[EXTUBATION FAILURE IN BURNS: INCIDENCE, RISK FACTORS AND PROGNOSIS]. / ÉCHEC D'EXTUBATION CHEZ LES BRÛLÉS: INCIDENCE, FACTEURS DE RISQUE ET PRONOSTIC.

The incidence of extubation failure varies between 2 and 25% depending on the studied population. Few studies have been conducted in burn victims. To determine the incidence, causes, risk factors and outcome of burned patients after a failed extubation, a retrospective single-center case-control study was conducted over a period of 3 years (January 2018-December 2021). All burned patients aged over 16, ventilated for at least 24 hours and having had at least one extubation attempt were included. Extubation failure was defined as the need for re-intubation within 48 hours. Eighty-eight patients had planned extubation. These patients were divided into 2 groups comparable in terms of age and sex. Failure group: including patients with failed extubation (N= 34) and a success group (N= 64) including patients who succeeded. The incidence of extubation failure was 36.6%. Hypophosphatemia, anemia <8g/dl, duration of mechanical ventilation of 8,5 days and abundant secretions during extubation were identified as risk factors for extubation failure (p<0.05). The main cause of failure was retention of secretion (50%). Extubation failure was associated with prolonged length of stay (34 vs. 19 days, P= 0.005), increased infectious complications (P=0.007) and mortality rate (79.4%, 1.5%, P<0.001).

[DISTRIBUTION OF CARBAPENEMASES IN TUNISIAN BURN PATIENTS]. / DISTRIBUTION GÉOGRAPHIQUE DES CARBAPÉNÉMASES CHEZ LES BRÛLÉS TUNISIENS.

Resistance to carpabenems in burns is rapidly spreading in many countries. Therefore identification of carbapenemase pathogen carriers is imperative in order to establish adequate infection control precautions and stop outbreaks of these multidrug-resistant bacteria. The aim of our study was to evaluate the distribution of carbapenemase producers in burn patients admitted to a burn center in Tunisia over 9 months. PCR for carbapenemase portage was performed in all patients within 48 hours of admission. Seventeen patients carried a single carbapenemase, 11 carried two, and 25 carried three. The enzymes detected were VIM (n=41), NDM (n=41) and OXA48 (n=32). Enzyme mapping revealed two main areas of carriage in central western Tunisia: Kairouan (NDM/OXA48) and Kasserine (NDM/VIM). Predictive factors for carriage of carbapenemase were: prior antibiotic therapy (n=24); mechanical ventilation (n=30); vascular catheterization (n=31) and a previous stay in intensive care (n=11).

Suicide by Self-Immolation in the Pediatric Population.

Self-immolation is a violent way of committing suicide. Few studies have focused on this phenomenon in children. The aim of this study was to determine the epidemiological profile of children who committed suicide by fire. A retrospective descriptive study was conducted in an intensive burn care department in Tunis, over a period of 10 years (2011-2020). Of a total 3077 patients, 761 were admitted for burns by suicide attempt, among them 62 children and adolescents (8%). The number was on average six per year. The highest annual prevalence was noted in 2011 (27% of cases). The mean age was 16 and a half years old. The majority of cases were adolescents aged 15 or older. There is a male predominance (sex ratio:3). Total burn surface area (TBSA) was on average 44%. The act of self-immolation occurred in public places in 58% of cases. Socio-economic environment was unfavorable in 60% of cases. The suicidal act of self-immolation was due to a family conflict in 34% of cases (n=21). Seven patients (11%) had a history of mental illness. Forty-three patients (70%) required mechanical ventilation. The length of hospital stay was on average 30 days. The mortality rate was 56.5%. In conclusion, self-immolation is frequent in the pediatric population; it induces severe burns associated with a poor prognosis.

L' immolation est un moyen de suicide particulièrement violent. Peu d'études se sont penchées sur ce phénomène chez l'enfant. Cette étude a pour but de déterminer le profil des enfants recourant au feu pour se suicider. Il s'agit d'une étude rétrospective réalisée sur une période de 10 ans (2011-2020) dans la réanimation spécifique du CTB de Tunis. Sur 3 077 patients admis, 761 avaient réalisé une tentative de suicide (TS) parmi lesquels 62 (8%) enfants ou adolescents. Vingt-sept pour cent des cas sont survenus en 2011 (6/an en moyenne). L'âge moyen est de 16 ans 1/2, la majorité des patients étant des adolescents de 15 ans ou plus. On observe un prédominance masculine (3M/1F). La surface atteinte moyenne représente 44% SCT. La TS est réalisée dans un espace public dans 58% des cas. Le contexte socio ­ économique est considéré défavorable dans 60% des cas, avec un contexte de conflit familial à l'origine de 34% (21 fois) des TS. Sept patients (11%) avaient un passé psychiatrique. Quarante - trois patients (70%) ont eu besoin de ventilation mécanique. La durée moyenne de séjour a été de 30 j, la mortalité de 56,5%. En conclusion, les TS par le feu ne sont pas rares chez les enfants. Elles entraînent des brûlures graves, au pronostic péjoratif.

[Acute Pancreatitis Related to Tigecycline in ICU Burn Patients]. / Pancréatitis Aiguë Liée à La Tigécycline Chez Des Patients Brülés En Réanimation.

Drug-induced acute pancreatitis (AP) associated with tigecycline (TGC) is considered a rare complication (incidence between 1‰ and 1%). In this paper, we report five cases of AP occurring after the administration of TGC in septic patients hospitalized in intensive burn care in Tunisia over 9 years. The diagnosis of AP was based on clinical and/or biological signs. Among 303 cases treated with TGC, AP occurred with an incidence of 1.65%. The mean age was 28±6 years. Only one patient had a history of chronic alcoholism. The prescribed dose was 200 mg as a loading dose, followed by 100 mg twice a day. The time to onset of symptoms after initiation of TGC was 5.4 days [2-7]. PA was suspected due to abdominal pain associated with nausea and vomiting (n=2), occlusive syndrome (n=1) and fortuitously increased pancreatic enzymes in 2 patients under mechanical ventilation. The mean lipase level at diagnosis was 447 IU ± 135 IU (4.5 to 10 times the normal). All the aetiologies of AP were ruled out, including gallstones, hypercalcemia, hypertriglyceridemia, trauma and infections. The mean time to symptom resolution after stopping TGC was 4±2 days [5-7] and to the normalization of pancreatic enzymes it was 9 days [2-20 days]. In conclusion, clinical and biological monitoring was necessary in patients treated with TGC in order to avoid severe forms, especially in at-risk patients.

[Procalcitonin: The Ideal Biomarker To Guide Initiation, Change and Withdrawal of Antibiotics in Septic Burn Patients?] / La Procalcitonine: Biomarqueur De Choix Pour Guider L'Initiation, La Modification Et L'Arrêt De L'Antibiothérapie Chez Les Brûlés Sepitques?

The goal of this study was to assess plasma procalcitonin (PCT) concentrations during infectious events of burns in the ICU. We conducted a prospective, observational study in a 20-bed Burn Intensive Care Unit in Tunisia. A total of 120 septic patients admitted to the Burn ICU were included in our study. Sepsis was assumed according to the French Burn Association criteria for the presence of infection. Serum PCT was measured over the entire septic episode every 48 hours until resolution of infection, based on clinical signs and decrease of PCT of about 80% compared to its initial value. Patients were assigned to two groups depending on clinical course and outcome: Group A = patients with favourable evolution; Group B = patients with unfavourable evolution. Monitoring of kinetics of PCT allowed us to judge the effectiveness of the initial antibiotic therapy, with a threshold of 43.5% decrease at day 3 of treatment, with a better sensitivity and specificity of 79.6% and 87.7% respectively. In addition, PCT monitoring allowed a reduction in the duration of antibiotic therapy of 5±2.8 days versus 8 to 10 days before the use of PCT.

Sténose trachéale chez les brûlés : incidence et facteurs de risque.

Tracheal stenosis remains frequent, especially in intensive care patients requiring prolonged intubation or tracheotomy. There is little data in the literature regarding this complication in burn patients. The aim of our study was to determine incidence, characteristics and risk factors of tracheal stenosis in burn patients. A retrospective study was conducted in a 20-bed burn ICU in Tunis over 7 years. It included all patients who presented tracheal stenosis confirmed by endoscopic and/or radiological exploration. Tracheal stenosis was confirmed in 15 patients with an overall incidence of 0.8% and an incidence of 3.5% in intubated patients. The mean age was 24 years, with TBSA of 28±15%. The burn was thermal in all patients. Facial burn was noted in all patients. Inhalation syndrome was observed in 12 patients. Duration of intubation was 16±12 days. Dyspnea, stridor and dysphonia were the most common symptoms. The onset of clinical signs was 30 days on average after extubation. All patients underwent bronchoscopy and/or cervico-thoracic scan for diagnosis. The average distance between the stenosis and vocal cords was 27 mm and the average degree of stenosis was 68%. The average length was 20 mm. Therapeutic management was based on: dilation in 3 cases, Montgomery tracheal T-tube insertion in 2 cases, and endoscopic laser therapy in 3 cases. Tracheal resection-anastomosis was performed in 5 patients. The evolution was favorable in 8 patients. Restenosis was observed in 2 patients. Five patients died. Inhalation injury, facial burn and prolonged intubation were recognized as risk factors that increase the likelihood of this complication.

Lactate: prognostic biomarker in severely burned patients.

Plasma lactate (PL) has been used as a marker of cellular hypoxia and shock. The correlation between PL and clinical outcome has been well accepted in hemorrhagic and septic shock. In contrast to the existing evidence, there are no or almost no data dealing with lactate and burn-related outcome. We attempted to assess whether early plasma lactate (PL) is a useful parameter to predict outcome in burned patients. A prospective study was conducted in a 20-bed adult burn ICU at a university-affiliated teaching hospital in Tunis. Patients admitted within the first 24h post burn with greater than 10% total body surface area (TBSA) burned were enrolled in the study. There were 60 males and 20 females. Mean age was 40.7 ± 19.5 years old, and average TBSA was 32 ± 21%. At admission, 86.7% patients had an initial lactate value of more than 2 mmol/L. In our study, an initial lactate value of 4 mmol/L provided the best sensitivity and specificity: 88% and 79% respectively for predicting sepsis, with an area under the ROC curve of 0,82. Furthermore, plasma lactate cut-off value for mortality prediction was 4.46 mmol/l with a good sensitivity (86%) and specificity (92%). Mortality rate was 36.25%. Plasma lactate appears to be a powerful predictor biomarker of sepsis and mortality in burn patients.

Le lactate plasmatique (LP) est utilisé comme marqueur de choc et d'hypoxie cellulaire. La corrélation entre LP et pronostic est validée dans les chocs hémorragique et septique. Il n'y a que peu voire pas de données concernant PL et pronostic chez les brûlés. Nous avons étudié si la mesure précoce de PL avait une valeur pronostique chez les brûlés. Une étude prospective a ainsi été menée dans l'unité de réanimation pour adultes brûlés (20 lits) du CHU de Tunis. Les patients (60 hommes et 20 femmes) admis dans les 24 h d'une brûlure touchant plus de 10% de SCT ont été inclus. L'âge était de 40,5 +/- 19,5 ans, la surface brûlée de 32 +/- 21%. La grande majorité (86,7%) des patients avaient LP > 2 mmol/L à l'admission. Une valeur > 4 mmol/L étaient la plus prédictive de complication septique, avec une sensibilité de 88%, une spécificité de 9% et une aire sous la courbe ROC de 0,82. La mortalité était de 36,25% et un seuil de LP à 4,46 mmol/L prédisait le décès avec une sensibilité de 86% et une spécificité de 92%. LP semble donc être un marqueur prédictif fiable de sepsis et de mortalité chez les brûlés.

Procalcitonin: a diagnostic and prognostic biomarker of sepsis in burned patients.

The goal of this study was to analyse plasma procalcitonin (PCT) concentrations during infectious events of burns in ICU. We conducted a prospective, observational study in a 20-bed Burn Intensive Care Unit in Tunisia. A total of 121 patients admitted to the Burn ICU were included in our study. Serum PCT was measured over the entire course of stay in patients with predictive signs of sepsis according to the Americain Burn Association Criteria for the presence of infection. Patients were assigned to two groups depending on the clinical course and outcome: Group A = non septic patients; Group B = septic patients. A PCT cutoff value of 0,69 ng/ml for sepsis prediction was associated with the optimal combination of sensitivity (89%), specificity (85%), positive predictive value (82%) and negative predictive value (88%). Serum procalcitonin levels can be used as an early indicator of septic complication in patients with severe burn injuries as well as in monitoring the response to antimicrobial therapy.

Le but de cette étude était d'analyser la concentration de procalcitonine plasmatique (PCT) mesurée au cours des cas d'infection chez les patients brûlés en soins intensifs. Nous avons mené une étude observationnelle prospective dans une unité de soins intensifs de 20 lits en Tunisie. Un total de 121 patients admis ont été inclus dans notre étude. La PCT a été mesurée pendant toute la durée du séjour chez les patients avec des signes prédictifs de septicémie selon les critères de l'American Burn Association pour la présence de l'infection. Les patients ont été répartis en deux groupes en fonction de l'évolution clinique et les résultats: Groupe A = pas de patients septiques; Groupe B = patients septiques. Une valeur PCT de 0,69 ng/ml est associée à la combinaison optimale de sensibilité (89%), spécificité (85%), valeur prédictive positive (82%) et valeur prédictive négative (88%). Les niveaux de procalcitonine sérique peuvent être utilisés comme un indicateur précoce de complication septique chez les patients atteints de brûlures graves, ainsi que dans le contrôle de la réponse à la thérapie antimicrobienne.