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ORIGINAL ARTICLE
Year : 2018  |  Volume : 26  |  Issue : 1  |  Page : 38-43

Oxidative stress in major thermal burns: Its implications and significance


1 Department of Plastic Surgery, Government Stanley Medical College Hospital; Formerly Department of Plastic Surgery, Government Kilpauk Medical College Hospital, Chennai, Tamil Nadu, India
2 Department of Plastic Surgery, K.K. Child Trust Hospital, Chennai, Tamil Nadu, India

Date of Web Publication11-Mar-2019

Correspondence Address:
Dr. Ranjith James Babu
New No. 16, Ayyasamy Nagar, East Tambaram, Chennai - 600 059, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijb.ijb_37_17

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  Abstract 


Introduction: Thermal burns could prove dreadful to humankind. The morbidity and mortality is the interplay of intraneous and extraneous factors. Multidisciplinary approach plays a cardinal role in managing this catastrophe. This study is carried out to analyze the oxidative stress in thermal burns, its implications in management, and the significance it carries with it.
Materials and Methods: This prospective study was carried out in 30 patients from January 2016 to December 2016. Quantitative analysis of oxidative stress and total antioxidant capacity was done on postburn day 3 and every 5 days thereafter.
Results: The quantitative oxidative stress level was high, and antioxidant capacity was low in patients who had higher percentage total body surface area burn and predominant deep burn with temporal analysis. The patterns were strikingly different in patients who had mortality with patients who survived.
Discussion: Thermal burn releases reactive oxygen species which causes profound changes in internal and external milieu. This alters the physiological response to treatment and impresses on the morbidity and mortality of the patient.
Conclusion: Thereby, it could be construed that oxidative stress along with tailored intervention, timing of treatment, and recalcitrant attitude to treatment methodology has a significant role in determining the outcome of burn patients.

Keywords: Antioxidant capacity, burn injury, oxidative stress


How to cite this article:
Babu RJ, Babu M. Oxidative stress in major thermal burns: Its implications and significance. Indian J Burns 2018;26:38-43

How to cite this URL:
Babu RJ, Babu M. Oxidative stress in major thermal burns: Its implications and significance. Indian J Burns [serial online] 2018 [cited 2019 May 25];26:38-43. Available from: http://www.ijburns.com/text.asp?2018/26/1/38/253855




  Introduction Top


Thermal burns are considered as one of the major catastrophic events in human beings.[1] Burn destroys the cutaneous barrier and causes marked physiological changes in organ systems.[2] The final result is dependent on baseline severity and tailored intervention. Multidisciplinary approach is pivotal in burn management which could play a decisive role in its outcome.[3]

The thermal injury acts at various levels which involve the microcirculation of the skin and muscle. Immediately after a thermal burn, there is fluid loss through the capillaries. Biochemical mediators act at various levels and widespread domains to bring changes at cellular levels.

Reactive oxygen species are released by involved tissues which alter capillary permeability.[4] The consequent inflammation and ischemia resulting from burn injury trigger the release of reactive oxygen species which are quite unstable reactive metabolites of oxygen. The pathological response produced by the release of these unstable molecules is enormous. Hence, burn wound care takes a center stage with this disruptive forces operating in the other direction.[5] Measures should be comprehensive to bring down mortality and morbidity.

By and large, the goal of the treatment is to heal the local burn and recover skin function to its near normal. This also takes into consideration the systemic response and oxidative stress in burn injury. Various studies have been done to analyze the oxidative stress in thermal burns. Parihar et al. state that oxidative stress has its effect locally and systemically, and therefore, antioxidant therapy is quite important.[6] Pintaudi et al. state that there is a marked imbalance in oxidative stress and antioxidant status which reflects the severity of the injury.[7] This study is carried out to assess the oxidative stress in burn patients from 20% total body surface area (TBSA) to 50% TBSA burns. This study also takes into account the tailored intervention which is applied befitting the patient. Whether the intervention applied to the burn injury and the accompanying oxidative stress has a say in the overall outcome of the patient is of primary interest. This study is intended to bring out whether oxidative stress has a bearing toward the outcome of the patient. This could have a clear understanding of the oxidative stress and its interplay in the local and systemic milieu.

Aims

The aim of this study is to analyze temporal oxidative stress and antioxidant capacity profiling postthermal burn injury state and to determine its implications and significance in the outcome of major thermal burn injuries.


  Materials and Methods Top


Settings and design

Prospective design

A prospective study conducted in 30 patients with 20%–50% TBSA burns. The study was conducted in Government Kilpauk Medical College Hospital, Chennai, Tamil Nadu, India, after getting the approval of the Institutional Ethics Committee reference number 10/2015. A study conducted during the period of January 2016–December 2016. All patients studied with respect to a protocol that consists of personal data, i.e. age and sex, date of burn, date of surgery, and date of discharge/date of death [Table 1].
Table 1: Patient presentation and response to treatment methodology

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Inclusion criteria were hospitalization within 24 h of burn, burn surface 20%–50% TBSA burns comprising of mixed burns, survival after the first 3 days overcoming the state of hypovolemic shock, absence of trauma associated with burns, and age group of 20–40 years comprising of both male and female.

Exclusion criteria were burn surface <20% and >50% TBSA burns, <20–>40 years, and comorbid factors (Type II diabetes mellitus, systemic hypertension, hepatic dysfunction, renal dysfunction, and epilepsy).

Quantitative estimation of oxidative stress and total antioxidant capacity (TAC) in 20%–50% TBSA burns was on postburn day 3 and every 5 days thereafter.

Sample collection

Blood samples were collected from peripheral vein. Then, the blood samples were filled into vacutainers containing heparin. Blood in heparinized vacutainer was subjected to centrifugation for 15 min at 10,000 rpm to yield red blood cell (RBC). The RBCs were subjected to two washes with isotonic saline. This resulted in the removal of the buffy coat. The RBC was aliquoted and stored at −80° centigrade.

Evaluation of oxidative stress markers

To 200 ml of frozen RBC, 3 ml of phosphate buffer pH 7.4 was added. It was mixed well and centrifuged at 10,000 rpm for 10 min. The RBC membrane pellet was washed twice with double distilled water, and then it was centrifuged. The RBC membrane pellet was made up to 0.5 ml with double distilled water. Thiobarbituric acid-reacting substances (TBARS) assay was performed to evaluate the oxidative stress marker.

Estimation of lipid peroxide

The most common method employed is to acid hydrolyze all lipid peroxide. This resulted in the formation of malondialdehyde (MDA), and then the product was measured after complexing with thiobarbituric acid. Since a small amount of MDA may arise from other sources, the assay is more correctly referred to as measuring TBARS. Lipid peroxidation in erythrocyte membrane was determined by the estimation of TBARS by employing the method of Yagi.[8]

Principle

Biomembranes contain large amounts of polyunsaturated fatty acids which are highly susceptible to peroxidative breakdown. This resulted in the formation of MDA. MDA reacts with thiobarbituric acid to yield a brilliant pink which is captured in the spectrophotometer with absorption maxima at 532 nm.

Procedure

To 0.5 ml of sample (RBC membrane pellet), 0.9 ml of 10% trichloroacetic acid and 2 ml of 0.67% thiobarbituric acid reagent were added, and it was kept in boiling water for 20 min. Then, the tubes were cooled after centrifugation. The absorbance of the supernatant part was read with spectrophotometer with absorption maxima at 532 nm. Results were expressed as micrometer of MDA.

Plasma total antioxidant status

Plasma TAS was determined with commercial kits according to the method of Miller et al.[9]

According to this method, antioxidants present in the added sample cause suppression of the blue-green production to a degree which is proportional to their concentration. The results are reported in millimoles (mM). The sensitivity of the assay is for antioxidant levels up to 2.5 mM.

Statistical analysis

The mean value, standard deviation, and standard error of the mean were computed for all variables. The statistical significance was determined using ANOVA. P < 0.05 was considered as statistically significant.


  Results Top


[Table 1] portrays that out of 30 patients, nine had mortality. Out of these nine patients, six patients had inhalational burns. The other three had deep burns involving anterior trunk and upper limbs which comprised a major proportion of the mixed burn. Out of the remaining 21 patients who survived, three patients had inhalational burn injury. Out of these 21 patients, five patients were tailored for conservative dressing, and the remaining 16 patients were tailored for debridement and grafting.

Six patients had deep inhalational burns and the other three had deep burn component predominating in the mixed burn. These patients could not be optimized for surgery and had a strong inclination towards mortality being recalcitrant to treatment methodology. Their hemodynamics were found wavy after overcoming the hypovolemic phase and proved obstinate to relent toward positive patterns. A 24% TBSA burns that had mortality had a deep inhalational burn injury and facial burns. The other mortality patients ranged from 45% to 50% TBSA burns.

In [Figure 1], oxidative stress assay showed an increase in all the three groups from postburn day (PBD)-3 to PBD-8. The mortality group had an incremental increase in the quantitative expression. In patients treated with conservative dressing and grafted cases, there is a decline in the oxidative stress subsequently measured at various time points.
Figure 1: Oxidative stress assay. PBD: Postburn day

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Oxidative stress assay was measured on postburn day 3 and every 5 days thereafter.

[Figure 1] reveals that the mean baseline MDA ranged from 61.45 ± 5.52 to 63.15 ± 5.32 μm in all the three groups studied on postburn day 3. The average value of the patients in each group is depicted at various time points.

On PBD 8, oxidative stress in patients treated conservatively was 64.15 ± 5.14 μm, surgical group was 66.75 ± 5.56 μm, and mortality in patients was 66.72 ± 8.86 μm. On PBD 13, the patients treated conservatively were 59.42 ± 5.76 μm, surgical group was 61.35 ± 5.86 μm, and mortality in patients was 72.64 ± 5.25 μm. On PBD 18, the patients treated conservatively were 52.75 ± 6.28 μm and the surgical group was 54.25 ± 6.45 μm. On PBD 23, the patients treated conservatively were 48.25 ± 5.20 μm and the surgical group was 42.65 ± 7.46 μm. P<0.05 which is statistically significant.

In [Figure 2], the TAC assay showed a decrease in all the three groups from PBD-3 to PBD-8. The mortality group had a significant dip in the quantitative expression. In patients treated with conservative dressing and grafted cases, there is an incline in the antioxidant capacity subsequently measured at various time points.
Figure 2: Total antioxidant capacity assay. PBD: Postburn day

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The antioxidant capacity was measured on postburn day 3 and every 5 days thereafter.

[Figure 2] reveals that the mean baseline antioxidant capacity ranged from 0.62 ± 0.28 to 0.76 ± 0.32 millimol in all the three groups studied on postburn day 3. The average value of the patients in each group is depicted at various time points.

On PBD 8, the antioxidant capacity in patients treated conservatively was 0.59 ± 0.38 millimol, surgical group was 0.52 ± 0.38 millimol, and mortality driven patients was 0.55 ± 0.32 millimol. On PBD 13, the patients treated conservatively was 0.96 ± 0.36 millimol, surgical group was 0.89 ± 0.44 millimol, and mortality driven patients was 0.42 ± 0.12 millimol. On PBD 18, the patients treated conservatively were 1.35 ± 0.42 millimol, and the surgical group was 1.24 ± 0.48 millimol. On PBD 23, the patients treated conservatively were 1.84 ± 0.46 millimol, and the surgical group was 2.05 ± 0.52 millimol. P < 0.05 which is statistically significant.

The quantitative TAC in conservatively treated cases shows a decreased trend from PBD-3 to PBD-8. From PBD-8, it showed an upregulation toward PBD-18 and further elevation on PBD-23. In grafted cases, wherein grafting was done between PBD-14 and PBD-20, the upregulation in TAC from PBD-18 to PBD-23 was more in relation to conservatively managed patients. In mortality cases, the TAC revealed a dip. Mortality was witnessed in these patients from PBD-9 to PBD-15.

In the mortality group, there was an upregulation in oxidative stress and downregulation in TAC at various time points when analyzed temporally.

Analysis between oxidative stress, total antioxidant capacity, and % TBSA burn

There was an upregulation of oxidative stress and downregulation of TAC with higher % TBSA burn and the predominant deep burn in the mixed burn. The patients, who responded to conservative treatment or surgical intervention, had a positive trend with declining oxidative stress and inclining TAC as treatment progressed. Mortality driven patients did not respond to the given treatment, and hence, oxidative stress was quite an upsurge with TAC taking a downtrend.


  Discussion Top


There are myriad systems that generate reactive oxygen species and that include the intracellular sites of endothelial cells, smooth muscles, macrophages, polymorphonuclear cells, and platelets.

Peroxidation of membrane phospholipids and nucleic acid phospholipids causes vascular damage. There is a significant change in the anatomical architecture and the physiological permeability in the cellular membranes.[10]

The catabolism of membrane phospholipids results in the production of MDA which is considered a true biological marker by which oxidative stress response is assessed. Due to lipid peroxidation, there is an increase in MDA levels. Gosling et al. depicted that in patients with severe burns the amount of lipid peroxidation was proportionately higher.[11] Yang et al. noted an increase in lipid peroxidation in the first 3 days of burn injury.[12] Daryani et al. found an increased lipid peroxidation products in lung and liver during the first 3 days of postburn.[13] Nishigaki et al. found the increased levels of lipid peroxidation products on the burnt skin.[14] Demling et al. and Woolliscroft et al. have noted elevated levels of these compounds to first 5 days of burn injury.[15],[16] Kumar et al. have observed elevated levels until day 10.[17]

The TAC is quantitatively estimated in our study. TAC will find a significant dip if there are high levels of reactive oxygen species. The upsurge of antioxidant compounds increases the TAC. The increased TAC is quite a valuable and significant index which gives a clear understanding on the amount of antioxidant embodiment presents in the human system. TAC is a sensitive marker whereby it reflects the oxygen supply to the tissues.[18] Hence, it carves a strategy wherein the supply-demand cynosure becomes quite evident.

The determination of TAC is an original and significant way in determining appropriate therapy and prevention of complication caused by the imbalance equations. Overproduction of reactive oxygen species secondary to increasing oxidative stress drives low the TAC. There are antioxidant systems that work to protect cell membranes from the oxidative burst. They do so by blocking the oxidative radical reactions of reactive oxygen species. In plasma, a heterogeneous mixture of several antioxidants such as superoxide dismutase, glutathione peroxidase, Vitamin A, C, E, etc., would play a pivotal role in suppressing oxidative stress.[19]

Out of 30 patients in our study, 16 patients underwent debridement and grafting whereas five patients were treated conservatively. Nine patients had mortality which could be construed to deep inhalational burns, higher % TBSA burn, predominant deep burn in the mixed burn milieu, and headstrong attitude of the systemic burn to the treatment methodology.

There was a statistically significant difference in the lowering of oxidative stress and an increase in TAC in the surgically intervened group with relevance to the conservatively treated group. The conservative group was taken as reference and should not be compared in any way to the surgically intervened group as both interventions were varied and tailored according to the wound status.

In all the above-mentioned studies regarding lipid peroxidation, the cellular and molecular changes in a thermal burn injury and the responses to the injury have been cited. The therapeutic intervention which is to be carved out to address the oxidative stress is quite important, and our study has looked at that angle. Hence, in our study, the quantitative oxidative stress and antioxidant capacity have been measured, and its behavior to the treatment methodology has been evaluated. The recalcitrant nature of mortality cases with relevance to treatment has also been observed. The existing pathology in the internal and external environment has already been dealt with in the previous studies. This study has given an analysis which is quite outward in nature with relevance to quantitative assessment, decrease in morbidity in certain cases with tailored treatment, and mortality driven dynamics in certain cases. This means tailored treatment, adept application, and the timing of treatment can help in the modulation of the oxidative stress to a certain extent where the behavior of the oxidative stress is quite unpredictable and variable. This is the relevance which our study is intended to bring out. This could possibly reflect the dynamics of treatment strategy wherein ample weightage is given to oxidative stress. This art of treatment is just one of the many entities which could have a bearing, reflecting a positive outlook in minimizing morbidity and mortality.


  Conclusion Top


The treatment strategy when tailored and applied adeptly could play a significant role to reduce oxidative stress and to enhance antioxidant capacity in thermal burn injuries. This could herald direction of progress as mortality patients never showed a positive trajectory toward improvising. Thus, oxidative stress is quite a significant system in itself whereby tailored and timely applied intervention could possibly augment the battle against it.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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6.
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9.
Miller NJ, Rice-Evans C, Davies MJ, Gopinathan V, Milner A. A novel method for measuring antioxidant capacity and its application to monitoring the antioxidant status in premature neonates. Clin Sci (Lond) 1993;84:407-12.  Back to cited text no. 9
    
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11.
Gosling P, Sutcliffe AJ, Cooper MA, Jones AF. Burn and trauma associated proteinuria: The role of lipid peroxidation, renin and myoglobin. Ann Clin Biochem 1988;25 (Pt 1):53-9.  Back to cited text no. 11
    
12.
Yang H, Sheng Z, Guo Z, Shi Z, Lu J, Chai J, et al. Oxygen free radical injury and its relation to bacterial and endotoxin translocation after delayed fluid resuscitation: Clinical and experimental study. Chin Med J (Engl) 1997;110:118-24.  Back to cited text no. 12
    
13.
Daryani R, Lalonde C, Zhu D, Weidner M, Knox J, Demling RH. Effect of endotoxin and a burn injury on lung and liver lipid peroxidation and catalase activity. J Trauma 1990;30:1330-4.  Back to cited text no. 13
    
14.
Nishigaki I, Hagihara M, Hiramatsu M, Izawa Y, Yagi K. Effect of thermal injury on lipid peroxide levels of rat. Biochem Med 1980;24:185-9.  Back to cited text no. 14
    
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Demling R, Ikegami K, Lalonde C. Increased lipid peroxidation and decreased antioxidant activity correspond with death after smoke exposure in the rat. J Burn Care Rehabil 1995;16:104-10.  Back to cited text no. 15
    
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Woolliscroft JO, Prasad JK, Thomson P, Till GO, Fox IH. Metabolic alterations in burn patients: Detection of adenosine triphosphate degradation products and lipid peroxides. Burns 1990;16:92-6.  Back to cited text no. 16
    
17.
Kumar R, Seth RK, Sekhon MS, Bhargava JS. Serum lipid peroxide and other enzyme levels of patients suffering from thermal injury. Burns 1995;21:96-7.  Back to cited text no. 17
    
18.
Rice-Evans C, Miller NJ. Total antioxidant status in plasma and body fluids. Methods Enzymol 1994;234:279-93.  Back to cited text no. 18
    
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