Investigating the interrater reliability of a novel functional outcome measure for use in the burns intensive care unit: The Functional Assessment for Burns - Critical Care (FAB-CC).

INTRODUCTION: Intensive Care Unit Acquired Weakness challenges the clinical care of critically ill patients. Despite a surge in validated ICU functional outcome measures following the publication of Clinical Guideline 83 'Rehabilitation After Critical Illness' by the National Institute for Health and Care Excellence (2009), there are none composed specifically for use in the Burns ICU. We therefore developed and tested the inter-rater reliability of a burn specific novel functional outcome measure; The Functional Assessment for Burns-Critical Care (FAB-CC). OBJECTIVES: This research aimed to investigate the interrater reliability of the FAB-CC. METHODS: A quantitative reliability study assessed the ability of the FAB-CC to obtain accurate data when utilised by three separate raters (m=3) scoring the same clinical episodes (n=24). RESULTS: The Intraclass Correlation Coefficient (ICC) for the FAB-CC as a complete tool revealed excellent agreement (ICC 0.998; P<0.001, 95% confidence interval 0.996-0.999), with Cronbach's Alpha (α 0.999). Individual components of the FAB-CC displayed excellent agreement (ICC>0.983; P<0.001) with narrow 95% confidence intervals. CONCLUSIONS: The FAB-CC is a novel functional outcome measure that is reliable for use with critically ill burn patients. It has demonstrated real clinical utility in the identification and management of ICU-AW in this unique patient group.

Percutaneous dilational and surgical tracheostomy in burn patients: incidence of complications and dysphagia.

The aim of this study is to evaluate the incidence of complications and dysphagia in relation to the timing of tracheostomy and tracheostomy technique in 49 consecutive adult burn patients. We analysed prospectively collected data. Bronchoscopy was used to diagnose tracheal stenosis and a modified Evans blue dye test was used to diagnose dysphagia. Eighteen patients received a percutaneous dilatational tracheostomy (PDT) and thirty-one patients received an open surgical tracheostomy (OST). Eight patients developed significant complications (16%) following tracheostomy, there is no difference in the incidence of complications; post op infection, stoma infection or tracheal stenosis between PDT and OST groups. Patients with full thickness neck burn who developed complications had a tracheostomy significantly earlier following autografting (p=0.05). Failed extubation is associated with dysphagia (p=0.02) whereas prolonged intubation and ventilation prior to tracheostomy independently predicts dysphagia (p=0.03). We conclude that there is no difference in the complication rates for PDT and OST in our burn patients. We recommend early closure of neck burns and tracheostomy through fully adherent autograft or at least 10 days after grafting to reduce stomal infections. For patients with no neck burn, we support early tracheostomy to reduce the likelihood of dysphagia.

Noninvasive Positive Pressure Ventilation in burns.

OBJECTIVE: Acute respiratory failure is a common complication of the severely burn-injured patient. Endotracheal intubation and mechanical ventilation is associated with a high rate of complications. Noninvasive Positive Pressure Ventilation (NIPPV) has been shown to be as effective as conventional ventilation in improving gas exchange and is associated with fewer complications with patients in acute hypercapnic and hypoxaemic respiratory failure. We report our experience with NIPPV in 30 burn patients. METHOD: The records of all burn patients from 1998 to 2000, where NIPPV was used as part of their management at the St. Andrew's Centre for Plastic Surgery and Burns, were reviewed. RESULTS: Mean age was 47.56 years (range 12-81). Nine patients were female. Mean burn size was 24.4% total body surface area (TBSA) (range 3-54). Inhalation injury was confirmed in eight cases. A positive diagnosis of pneumonia was made in 29 patients. The mean PaO(2)/FiO(2) ratio prior to institution of NIPPV was 28.98Kpa (range 8.75-52). Intermittent Positive Pressure Breathing (IPPB) was the most common ventilatory mode employed (25 patients) and the face mask was the most used interface (18 cases). Twenty-two patients (74%) avoided endotracheal intubation and their respiratory function continued to improve after NIPPV was discontinued. One patient (3%) died and seven patients (23%) were reintubated. Three out of the seven were electively reintubated for burns surgery. CONCLUSION: In burn-injured patients with acute respiratory failure, NIPPV appears to be effective in supporting respiratory function such that endotracheal intubation can be avoided in most cases.