Indian Journal of Burns

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Originall Article Original Arrticle

Ind Indian dian Journal Jo ournal of of Burns

A retrospective study of 69 patients admitted at the intensive care unit University Clinical Center of Kosovo during the period 2008-2012 Shkelzen B. Duci1, Hysni M. Arifi1, Mimoza E. Selmani4, Agon Y. Mekaj2, Zejn A. Buja1, Enver T. Hoxha1, Astrit R. Hamza3 Departments of 1Plastic Surgery, 2Neurosurgery, 3General Surgery and 4Orthodontics, Dentistry Faculty, University Clinical Center of Kosovo, Rrethi i Spitalit p.n. 10000, Prishtina, Kosovo

Correspondence to: Dr. Shkelzen B. Duci, Department of Plastic Surgery, University Clinical Center of Kosovo, Rrethi i Spitalit p.n. 10000, Prishtina, Kosovo. E-mail: [email protected]

Abstract Background: Burns are the third most common cause of mortality in children and adolescents. It is also a major cause of morbidity and mortality in individuals of all age groups, particularly in individuals living in the developing countries. Objective: The objective of this study is to determine the causes of extensive burn injuries in our population, sex, age, distribution of extensive burn injuries by years, duration of treatment, the methods of treatment and mortality. Materials and Methods: In this retrospective study, we retrospectively analyzed data of 69 patients during the 4-year period between January 2008 and January 2012, with extensive burn injuries admitted to the ICU-University Clinical Center of Kosovo. Among them, 53 patients were males and 16 were females with a male to female ratio of 3.3:1. Conclusion: The high rate of transferring patients for treatment abroad to other countries of 28.9% and high mortality rate of extensive burns in our country with 11 cases (15.9%) is a reflection of lack of burn care in our department.

Key words: Burns, extensive, mortality

INTRODUCTION Access this article online Quick Response Code:

Website: www.ijburns.com

DOI: 10.4103/0971-653X.147015

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Burns are the third most common cause of mortality in children and adolescents.[1,2] They are also a major cause of morbidity and mortality in individuals of all age groups, particularly in individuals living in the developing countries.[1,3] The epidemiology of burns is diverse across the world and also within a country because of differences in the cultural and socio-economic factors and the availability of healthcare facilities.[4] The incidence of burns varies across countries, populations, and time. Indian Journal of Burns || December 2014 || Vol 22 || Issue 1


Duci, et al.: Burns, intensive care unit

The severity of a burn depends on the degree of heat, duration of exposure, and thickness of the involved skin. The treatment of burns requires a multidisciplinary approach and it is cost intensive. The main components of treatment are surgical intervention (early excision/skin grafting), volume therapy, and the prevention of sepsis and multi-organ failure, nutrition, and rehabilitation. A burn center must be well-equipped, and have various specialists, including general surgeons, plastic and reconstructive surgeons, infectious disease specialists, anesthetists, dieticians, psychologists, pediatricians, physiotherapists, microbiologists, and epidemiologists.[5-8] The risk of death from a major burn is associated with burn area, advanced age, the presence of a full-thickness burn, the presence of inhalation injury, and female gender. Advances in burn care have contributed to decreasing mortality from burn injuries over the last two decades, and these include improved resuscitation, modern hemodynamic monitoring, adequate nutritional support, and early tangential excision and grafting.[9-11] According to the 2011 registration, estimated population in Kosovo is 1,800,000. The plastic surgery department is the only department that treats burn injuries in our country. The plastic surgery department functions within the University Clinical Center of Kosovo. Patients with extensive burns are treated by a plastic surgeon in close cooperation with the anesthesiologist since, there is no dedicated burn unit available in our country. These patients are initially admitted to the intensive care unit (ICU). After initial resuscitation and after these patients have survived the early complications of extensive burns, they are transferred to our department for further treatment. Emergency resuscitation in our country is not performed properly in many cases, which occasionally leads to early major complications. Delayed transportation and admission to the ICU is responsible for most of the deaths in cases of extensive burns.

Objective The medical records of 69 patients who were treated during the last 4 years period were retrospectively analyzed concerning age, gender, the cause of the burn, distribution of the burn injuries by years, duration of the hospital stay and mortality.

MATERIALS AND METHODS In this study, we retrospectively analyzed data of 69 patients with extensive burns injuries treated in the 20082012 period in ICU - University Clinical Center of Kosovo. The data was collected and analyzed from the archives and protocols of the University Clinical Center of Kosovo. From statistical parameters for age and cause were calculated arithmetic median and standard deviation, the differences between the seven age groups were measured with one-way analysis of variance. P < 0.05 was considered to be statistically significant. Indian Journal of Burns || December 2014 || Vol 22 || Issue 1

RESULTS In the ICU-University Clinical Center of Kosovo, there are two anesthesiologists and two residents of anesthesiology in training on rotation and ten staff nurses. The specialists of other fields are on call service (general surgeon, plastic surgeon, pediatric surgeon, etc.). There are 20 beds. These patients are initially admitted to the ICU and later are transferred to the plastic surgery department for further treatment. The indications for hospitalization in our ICU are listed below: 1. Second degree burns that are larger than 20% of total body surface area (TBSA) in adults and larger than 10% in children. 2. Third degree burns that are larger than 10% in children and adults. 3. Respiratory tract injury, fractures, inhalation injuries, and burns with comorbid diseases. 4. All high voltage electrocutions.

The age and sex distribution of the patients 53 cases were males and 16 cases were females with a male to female ratio of 3.3:1 [Table 1]. Out of 69 patients with burn injuries admitted to ICU, in 43 cases, or 62.3% the cause of burns were scalds, in 13 cases or 18.8% the cause of burns were flame (in all cases gas flame), in 11 cases or 15.9% high voltage injuries and in 2 cases or 2.8% the cause of burns were lightening burn injuries. While the numbers of children 38 cases (0-16 years) and adult 31 (16 years over) patients were about the same, 0-9 years age group was the most common (49.2%) among children, whereas 20-40 years age group was the most common (30.4%) in adult groups.

The cause of burns Table 2 shows that the most common cause of burn injuries was scalds with 38 cases (55%) which dominates in the age group 0-9 years. 34 cases (49.2%) were due to flame burns which were maximum in the 10 to 19 years age group, burns caused from high voltage electrocution were more common in the age group 20 to 29 years with 7 cases, lightening burns with 2 cases also prevailed in the age group 20-29 years.

Age groups Regarding the age group, burn injuries were found to be more dominant in the age group from 0 to 9 years with 34 cases (49.2%), followed by age group 20-29 years with 14 cases (20.2%), 30-39 years 7 cases (10.1%), 10-19 years 7 cases (10.1%) and over 60 years with 5 cases (7.2%) [Table 3]. Patient with extensive burn injuries admitted to ICU had a very wide age distribution: from 5 months to 73 years old, with an average age of 21.5 years.

Distribution of extensive burns by years Distribution of extensive burns in years had the following features: year 2008 was the year where the 89


Duci, et al.: Burns, intensive care unit Table 1: General characteristics of patients with extensive burn injuries Gender and age

No. (n = 69)

Percentage

53 16

76.8 23.1

34 7 14 7 1 1 5

49.2 10.1 20.2 10.1 1.4 1.4 7.2

Gender Male Female Age groups 0-9 10-19 20-29 30-39 40-49 50-59 60+

Table 2: Causes of extensive burns Causes

No.

Total no. (%)

Scald Flame High voltage injuries Lightening

38 14 15 2

55 20.2 21.7 2.8

Table 3: Causes of burns by age group* Cause

Scald (%)

Flame (%)

Age groups 0-9 34 – 10-19 – 6 20-29 3 2 30-39 1 3 40-49 – – 50-59 – 1 60+ – 2 Total 38 (55) 14 (20.2) Mean ± SD 12.67±18.50 2.8±1924

High voltage Lightening (%) (%) – 1 7 3 1 – 3 15 (21.7) 3.0±2449

– – 2 – – – – 2 (2.8) 2.000±0.0

One - way analysis of variance *P < 0.0300, Bartlett’s test for equal variances *P < 0.0001. SD: Standard deviation

incidence of extensive burn injuries was the highest with 22 cases (31.8%), 2009 with 18 cases (26%), 2010 with 14 cases (20.2%), 2012 with 11 cases (15.9%), 2011 with 4 cases (5.7%).

Duration of hospitalization Duration of treatment ranged from 0 to 176 days. The mean length of the hospitalization was 42.5 days.

The depth of burns and surgical interventions The median TBSA determined based on medical records was 32% with a range of 11-70%. Escharectomy was required in 9 cases or 8% of cases, 20 cases or 28.9% with extensive burn injuries had full-thickness burns and underwent a surgical procedure with early surgical excision of burn wound followed by skin grafting. 19 cases or 27.5% has a medium thickness burns and underwent 90

conservative treatment without surgical interventions. In the study, we did not include patients who were transferred to other countries for treatment because the data of the future outcome of these patients is lacking.

Transferred patients A total of 19 cases or 27.5% were transferred abroad for treatment in other countries with TBSA above 40%. 10 cases in Turkey, 4 cases in Serbia, 2 cases in Albania, 2 cases in Former Yugoslav Republic of Macedonia (FYROM) and 1 case in Italy.

Mortality and its causes 11 patients or 15.9% died. Details are as follows—In 2008, three patients were above 60 years of age and had a full-thickness burn with TBSA above 60%, two patients were from age group 0 to 9 years and one was with TBSA 40% and another with TBSA 35%. In 2009, two patients were above 60 years of age one with TBSA 60% and another with TBSA 35%, one was 39 years old and had full-thickness burns with TBSA 70%. In 2010, we recorded two cases from the age group 0 to 9 years with TBSA 25%. In 2012, we recorded one case 73 years old with TBSA 30%. All 11 fatal cases had at least one or more positive blood and wound culture for microorganism of Pseudomonas, Klebsiella and Staphylococcus aureus with single isolation or in combination. Seven cases had acute renal failure, which responded to hemofiltration during treatment. Six cases with flame burns also had inhalation injury, and two of these cases needed mechanical ventilation. Multiple organ dysfunctions were the main cause of death in all fatal cases.

DISCUSSION Burns are serious, complex injuries that frequently lead to disability and death. Consequently, their diagnosis and treatment requires a special approach. Although various scoring systems have been reported for estimating the mortality risk of burned patients, there is no standard accepted system.[5,12] However, gender, age, burn surface area, presence of inhalation injury, comorbid disease, coexisting trauma, and pneumonia have been reported to affect mortality. Advances in the treatment of burns in the last two decades have contributed to the decrease in mortality.[5,13,14] In this study, we retrospectively analyzed data of 69 patients in 4 years period with extensive burn injuries admitted to the ICU-University Clinical Center of Kosovo. Burn injuries in this study was predominantly in male patients with 53 cases or 76.8% against only 16 cases who were female or 23.1%. This finding in our study is similar to the 5 years retrospective study conducted by Schembri et al. who reported a male predominance of 72.7% versus 27.3% of females.[15] Indian Journal of Burns || December 2014 || Vol 22 || Issue 1



This predominance of male gender in our population is related to socio-economic and cultural habits in our country, male gender in our country are the main carriers of heavy physical works also our families in our country are dependent from the financial aspect of this gender, while women in our country especially in rural areas are mainly housewives. The scald burns in our study dominates in the age group 0-9 years with 49.2%, the flame burns dominates in the age group 10-19 years with 8.6%, high voltage electrocution dominates in the age group 20-39 years with 14.4%, lightening with two cases were recorded in the age group 20-29 years. This finding in our study is similar with an 8 year retrospective study conducted by Ho et al. who reported dominance of scald burns in children with 51.7%.[16] We have noted that scald burns in our population dominates in the age group 0-9 years, the children are prone to be affected more by scald burns due to several circumstances peculiar to our population: Playfulness of children at this age, poor socio-economic conditions, especially in rural areas of our country, and some traditional habits such as preparing tea on low stoves, and eating breakfast while sitting on the floor. The second major cause of extensive burns in our population was flame (gas explosion). This is related due to use of gas burning stoves and gas stoves for heating of water, milk and soup. The third major cause of extensive burn injuries in our population was high voltage electrocution. Electrical burns have usually been more frequent in undeveloped countries with an inefficient electric energy system and a low social and economic level, as in our country, Kosovo. The consequences of the Kosovo war (1998-1999) included the destruction of the country’s production infrastructures and the disruption of the electricity supply system. With the deterioration of the electricity supply system in Kosovo, the number of patients with electrical injuries increased, with the highest rate in Europe. In Kosovo, the electricity supply system consists of two old power stations that are unable to satisfy all needs of electric current, as is normally the case with outdated electricity distribution systems.[17] In our study, we found the incidence of electrical burns to be higher during winter and summer months. This is due to several reasons. Due to a significant drop in temperatures during the winter period, the electrical power supply is not sufficient due to high demands and therefore is not a reliable source of energy. Thus, people are forced to utilize alternative means of energy for their households. This can lead to accidents associated with electrical burns and other means of injuries. Majority of construction projects in our country take place during summer time. The installation of high voltage Indian Journal of Burns || December 2014 || Vol 22 || Issue 1

electrical cables is frequently performed by inexperienced personnel leading to a variety of accidents including severe electrical burns. There was a massive power supply shortage, especially immediately post-war period. People were living without electrical power supply for up to 12 h a day for the first 7 years post-war. The situation got better after 2010. There are still shortages in the electrical supply in present time, however far less compared with the early post-war period. In view of this hugely dysfunctional electrical power system, people were forced to look for alternative means of electrical supply. This of course led to numerous accidents. Therefore, the decrease of burn injuries incidence after 2010 is related with stabilization of electrical power supply in our country compared with previous years. After 1999, the country emerged from the war and our population confronted with frequent outages of electricity especially during the winter season due to overload. Our population was thus forced to find alternatives for electricity driven appliances (gas burning stoves and gas stoves for heating of water, milk and soup). In our study, we have recorded two cases with lightening burns in the age group 20-29 years. Two cases with lightening burns were shepherds who cared for grazing in open fields. Another significant finding in our study is the high rate of mortality 15.9% compared with studies from other developing countries which ranged from 6.5% to 12%, respectively.[18-21] Department of Plastic Surgery in our country is the only department which treats patients with burn injuries. Kosovo has about 2 million inhabitants, and has not yet specialized center for treatment of extensive burn injuries.

CONCLUSION On the basis of the results from our study, we can conclude that: • A high rate of childhood extensive burns requires hospital admissions and prolonged hospital stays. Therefore, burns in childhood cause great financial expense and social burdens on individuals, families, society, and the nation. To reduce this burden, a burn prevention strategy and prevention program in the country should be developed. Simple preventive measures can help to eliminate burn injuries. The most effective way is public education. Especially, parents with preschool children should be offered education about preventive measures against burns. Education programs that inform and warn people about the causes of all types of burn injury should be offered by the government and health care personnel • The high rate of transferring patients for treatment outboard in other countries with 28.9% and high mortality 91



rate of extensive burns in our country with 11 cases (15.9%) is a reflection of lack of a good burn center in our country. • Electrical burns are deep tissue lesions caused by the passage of electric current in the human body that are characterized by higher morbidity and invalidity than burns of any other etiology. They constitute one of the severest medical problems in our country • Preventive strategies to reduce the burns incidence in the most affected areas include training in primary schools about burn awareness and prevention, child safety in the home, safe use of paraffin stoves, and first aid education. Improved nutrition, housing and socio-economic status and the enacting of legislation aimed at reducing scald risk by keeping home and public water heater temperatures to 55°C.

ACKNOWLEDGMENTS We thank the archive and all the staff of the Department of Plastic Surgery for their technical support.

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How to cite this article: Duci SB, Arifi HM, Selmani ME, Mekaj AY, Buja ZA, Hoxha ET, Hamza AR. A retrospective study of 69 patients admitted at the intensive care unit University Clinical Center of Kosovo during the period 2008-2012. Indian J Burns 2014;22:88-92. Source of Support: Nil, Conflict of Interest: None declared.

Indian Journal of Burns || December 2014 || Vol 22 || Issue 1