The Influence Of Inhalation Injury On The Fluid Resuscitation Of Severely Burned Patients

Objective:1.Examine the difference in fluid resuscitation between severely burned patients combined with inhalation injury and those who were free from inhalation injury.2.Appraise the effects of tracheotomy on fluid resuscitation of severely burned patients combined with inhalation injury,and to investigate whether additional fluid volume is needed.3.Analyze the difference in fluid resuscitation between severely burned patients combined with high grade inhalation injury(AIS 3,4)and those combined with low grade inhalation injury(AIS 1,2)Method:A retrospective analysis enrolling 108 adult patients(101 cases included,7 cases excluded)who were admitted from May 01,2009 to December 01,2019 in 4 tertiary hospitals in Shaanxi Province(including Second Affiliated Hospital of Air Force Military Medical University,Shaanxi Provincial People’s Hospital,Xi’an Central Hospital,Yan’an University Affiliated Hospital)was conducted.The demographical data,including age,gender,body weight,total burn surface area,III degree of burn area,the presence of inhalation injury and AIS socre,the application of tracheotomy,resuscitation-associated parameters and resuscitation evaluation parameters during 24 h,48h and 72 h postburn,the mortality were also recorded.According to the diagnosis of INHI based on the distribution of thermal injury,clinical symptoms and results of fiber bronchoscopy,101 selected cases were then categorized into two groups: INHI group(group A,n=82)and Non-INHI group(group B,n=19).To appraise the effects of tracheotomy on the fluid resuscitation severely burned patients combined with INHI,patients in the INHI group(group A)were further divided into tracheotomy group(group C,n=56)and non-tracheotomy group(group D,n=26).To analyze the difference in fluid resuscitation between severely burned patients combined with high grade inhalation injury(AIS 3,4)and those combined with low grade inhalation injury(AIS 1,2),patients in the INHI group(group A)were further categorized into high-grade INHI group(group E,n=23)and the low-grade INHI group(group F,n=59).Continuous variables were reported as means and standard deviations or medians and interquartile ranges(IQR),while dichotomous and categorical variables were presented as count and relative percentage in each group.Statistical analyses were conducted using SPSS(version 25.0;IBM,USA)and R(http://www.R-project.org)and Empower Stats software(www.empowerstats.com,X&Y solutions,Inc.Boston MA).We used Student t tests to analyze differences among groups where data was normally distributed,while Mann-Whitney U tests were performed to analyze the differences among groups where data was not normally distributed.Pearson’s chi-square or Fisher’s exact test were also used to examine differences among categorical data,frequencies or rates were included.Besides,data were processed with the analysis of variance for repeated measurement,and the values of P were adjusted by Bonferroni.A case-control matching analysis was performed to eliminate the difference in total burn surface area between the two groups.Further analyses between groups before and after matching were performed.A two-tailed p-value less than 0.05 was considered to suggest statistical significance.Results:1.The influence of INHI on the fluid resuscitation of massive burn patients1.1 The total burn surface area in the INHI group was 70%(55%,85%),while that in the Non-INHI group was 56%(50%,61.5%),the total burn surface area in the INHI group were larger than those in the Non-INHI group(P<0.05).There were no significant difference were found in age,weight and gender between the two groups(P>0.05).No significant difference in demographics were found after matching.1.2 The incidence of tracheotomy in the INHI group was higher than that in the Non-INHI group(P<0.05).1.3 The fluid requirement in the INHI group was higher than that in the Non-INHI group(P<0.05).1.4 The urinary output in the Non-INHI group postburn was higher than that in the INHI group during the first to third 24 h post burn(P<0.05).The INHI group shows higher cumulative I/O than the Non-INHI group(P<0.05).No significant difference were found in heart rate,respiratory rate,MAP and HCT between the two groups(P>0.05).2.The influence of tracheotomy on the fluid resuscitation of massive burn patients combined with INHI2.1 No statistical difference in demographics including age,gender,weight and TBSA were found between the tracheotomy group and the non-tracheotomy group(P>0.05).The incidence of High grade of INHI in the tracheotomy group was found higher than that in the Non-tracheotomy group(P<0.05).2.2 No significant difference in fluid requirement,crystalloid requirement,colloid requirement were found between the two groups(P>0.05).A tendency of higher glucose volume was found in the tracheotomy group when compared with non-tracheotomy group.2.3 The mean urinary output was lower in the tracheotomy group during the first to third 24 h post burn(P<0.05).Besides,higher heart rate was also found in the tracheotomy group(P<0.05).No significant difference were found in respiratory rate,MAP,HCT and cumulative I/O between the two groups.3.The influence of differenct grades of INHI on the fluid resuscitation of massive burn patients combined with INHI3.1The total burn surface area and 3rd degree of burn area in the high-graded INHI group were 85%(70%,90%)and 60%(35%,71.5%)respectively,while those in the low grade INHI group were 70%(54.5%,80%)and 26%(15%,45.5%)respectively,the total burn surface area and 3rd degree of burn area in the high-grade INHI group were higher than those in the low-graded INHI group(P<0.05).There were no significant difference were found in age,weight and gender between the two groups(P>0.05).No significant difference in demographics were found after matching.3.2 The incidence of tracheotomy in the high-grade group was higher than that in the low-grade group(P<0.05).3.3 The fluid requirement in the high-grade group was higher than that in the low-grade group during the first to third 24 h post burn(P<0.05).3.4 Compared with the low-grade INHI group,the high-grade INHI group showed a relatively lower mean urinary output volume(P<0.05).No significant difference were found in heart rate,respiratory rate,MAP,HCT and cumulative I/O between the two groups(P>0.05).Conclusion:1.An appropriate increase in fluid requirement of severely burned patiens when combined with INHI is needed,so as to achieve a more effective resuscitation.2.Timely tracheotomy to build artificial airways contributes to the improvement of prognosis of severely burned patients combined with INHI.Higher volume of water intake should be considered for patients accepted tracheotomy.3.Severely burned patients combined with high-grade INHI require larger volume of fliud when compared with those combined with low-grade INHI.Clinical practitioners should adjust the fluid strategy according to the actual fluid requirement to achieve a high-quality resuscitation.