LETTER TO THE EDITOR
Dear Editor,
Abdominal complications in patients with major burns without abdominal injury has been described. We identified this complication within our burns centre, both during acute resuscitation and later during the inpatient stay. We sought to define incidence, outcomes, and associated factors contributing to abdominal complications in major burns. We examined all patients admitted to our regional burns centre with major burns (>40% TBSA) and abdominal pathology between November 2003 and May 2016. We found that there were 316 patients who met these criteria. Of these patients, 18 were documented to have abdominal complications on the International Burn Injury Database,1 a prospectively completed database of all patients admitted to the centre. Data included age, gender, total body surface area burn, inhalation injury, disposition, length of stay, resuscitation volume, time from injury to diagnosis, vasopressors, and early tube feedings. Of the 316 patients admitted to the Regional Burn Centre, 18 (5.7%) were diagnosed with abdominal pathology with mean burn percentage total body surface area (%TBSA) of 60 (range 40-95% TBSA), of which 5 (26%) had abdominal catastrophe (infarction/perforation). Seven (37%) patients had upper GI bleeding, 6 (32%) patients had paralytic ileus, and 1 (5%) patient developed pancreatitis. All but two cases were due to flame burns. All patients were formally resuscitated on admission. 10/18 (55.6%) patients with abdominal complications died. Three patients were taken to theatre for laparotomy for ischaemic small bowel resection. Two patients were not fit for surgical intervention. The average length of stay was 1.07/%TBSA. On average abdominal catastrophe occurred on day 23 post-admission, ileus on day 17 and GI bleed on day 21. Of the three groups, we found that those in the ileus group had received on average a higher resuscitation fluid volume of 146% of the parkland formula compared to 108% for the GI bleed group and 105% for the abdominal catastrophe group. There was no association identified between vasoconstrictive agents given and the type of complication seen, contrary to our expectations, as we expected this to be higher in the patients with infarcted bowel.
Abdominal compartment pressures were measured in 7 of the patients that developed abdominal complications. The measurement was obtained by the use of a pressure transducer connected to the patient’s bladder catheter. Of these, four patients were diagnosed with infarcted bowel and the other 3 with ileus. Clinically all patients developed distended abdomens, with high nasogastric aspirates and reduced bowel sounds. A patient with an infarcted bowel also developed coffee ground vomiting. The average pressure of those with bowel infarction was 20.25mmHg, and for those with ileus was 23mmHg. Intra-abdominal hypertension (IAH) is defined as a sustained or repeated pathologic elevation of IAP > 12mmHg, with abdominal compartment syndrome (ACS) defined as a sustained increase in IAP > 20 mmHg that is associated with new organ dysfunction/ failure.2-3
In summary, significant abdominal complications occur in approximately 6.3% of patients admitted with major burn injuries >40% TBSA, according to this study. Abdominal catastrophe without abdominal trauma occurs in 1.58% with an associated mortality of 55%. We do not routinely measure abdominal compartment pressures in our patients, however more aggressive monitoring for abdominal complications by measuring intra-abdominal compartment pressures may identify abdominal hypertension earlier and allow for early intervention that may improve outcomes.
References
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