207/265); this was

followed by 6.8% (18/265) occurring during leisure activities

(e.g. barbecue), 6.0% (16/265) with suicidal implications and

3.4% (9/265) in road traffic accidents. Other burns occurred in

occupational (0.4%, 1/265), homicidal (1.5%, 4/265) and othertory complications. We used a logistic regression approach to

evaluate mortality, haemodynamic and respiratory complica-

tions, and a linear regression model to analyse LoS with a

forward stepwise approach ( p < 0.25 as threshold for entering

or removing variables). Analyses were performed with SPSS

software (Version 11.0 SPSS, Chicago, IL).

3. Results

3.1. General epidemiology

People aged 65 years and over accounted for 16% of allple aged I65 years between January 1990 and December

b u r n s 3 4 ( 2 0 0 8 ) 9 6 5 9 7 4968(2.6%, 7/265) contexts. In two cases the circumstances were

unclear. The noxious agent inmost burnswas either hotwater

(30.9%, 82/265) or flame (65.3%, 173/265). Other agents included

electric current (3/265), lightning (2/265), chemical compounds

(1/265), frost bite (1/265) and combined accident patterns (3/

265, see Fig. 1).

The average age of our patient collective was 76.5 (65100

years) and Fig. 2 shows the distribution pattern according to

the four age groups. Of the 265 patients, 160 (60.4%) were

women and 105 (39.6%) weremen. Themean TBSAwas 17.1%,

where the median represented 10.0% (520%, interquartile

range).

3.2. Mortality

Of the 265 cases, 81 (30.6%) were fatalities; IT was confirmed in

17.7% of the population (47/265). Statistically, gender had no

significant influence on mortality (p = 0.34), and nor did the

aetiology of the injury. The presence of IT correlated

significantly with death (p < 0.001); 70.2% (33/47) of patients

with IT died. Without IT, mortality was 22.0% (48/218).

Age and TBSA (total, deep or third-degree burns) signifi-

Fig. 2 The influence of age on in-hospital mortality. With

increasing age, mortality significantly (yp = 0.01)increased.cantly influenced mortality ( p < 0.001). Splitting of age groups

clearly revealed the age-dependence; mortality rose to 61.5%

among burn victims aged 90 years and older (Figs. 2 and 3).

All three scores (Ryan, ABSI and Baux) had a significant

predictive value, with p < 0.001 for mortality, as shown in

Tables 2a2c [15,17,21]. Premorbid conditions had no statis-

tically significant influence on mortality (Table 3).

3.3. Haemodynamic and respiratory complications

To identify whether a given parameter on admission had an

impact on the occurrence of haemodynamic (Tables 4a and 4b)

or respiratory complications (Tables 5a and 5b), we analysed

the same set of data.

The occurrence of haemodynamic complications was not

significantly influenced by age or gender, but was significantly

related to TBSA (total, deep or third-degree), presence of IT,

and any of the three scores (all p < 0.001). The only premorbid

disease which was significantly linked to the development of

haemodynamic complications was CARDIAC (p = 0.001).The development of respiratory complications was not

significantly linked to gender. However, age was significantly

associated with an increased number of intubations and

mechanical ventilation (NONE versus WITH/PLUS, p = 0.04).

The occurrence of a flame injury ( p = 0.04), the TBSA (total,

deep or third-degree), IT and the three scores (all p < 0.001)

were significantly linked to the development of respiratory

complications. The following premorbid conditions were also

subject to intensified respiratory management: CARDIAC

( p = 0.004), ALC and PSY (both p = 0.01).

Fig. 3 Mortality by total body surface area burned (TBSA):

(A) total area (TBSAtot); (B) deep burns of 2B and 3rd degree

(TBSAdeep); (C) third-degree burns alone (TBSA3). With

increasing extent of TBSAtot, non-survival becomes more

likely. This is also reflected in TBSAdeep and TBSA3, with

their shrinking share of total burn size, but rising

mortality (yall p < 0.0001).

Table 2a Mortality related to Ryan scorea

Score Mortality (%)

0 0 (0/0)

1 21 (45/214)

2 50 (15/30)

3 100 (21/21)

a Since the Ryan score includes age 60 years as single factor,there was no score below 1 in our population. Mortality rose

b u rn s 3 4 ( 2 0 0 8 ) 9 6 5 9 7 4 969Neither of the two groupsof complications, haemodynamic

(p = 0.08) or respiratory (p = 0.054), had a significant impact on

LoS among either non-survivors or survivors.

3.4. Length of stay

Among the 184 survivors, the median LoS was 26.0 (1152),

interquartile range days and correlated significantly with

TBSA ( p < 0.001), the Baux, ABSI (both p < 0.001) and Ryan

(p = 0.006) scores, and presence of combustion injury (117/184;

p = 0.02) and IT (14/184; p = 0.001). Premorbid conditions

significantly linked to an increased LoS were CVD (25/184;

p = 0.003) and ALC (13/184; p = 0.02) with a median LoS of 21.5

(1475) and 54 (32109) days, respectively. In our study

significantly with higher score values in all scoring methods

( p < 0.001).

Table 2b Mortality related to abbreviated severity ofburn index (ASBI) scorea

Score Mortality (%)

11 11.1 (7/63)1213 15.7 (13/83)

1415 24.5 (13/53)

16 72.7 (48/66)a At an ABSI score 16 mortality jumped to 72.7%.population, neither age nor gender influenced the LoS.

3.5. Subset analysis

3.5.1. Diabetic groupWhen comparing the diabetic (12.1%, 32/265) with the non-

diabetic (87.9%, 233/265) patients, there was no statistically

significant difference for age (77.7 years versus 76.3 years,

respectively) or TBSA (15.0 19.3% versus 17.4 19.1%,respectively). Furthermore, no significant factor predisposing

people with DIAB to increased haemodynamic or respiratory

complications, mortality or LoS could be found. Of the

premorbid conditions, only RENAL showed a tendency to be

Table 2c Mortality related to Baux scorea

Score Mortality (%)

30%): high vs.other

Of the 265 patients, 9.9% (high group, 36/365) had a TBSA total

>30% and >20% TBSA with 2B and third degree. When this

group was compared with the remaining patients, referred to

as the other group (229/365), mortality was significantly

increased in the high group (91.7% versus 21.0%, p < 0.0001), as

was the prevalence of IT (72.2% versus 9.2%, p < 0.001). Of the

three survivors in the high group (3/36), none had IT. Among

premorbid conditions, only PSY was significantly more

prevalent among the high group (33.3% versus 17.9%,

p = 0.03). Diabetes was diagnosed in five patients of the high

group (5/35, 13.9%), which eventually died. However, statis-

tically DIAB was not a significant risk factor for mortality.

Table 3 Premorbid conditions and mortality: nosignificant correlation

Condition Number ofdeaths withcondition

Percentagedead withcondition

Significance

Hypertension 20 24.1 N.S.

Cardiovascular 8 24.2 N.S.

Cardiac 22 40.0 N.S.

Diabetes 11 34.4 N.S.

Respiratory 2 9.1 N.S.

Neurological 12 33.3 N.S.

Digestive tract 6 18.8 N.S.

Renal 1 25.0 N.S.

Psychiatric 20 37.7 N.S.

Alcoholism 9 40.9 N.S.

Allergies 3 20.0 N.S.

Neoplastic 6 33.3 N.S.

Other 20 24.1 N.S.

N.S., not significant.The presence of any haemodynamic complication was

significantly more common in the high group (69.4% versus

29.7%, p < 0.001). After grouping according to specific

complications, a statistically significant difference was

confirmed for severe arrhythmia (25.0% of the high group

versus 10.9% of the other, p = 0.03) and other shock states

(44.4% versus 12.2%, p < 0.001). However, septic shock

showed a non-significant positive correlation (30.6% versus

13.3%, p = 0.09) and severe HTN did not reach statistical

significance. The demand for ventilator-assisted support

(respiratory complications) was significantly more prevalent

in the high group (WITH 30.6% versus 17.9% and PLUS 55.6%

versus 14.4%, both p < 0.001). It is also to be noted that people

in the high group had a significantly greater demand for renal

replacement therapy than those in the other group (25.0%

versus 7.9%, p < 0.005).

3.6. Regression analysis and predictive value

In the multiple logistic regression analysis, all the scores had a

significant predictive value for mortality. We also found that,

from a statistical point of view, the Baux score was the most

Table 4a Haemodynamic complications among 265 burned p

Condition Number with condition developinga haemodynamic complication

Hypertension 29

Cardiovascular 15

Cardiac 30

Diabetes 12

Respiratory 8

Neurological 15

Digestive tract 12

Renal 1

Psychiatric 24

Alcoholism 11

Allergies 3

Neoplastic 9

Other 29

pm

b u r n s 3 4 ( 2 0 0 8 ) 9 6 5 9 7 4970accurate in estimating the risk for mortality in the study

population. As the regression analysis of this isolated collective

(65 years) suggested, adding the deep TBSA (odds ratio: 4.62;95% confidence interval: 1.6013.38) to the Baux score (odds

ratio: 1.09; 95% confidence interval: 1.061.12) improved its

predictive power (HosmerLemeshow, p = 0.50).

The results for haemodynamic complications were com-

parable with those for mortality; the Baux score in combina-

tion with deep surface burns rendered most accurate results

and proved to be a relevant predictive factor.

The regression analysis yielded statistically convincing

results for neither LoS nor the development of respiratory

complications.

3.7. Modes of discharge

Of the 265 burn victims, 81 died. The 184 survivors were either

discharged to a rehabilitation centre (46.2%, 85/184), or sent

home (31.5%, 58/184), transferred to another hospital (8.7%, 16/

184) or within our hospital (7.6%, 14/184). The remaining 11

N.S., not significant.a Only cardiac diseases were significantly associated with the developatients did not fit into any of these discharge groups. Since

77.7% of survivors were not transferred within the same or to

another hospital (see Fig. 4), this relatively high share best

reflects our hospital LoS (HOS).

Table 4b Haemodynamic complications among 265burned people: statistics according to haemodynamiceventa

Event Total number ofpatients withhaemodynamiccomplication

Percentage withhaemodynamiccomplication

None 172 64.9

Septic shock 53 20.0

Severe arrythmia 34 12.8

Severe hypertension 12 4.5

Other shock states 60 22.6

a In decreasing order septic shock, severe arrythmia and severe

hypertensive states were the predominant haemodynamic events.4. Discussion

The aim of the current studywas to verify among a population

of burned people aged 65 years, in a single burn centre,adequate prediction markers and relevant premorbid condi-

tions on admission leading to an increased complication rate,

mortality or HOS. This study was not intended to be an

instrument of decision making, but rather a tool for develop-

ing a more refined burn score, indicating factors probably

requiring more attention and leading to an improvement of

therapeutic strategies in burn patients.

4.1. General considerations

Most burns treated at our centre resulted from domestic

incidents; hot water scalds represented about one-third of

these (mostly typical bathing accident patterns), which stands

for a rather high fraction compared with the literature. In

France, the local public service providers deliver boiling hot

water via the taps, and the high percentage of scalds is

therefore not surprising. As one prevention strategy among

eople: statistics itemised by premorbid conditiona

Percentage with condition developinga haemodynamic complication

p-Value

34.9 N.S.

45.5 N.S.

54.5 0.001

37.5 N.S.

36.4 N.S.

41.7 N.S.

37.5 N.S.

25.0 N.S.

45.3 N.S.

50.0 N.S.

20.0 N.S.

50.0 N.S.

34.9 N.S.

ent of haemodynamic complications.injury-prone persons, this is certainly an area for improve-

ment [22,23]. Mandatory retirement age in France is 65 years,

and work-related injuries were therefore almost not observed

in our study (one case only).

4.2. Mortality and morbidity

In the population analysed, gender did not influencemortality

or LoS at any step of the analysis [5]. Age, TBSA and the Baux,

Ryan and ABSI scores were among the significant parameters

found to influence mortality, in agreement with other reports

[14,17,24]. The simplistic Baux score, adding age to TBSA,

yielded the most accurate results from a statistical point of

view, in this as in previous studies [7].

We divided patients into four age groups oriented on the

Medical Subject Headings (MeSH) database definition of aged

and 80 and above, splitting these again into two subgroups.

This allowed for better comparison and demonstration of age

dependence. Studies comparing younger with older popula-

tions [22] or all age groups [14] revealed a significant risk for

Table 5a Respiratory complications among 265 people with

Treatment Therapy

NONE Oxygen delivery

WITH +Intubation or tracheotomy

with artificial ventilation

PLUS +PEEP > 10 and FiO2 > 0.6

NONE, no additional treatment; WITH, oral or nasal intubation, with or

WITH additionally requiring a positive end-expiratory pressure and >10a A total of 105 patients (39.6%) received mechanical ventilation, and 53

above 10 cmH2O and an inspiratory fraction of oxygen (FiO2) above 0.6.

Table 5b Respiratory complications among 265 people with

b u rn s 3 4 ( 2 0 0 8 ) 9 6 5 9 7 4 971Condition Number of patients with condition,developing a respiratory complication

Hypertension 56

Cardiovascular 21

Cardiac 24

Diabetes 21

Respiratory 13

Neurological 23

Digestive tract 21

Renal 3

Psychiatric 24

Alcoholism 6

Allergies 10mortality with increasing age; one paper showed that among

people aged 80 years, HOS depended on presence of IT andnumber of surgical operations [2]. We found similar results,

but did not include the number of operations in our statistics.

Focusing on IT, this is on the one hand an important factor

related to the development of complications or death [12]. On

the other hand, IT does not correlate with mortality in all

available studies [2]. Since this factor has been integrated in

most burn scores, it merits special attention as a therapeutic

guideline for risk assessment of associated complications, but

its value as a selective predictionmarker is inconsistent [9,10].

Neoplastic 9

Other 56

N.S., not significant.a Other cardiac, psychiatric diseases and alcoholism were significantly a

Fig. 4 Modes of discharge of 184 survivors; 77.7% of all

patients were discharged to a rehabilitation centre or back

home.burns: statistics according to treatmenta

Number of patientsreceiving therapy

Percentage of patientsreceiving therapy

160 60.4

52 19.6

53 20.0

without later tracheotomy, and artificial ventilation; PLUS, same as

cmH2O; inspiratory fraction of oxygen (FiO2) > 0.6.

(50.5%) of these required a positive end-expiratory pressure (PEEP)

burns: statistics itemised by premorbid conditiona

Percentage of patients with condition,developing a respiratory complication

p-Value

67.5 N.S.

63.6 N.S.

43.6 0.004

65.6 N.S.

59.1 N.S.

63.9 N.S.

65.6 N.S.

75.0 N.S.

45.3 0.01

27.3 0.01

66.7 N.S.In our study, IT was significantly associated with respiratory

and haemodynamic complications, as well as mortality and

LoS.

Agewas significantly associatedwith intensified respiratory

management. It is hypothesized that intubation was more

freely performed inolder patients before, onor after admission.

From the data available we could not decide whether this was

due to the treating clinicians judgment or was an age-

dependent phenomenon.

4.3. Total body surface area burned >30% (high group)

The mortality rate in our high group agrees with the literature,

which is either comparable [7,17,25,26] or excluded for further

analysis because of the high death toll [27]. The exact causes of

death cannot be defined from the data available and post-

mortemswere not performed routinely. Themost likely causes

of death, however, can be found in the significantly higher rates

ofhaemodynamicand respiratory complications. Furthermore,

renal replacement therapy (an indicator for acute renal

insufficiency, for example due to multiple organ failure or

rhabdomyolysis) was significantly more prevalent among a

quarter of the high group. The fact that septic shock showed

only a positive correlating trend in the high group can be

explained by the considerable number of individuals succumb-

ingwithin 10days after admission. Koller et al. found in a group

aged >65 years, with a smaller mean TBSA of 22%, that 78% of

thepatientsdied fromaninfectiouscomplication,butalmostall

50.0 N.S.

67.5 N.S.

ssociated with the development of respiratory complications.

b u r n s 3 4 ( 2 0 0 8 ) 9 6 5 9 7 4972were tested positive for mulit-resistant bacteria in period of

more than 14 days after admission. It seems that deaths in our

high group during the first 10 days were more probably due to

haemodynamic, respiratory and renal instability than to septic

shockwithdefinedbacterial infection,whichwasmore likely to

occur after 14 days following admission [28].

4.4. Premorbid conditions

4.4.1. Comparative dataSince all data were collected prospectively, the subset

classification of diseases was rather accurate. Some

studies included the number of different premorbid condi-

tions to account for a higher mortality, which resulted in

inconclusive findings. In particular, older age groups have

beenexcluded in separate analyses of burnedpeople, because

the predominance of premorbid conditions and their pre-

sumed impact onoutcomemight have biased the actual focus

of a given study, as in protein energy malnutrition [27] or

diabetes [29].

Wibbenmeyer et al., in an investigation of 308 burned

people aged >60 years, found only age, TBSA and IT to be

significantly related tomortality. As in our study, therewas no

significant difference in the presence of comorbidities among

either those surviving or those succumbing to their injuries [7].

Covington et al. confirmed this in an evaluation of 252 burned

people aged >55 years, and suggested that the number of

premorbid conditions explained prolonged HOS and lower

survival rate. Among the predictors found to be significantly

associated with more than one pre-burn health problem were

lower respiratory tract infections and sepsis [13]. Other studies

also concentrated on the number of premorbid conditions, but

not on specific subcategories; Lionelli et al., assessing 201

burned people aged >75 years, showed that age adjusted for

TBSA and IT (both significant) was again significantly

correlated to mortality. Although the cause of death was

separated into cardiac, pulmonary or renal organ failure, there

was no significant correlation between number of comorbid-

ities and death [12]. In contrast, Rao et al. identified in a group

of 63 burned people aged >65 years a significant positive

correlation of TBSA and the number of pre-existing comorbid-

ities to mortality, but not to age [6]. Still et al. observed among

236 burned people aged >60 years that more than one

premorbid condition (70.3%) versus no premorbid condition

(29.7%) was linked to increased LoS but not to mortality. Most

other such studies that are available do not focus on

premorbid conditions and their correlation to mortality or

LoS [3035].

All these data, as ours, have in common that they rely on a

single centres experience; some differ in the age groups

analysed and study endpoints, which renders comparative

interpretation difficult.We hypothesised that the contribution

of a single condition had an overall greater impact on

mortality and morbidity (e.g. cardiac versus allergic condi-

tions) and that summing the number of conditions was not an

accurate method for evaluation.

However, most authors examining premorbid conditions

among people with burns could not identify a specific diseaseentity which led to poorer prognosis [8,9,28]. A recent study of

comorbidities among a national sample in the United States ofover 30,000 burned people in all age groups revealed that

various illnesses were associated with increased mortality or

LoS, including ALC, CARDIAC and CVD [25]. We tried to find

premorbid conditions which led to haemodynamic or respira-

tory complications, and observed that CARDIAC yielded

positive correlating resultswith both. Although the prevalence

of CARDIAC or CVD is quite high in this age group in general,

the percentage was rather low in our population compared

with the literature [36,37]. However, whether this was due to

under-diagnosis, or to the fact that most patients did not

require a specific cardiological work-up, cannot be determined

retrospectively.

The contributions of ALC and PSY to respiratory complica-

tions are closely linked to IT, since the majority of the injuries

occurred in closed environments (data not shown). In our

group, PSY were significantly linked to high TBSA (>30%) and

thus increased mortality. Additionally, the impact of PSY

associated with delayed wound healing, extended time to

mobilisation and decreased compliance is not negligible [38].

4.4.2. The diabetic contextAlthough we had expected DIAB to have a greater impact, e.g.

increasing LoS due to poorer wound healing and diabetes-

associated cardiovascular, renal or immunocompromising

conditions, we did not find a significant influence onmortality

or morbidity. In comparison with the literature, the percen-

tage of patients with DIAB in our study population seemed

relatively low; possibly under-diagnosis affected this result.

McCampbell et al. showed that mortality (2%) did not differ

significantly between diabetic and non-diabetic cohorts in all

age groups. The rates for different infections among burned

people aged 1865 yearswere significantly higher among those

with DIAB, among whom the number of full-thickness burns

was also significantly higher [29]. In a national review, DIAB

wasnot significantly associatedwith in-hospitalmortality, but

was significantly associated with increased HOS after con-

trolling for demographic and burn characteristics [25].

Our patients did not receive tight glucose control until 2002,

but whether this had an overall impact remains unclear. Since

the introduction of intensive insulin therapy for individuals in

intensive care units [39], glucose control has gained consider-

able attention. However, studies covering this topic among

burned people are scarce and concern mainly children [40];

there was no significant difference in LoS, but burned children

with DIAB who received intensive insulin therapy were four

timesmore likely to survive than those receiving conventional

insulin therapy and, when adjusted for LoS, the incidence of

urinary tract infections was significantly lower among the

intensive therapy group [41]. In another report, burned

children with poor glucose control had a significantly greater

incidence of positive bacterial blood cultures, when corrected

for LoS, and significantly reduced skin graft take compared

with normoglycaemic children [42]. However, as the authors

also noted, a definite correlation between the intensive insulin

therapy regimen and outcome could not be established, and

failure to control blood sugar levels despite intensive insulin

therapy could be independently associated with mortality

within intensive care units [43]. To the best of our knowledge,there do not exist any studies examining the effects of DIAB or

intensive insulin therapy among elderly people with burns,

4.6. Care approach

a stable condition. In the literature the concept of early excision

It was also found that this age group undergoing surgery

[1] Department ofEconomic andSocialAffairs.Worldpopulation

b u rn s 3 4 ( 2 0 0 8 ) 9 6 5 9 7 4 973but we do not consider our study population appropriate for

relevant interpretation. Age andDIAB both act as independent

risk factors formortality ormorbidity. In burn patients, factors

like hypermetabolism, weight loss and protein malnutrition

render distinction of relevant factors for outcome forecast

more difficult.

4.4.3. Clinical indicatorsIn sum, premorbid conditions are good clinical indicators for

possible complications during treatment, but they do not aid

in predicting mortality or morbidity. The total number of

comorbidities in a case may eventually lead to an increased

HOS, e.g. if additional therapy is needed after completed burn

therapeutic work-up. However, this was not analysed in our

study. It seems that burns and their directly associated

problems are intrinsically responsible for mortality and

morbidity. In this context, all three scores, with the Baux

score, being from a statistical point of view the most relevant

in our series, proved to be indicative of mortality.

4.5. Selected parameters

Our burns centre has two different units; the first has eight

single-bed en-suite intensive care rooms, and the second

consists of six general ward style rooms with single beds. As

soon as intensive monitoring or care is no longer needed,

patients are transferred to the second unit and are then

discharged as soon as wound healing permits. Thus the LoS

presented in this study closely reflected the HOS, and patients

usually remained longer in hospital than in acute-unit only

settings. Another consequence of the two-unit policy is the

overall decreased burn size among our patients compared

with the literature, since even minor burns are treated in the

second unit. However, LoS is still a controversial parameter.

On the one hand, it is a good continuous quantitative value,

readily available in all units, but the complication rate might

be better reflected in the HOS. Some authors argue that this

parameter aids in indicating areas for treatment performance,

but HOS or LoS incorporate institutional policies. For example,

discharge of patients candependon cost pressure, but can also

be influenced by a retention of patients, in order to preserve a

current bed status and therefore the overall unit size [11,44].

We argue that the additional use of therapeutic interventions

needed for any given complication (e.g. modes of ventilation,

number of surgical operations, duration of antibiotic therapy),

data which are readily available in all units, might better

reflect the medical impact of a condition encountered during

hospital stay. LoS or HOS both depend on numerous factors,

some of them not primarily of medical nature, which lowers

their interpretive value.

We used the modes of discharge to further examine

morbidity. All burned patients aged 65 years were includedin this study, and about 31.5% could return to their previous

domestic environment; 46.2% were transferred to a rehabi-

litation centre. Altogether, these results seem promising for

burned people aged 65 years, since more than 75% may bedischarged without further need of in-hospital care. How-

ever, the functional outcome of these individuals cannotbe estimated from our data and studies of this type are

scarce [45].had a significantly longer HOS, but with the timing of surgery

having no effect on HOS or outcome [6]. Since all patients

scheduled for operations needed excision and grafting because

of third-degree burns, and were therefore treated with the

corresponding delay, we cannot rule out possible positive or

negative effects of a different surgical strategy.

4.7. Perspectives

This studywas limited to one centres experience. Evenwithin

one healthcare system, it remains difficult to match and

carefully compare data, mostly because of different treatment

approaches and selection of outcome parameters.

In the age of evidence-based medicine, physicians and

surgeons are facing difficulties when it comes to treatment of

burns,particularlyamongaged individuals. Economic,financial

or institutional restrictions augment the pressure on doctors to

encourage a sensible distribution of limited resources. The

danger of prognostic indices consists in the linking of financial

tomedical decisions [48]. However, it would be helpful for us to

identify areas of possible improvement in diagnosis or therapy.

Survival as a single outcome parameter does not suffice for

evaluating burn treatment; adding LoS/HOS and factors

complicating hospital stay based on therapeutic management,

as alreadyproposedbyDindo et al. for the evaluationof surgical

complications [44], can improve the explanatory power of a

study and facilitate meta-analysis of pooled results from

various burns centres. It would also be helpful to analyse

long-term results extending beyond the mode of discharge, a

parameter we selected for this report.

We suggest that standardizedparameters for future studies,

shouldbeset,at least, toprovideeasilyavailableanalysis factors

for apossible later pooling ofdata; that complications shouldbe

evaluated according to therapeutic actions (e.g. number of

operations,modesofventilation,durationofantibiotictherapy);

and that objective (e.g. modes of discharge) and qualitative

morbidity parameters (e.g. from standardised patient ques-

tionnaires) should be selected to evaluate long-term outcome.

Conflict of interest statement

None.

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Mortality and morbidity among elderly people with burns-Evaluation of data on admissionIntroductionMaterials and methodsPatient selectionTreatmentGrouping and definitionsStatistical analysis

ResultsGeneral epidemiologyMortalityHaemodynamic and respiratory complicationsLength of staySubset analysisDiabetic groupTotal body surface area burned (>30%): high vs. other

Regression analysis and predictive valueModes of discharge

DiscussionGeneral considerationsMortality and morbidityTotal body surface area burned >30% (high group)Premorbid conditionsComparative dataThe diabetic contextClinical indicators

Selected parametersCare approachPerspectives

Conflict of interest statementReferences