|Year : 2014 | Volume
| Issue : 1 | Page : 51-55
Burn injury associated with comorbidities: Impact on the outcome
Md Sohaib Akhtar1, Imran Ahmad1, Arshad Hafeez Khan1, Fahud M Khurram1, Ansarul Haq1, Rabeya Basari2
1 Aligarh, Uttar Pradesh, India
2 Department of Pathology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
|Date of Web Publication||15-Dec-2014|
Dr. Md. Md Sohaib Akhtar
Post Graduate Department of Burns, Plastic and Reconstructive Surgery, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Aims and Objectives: To evaluate the impact of comorbidities on the outcome of burn injuries. Materials and Methods: A retrospective analysis of 108 patients, treated between August 2010 and July 2013, was carried out. All patients were admitted, assessed and managed. The medical notes on 72 patients with comorbidity (Study group) were analyzed and matched with 36 other patients, without comorbidities (Control group), according to age, gender, and interval time between injury and admission. Information regarding types of burn injuries, depth of burn, comorbidities, operative procedures and final outcome were noted. Results: Patients were evaluated in terms of their duration of stay in the hospital and mortality. The comorbidities that influence these factors are renal disease, liver disease, cancer, pulmonary disorders, cardiac disease, obesity, peripheral vascular disorders, alcohol abuse, smoking and neurological disorders. Conclusion: It was found that the associated comorbid conditions influence the outcome of patients, injured due to burn, in terms of the duration of their stay in the hospital and mortality.
Keywords: Burn injury, co morbidity, impact
|How to cite this article:|
Akhtar MS, Ahmad I, Khan AH, Khurram FM, Haq A, Basari R. Burn injury associated with comorbidities: Impact on the outcome. Indian J Burns 2014;22:51-5
|How to cite this URL:|
Akhtar MS, Ahmad I, Khan AH, Khurram FM, Haq A, Basari R. Burn injury associated with comorbidities: Impact on the outcome. Indian J Burns [serial online] 2014 [cited 2019 Jul 19];22:51-5. Available from: http://www.ijburns.com/text.asp?2014/22/1/51/147005
| Introduction|| |
Burn injuries are commonly associated with various comorbid conditions. A clinical condition expected to have effect on the outcome of injury, and which is present prior to the injury and admission, is called a comorbid disease.  Influence of these comorbid conditions on the outcome of burn injuries is one of the contentious issues as limited studies are available, which focus on the impact of various associated comorbid diseases on the outcome of a burn injury. As per various studies, these comorbid conditions can interfere and change the progression and outcome of a burn injury. , Therefore, it is important to identify these conditions, which can influence survival of the patients with burn injuries.
The results of the effects of various pre-existing medical conditions ,,, and the specific medical comorbidities on the outcome of the burn-injured patients are controversial. ,,, Various studies show that the various comorbid diseases, including cardiovascular disease, ,,, renal disease, , neurological disease , and pulmonary disease, , have inconsistent impact on the outcome of the burn-injured patients. These comorbid conditions, including renal, cardiac, and pulmonary diseases, make the fluid resuscitation complicated, which is one of the most important factors in the early management of the acute burn patients. 
In this series, 108 patients have been included to show the impact of various comorbid conditions on the outcome in burn-injured patients.
| Materials and methods|| |
A retrospective analysis of 108 patients, treated between August 2010 and July 2013, was carried out. A total of 108 patients were included in the study. All patients were admitted, assessed and managed. The medical reports on 72 patients with comorbidity (Study group) were analyzed and matched with 36 other patients, without comorbidities (Control group), based on age, gender, and interval time between injury and admission. Information regarding types of burn injuries, depth of burn, total body surface area, comorbidities, operative procedures and final outcome were noted.
Physician's advice was taken for the treatment of comorbid disease. Types and doses of the different administered drugs and fluid were adjusted according to the associated comorbid disease. Fluid administration was monitored by urine output, central venous pressure and vital parameters.
An early surgical intervention was considered in all the operative cases without comorbid disease as compared with the patients with associated comorbid disease when the surgery was delayed till stabilization. A clearance was taken from the consulting physician for the same. Debridement and skin grafting were performed on 68 patients (63%), debridement and flap cover on 6 patients (6%) and only debridement on 7 (6.5%) patients [Table 1].
| Results|| |
Patients were evaluated in terms of duration of the hospital stay and mortality. The comorbidities influencing these factors are renal disease, liver disease, cancer, pulmonary disorders, cardiac disease, obesity, peripheral vascular disorders, alcohol abuse, smoking and neurological disorders. Most of the cases were with only 1 comorbidity (n = 44), 20 with 2 co morbidities, and 8 patients had more than 2 associated comorbid diseases. Renal disease was found to be the most common comorbid condition [Table 2] and [Table 3].
Most of the injuries occurred due to thermal burn, (n = 72) followed by electrical (n = 18), chemical (n = 8), scald (n = 6) and flame burn (n = 4) [Table 4]. Superficial partial thickness burn constituted the most common type of injury and fourth degree burn the least common [Table 5]. Majority of the cases had burn of total body surface area between 20-40% (54/108) [Table 6]. It was found that more the number of comorbidity associated, higher is the mortality. Cardiac disease was most commonly associated with mortality [Table 2]. A statistically significant difference during the stay in the hospital was found between patients without comorbidity and with comorbidity (P < 0.05). Males were more commonly associated with comorbid disease than females. Majority of the patients (30%) were of old age (>60 years) [Table 7]. Time interval between burn and admission were matched between the study group and control group [Table 8].
Statistical analysis was performed with the descriptive statistics. Significant differences were calculated using Chi-square test with P < 0.05 considered statistically significant. All data analysis was conducted using Statistical Package for the Social Sciences software (SPSS, version 20.0 software, SPSS Inc.).
| Discussion|| |
Patients with burn injury manifest differently in terms of age, mechanism, depth, location of burn and associated comorbidity.  Many factors, which are not under control of burn service team, can affect the outcome. Common factors include motivation, pre-existing psychological disorders and socio-economic conditions of the patients.  In earlier studies, the effects of comorbidities affecting the outcomes of the patients with burn injuries have not been adequately and concisely explored. Comorbidities are commonly associated with burn-injured patients, who significantly impair the outcome in terms of their stay in hospital and mortality. In this series, we have included 72 patients with various comorbid conditions to show the impact of the outcome of burn injury.
Previous reports showed contradictory results on the effects of comorbidities on mortality in burn-injured patients. Lionelli et al., and Wibbenmeyer et al., , found no correlation between comorbidities and mortality. Later, Rao et al., and Covington et al., , conclude in their study that there is an association between comorbid conditions and outcome of the burn injury. These studies show the impact of the cardiac and pulmonary diseases on the outcome. Further, old age associated with higher rate of mortality in burn patients is well described in the literature. , Older people tend to have an increase incidence of the associated co morbidity.
In this study, the impact of various comorbid diseases, including cardiac, pulmonary, renal, hepatic, neurological disorders, has also been demonstrated. A significant impact of these conditions on the hospital stay [Table 9] and mortality was found.
The charlson index predicts the possibility of mortality within 1 year in patients associated with various comorbidities, which have occasionally been used in burn and trauma patients. ,, Thombs uses this index to show the contribution of various medical conditions to mortality and duration of the hospital stays. 
In this study, certain comorbid conditions were observed and found to be responsible for a higher rate of mortality. For better understanding of the impact of morbidity and the consequences of thermal injury, the assessment of the health status of a patient with burn injury and his/her quality of life has been advocated by various researchers. ,
In terms of the timing of the operative intervention, an early excision was performed by following completion of resuscitation in all the patients without comorbid disease as compared with patients associated with comorbid disease, where intervention was delayed. This could be one of the reasons of better outcome in control group. This is in accordance with the earlier studies conducted by various authors. ,
The early response in severe burn patients includes decreased cardiac output and a higher rate of metabolism.  It has been well described in the literature, in which pulmonary functions are deranged and systemic physiology is altered in burn patients. 
Acute renal failure is one of the major complications in the patients with burn injuries.  This can be an early onset, due to hypovolemia and late onset due to septecemia and multi-organ failure. 
Patients with neurological disease having sensorimotor deficits are prone to more severe burn injuries and a longer period of contact with the burning agent.  These pathophysiologic alterations in burn injury may aggravate and influence the progression of the co-existing disease and, thus, affect the management of these patients.
| Conclusion|| |
It was concluded that the associated comorbid conditions influence the outcome of burn-injured patients in terms of duration of hospital stay and mortality. It was also found that more the number of associated comorbidity, more the hospital stay and mortality.
| References|| |
Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care 1998;36:8-27.
Uygur F, Özyurt M, Evinç R, Hosbul T, Çeliköz B, Haznedaro¢g lu T. Comparison of octenidine dihydrochloride (Octenisept ®
), polihexanide (Prontosan ®
) and povidon iodine (Betadine ®
) for topical antibacterial effects in Pseudomonas aeruginosa-contaminated, full-skin thickness burn wounds in rats. CEJ Med 2008;3:417-21.
Germann G, Barthold U, Lefering R, Raff T, Hartmann B. 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;23:195-203.
O'Keefe GE, Hunt JL, Purdue GF. An evaluation of risk factors for mortality after burn trauma and the identification of gender-dependent differences in outcomes. J Am Coll Surg 2001;192:153-60.
Covington DS, Wainwright DJ, Parks DH. Prognostic indicators in the elderly patient with burns. J Burn Care Rehabil 1996;17:222-30.
Wibbenmeyer LA, Amelon MJ, Morgan LJ, Robinson BK, Chang PX, Lewis R 2nd, et al
. Predicting survival in an elderly burn patient population. Burns 2001;27:583-90.
Barret JP, Gomez P, Solano I, Gonzalez-Dorrego M, Crisol FJ. Epidemiology and mortality of adult burns in Catalonia. Burns 1999;25:325-9.
Stassen NA, Lukan JK, Mizuguchi NN, Spain DA, Carrillo EH, Polk HC Jr. Thermal injury in the elderly: When is comfort care the right choice? Am Surg 2001;67:704-8.
Horbrand F, Schrank C, Henckel-Donnersmarck G, Mühlbauer W. Integration of preexisting diseases and risk factors in the Abbreviated Burn Severity Index (ABSI). Anasthesiol Intensivmed Notfallmed Schmerzther 2003;38:151-7.
Raff T, Germann G, Barthold U. Factors influencing the early prediction of outcome from burns. Acta Chir Plast 1996;38:122-7.
Lundgren RS, Kramer CB, Rivara FP, Wang J, Heimbach DM, Gibran NS, et al
. Influence of comorbidities and age on outcome following burn injury in older adults. J Burn Care Res 2009;30:307-14.
Committee NBCR: Standards and strategy of burn care: A review of burn care in the British Isles. chapter 2: An overview of burn injury: Nature and management, p 16 British Burns Association; 2006.
Patterson DR, Ptacek JT, Cromes F, Fauerbach JA, Engrav L. The 2000 Clinic Research Award. Describing and predicting distress and satisfaction with life for burn survivors. J Burn Care Rehabil 2000;21:490-8.
Lionelli GT, Pickus EJ, Beckum OK, Decoursey RL, Korentager RA. A three decade analysis of factors affecting burn mortality in the elderly. Burns 2005;31:958-63.
Rao K, Ali SN, Moiemen NS. Aetiology and outcome of burns in the elderly. Burns 2006;32:802-5.
McGill V, Kowal-Vern A, Gamelli RL. Outcome for older burn patients. Arch Surg 2000;135:320-5.
Ryan CM, Schoenfeld DA, Thorpe WP, Sheridan RL, Cassem EH, Tompkins RG. Objective estimates of the probability of death from burn injuries. N Engl J Med 1998;338:362-6.
Gabbe BJ, Magtengaard K, Hannaford AP, Cameron PA. Is the Charlson Comorbidity Index useful for predicting trauma outcomes? Acad Emerg Med 2005;12:318-21.
Taylor MD, Tracy JK, Meyer W, Pasquale M, Napolitano LM. Trauma in the elderly: Intensive care unit resource use and outcome. J Trauma 2002;53:407-14.
Thombs BD, Singh VA, Halonen J, Diallo A, Milner SM. The effects of preexisting medical comorbidities on mortality and length of hospital stay in acute burn injury: Evidence from a national sample of 31,338 adult patients. Ann Surg 2007;245:629-34.
Munster AM. Measurement of quality of life: Then and now. Burns 1999;25:25-8.
Anzarut A, Chen M, Shankowsky H, Tredget EE. Quality of life and outcome predictors following massive burn injury. Plast Reconstr Surg 2005;116:791-7.
McManus WF, Mason AD Jr, Pruitt BA Jr. Excision of the burn wound in patients with large burn. Arch Surg 1989;124:718-20.
Thompson P, Herndon DN, Abston S, Rutan T. Effect of early excision on patients with major thermal injury. J Trauma 1987;27:205-7.
Cuthbertson DP, Angeles Valero Zanuy MA, Leon Sanz ML. Post-shock metabolic response. 1942. Nutr Hosp 2001;16:176-82.
Asch MJ, Feldman RJ, Walker HL, Foley FD, Popp RL, Mason AD Jr, et al
. Systemic and pulmonary hemodynamic changes accompanying thermal injury. Ann Surg 1973;178:218-21.
Schiavan M, Di Landro D, Baldo M, De Silvesto G, Chiarelli A. A study of renal damage in seriously burned patients. Burns Incl Therm Inj 1998;14:107-12.
Cakir B, Yegan BC. Systemic response to burn injury. Turk J Med 2004:215-26.
Alden NE, Rabbitts A, Rolls JA, Bessey PQ, Yurt RW. Burn injury in patients with early-onset neurological impairments: 2002 ABA paper. J Burn Care Rehabil 2004;25:107-11.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]