BackgroundMajority burn mortality prognostic scores were developed and validated in western populations. The primary objective of this study was to evaluate and identify possible risk factors which may be used to predict burns mortality in a local Malaysian burns intensive care unit. The secondary objective was to validate the five well known burn prognostic scores (Baux score, Abbreviated Burn Severity Index (ABSI) score, Ryan score, Belgium Outcome Burn Injury (BOBI) score and revised Baux score) to predict burn mortality prediction.MethodsPatients that were treated at the Hospital Sultan Ismail’s Burns Intensive Care (BICU) unit for acute burn injuries between 1 January 2010 to 31 December 2017 were included. Risk factors to predict in-patient burn mortality were gender, age, mechanism of injury, total body surface area burn (TBSA), inhalational injury, mechanical ventilation, presence of tracheotomy, time from of burn injury to BICU admission and initial centre of first emergency treatment was administered. These variables were analysed using univariate and multivariate analysis for the outcomes of death. All patients were scored retrospectively using the five-burn mortality prognostic scores. Predictive ability for burn mortality was analysed using the area under receiver operating curve (AUROC).ResultsA total of 525 patients (372 males and 153 females) with mean age of 34.5 ± 14.6 years were included. There were 463 survivors and 62 deaths (11.8% mortality rate). The outcome of the primary objective showed that amongst the burn mortality risk factors that remained after multivariate analysis were older age (p = 0.004), wider TBSA burn (p < 0.001) and presence of mechanical ventilation (p < 0.001). Outcome of secondary objective showed good AUROC value for the prediction of burn death for all five burn prediction scores (Baux score; AUROC:0.9, ABSI score; AUROC:0.92, Ryan score; AUROC:0.87, BOBI score; AUROC:0.91 and revised Baux score; AUROC:0.94). The revised Baux score had the best AUROC value of 0.94 to predict burns mortality.ConclusionCurrent study evaluated and identified older age, total body surface area burns, and mechanical ventilation as significant predictors of burn mortality. In addition, the revised Baux score was the most accurate burn mortality risk score to predict mortality in a Malaysian burn’s population.

Background Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. A further therapeutic option may be open abdomen (OA) management with negative peritoneal pressure therapy (NPPT) to remove inflammatory ascites and attenuate the systemic damage from SCIAS, although there are definite risks of leaving the abdomen open whenever it might possibly be closed. This potential therapeutic paradigm is the rationale being assessed in the Closed Or Open after Laparotomy (COOL trial) (https://clinicaltrials.gov/ct2/show/NCT03163095). Initially, the COOL trial received Industry sponsorship; however, this funding mandated the use of a specific trademarked and expensive NPPT device in half of the patients allocated to the intervention (open) arm. In August 2022, the 3 M/Acelity Corporation without consultation but within the terms of the contract canceled the financial support of the trial. Although creating financial difficulty, there is now no restriction on specific NPPT devices and removing a cost-prohibitive intervention creates an opportunity to expand the COOL trial to a truly global basis. This document describes the evolution of the COOL trial, with a focus on future opportunities for global growth of the study. Methods The COOL trial is the largest prospective randomized controlled trial examining the random allocation of SCIAS patients intra-operatively to either formal closure of the fascia or the use of the OA with an application of an NPPT dressing. Patients are eligible if they have free uncontained intraperitoneal contamination and physiologic derangements exemplified by septic shock OR severely adverse predicted clinical outcomes. The primary outcome is intended to definitively inform global practice by conclusively evaluating 90-day survival. Initial recruitment has been lower than hoped but satisfactory, and the COOL steering committee and trial investigators intend with increased global support to continue enrollment until recruitment ensures a definitive answer. Discussion OA is mandated in many cases of SCIAS such as the risk of abdominal compartment syndrome associated with closure, or a planned second look as for example part of “damage control”; however, improved source control (locally and systemically) is the most uncertain indication for an OA. The COOL trial seeks to expand potential sites and proceed with the evaluation of NPPT agnostic to device, to properly examine the hypothesis that this treatment attenuates systemic damage and improves survival. This approach will not affect internal validity and should improve the external validity of any observed results of the intervention. Trial registration: National Institutes of Health (https://clinicaltrials.gov/ct2/show/NCT03163095).

BackgroundTrauma mortality due to exsanguination is the second most common cause of death. The objective of this study is to investigate the predictors for early death from exsanguination.MethodsA prognostic study was done to identify predictors of early mortality due to exsanguination. Data were extracted from our Trauma Surgery Registry database of Sultanah Aminah Hospital, Johor Bahru, Malaysia. All patients who were treated from May 1, 2011 to April 31, 2014 by the trauma team were included. Adult trauma patients included from the Trauma Surgery Registry were divided into two groups for analysis: early death from exsanguination and death from non-exsanguination/survivors. Univariate and multivariate analysis was performed to look for significant predictors of death from exsanguination. Variables analyzed were demography, mechanism of injury, organ injury scale, physiological parameters (systolic blood pressure (SBP), respiratory rate, heart rate, temperature), Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), New Injury Severity Score (NISS), Trauma and Injury Severity Score (TRISS) and cause of death.ResultsA total of 2208 patients with an average age of 36 (±16) years were included. Blunt trauma was the majority with 90.5%, followed by penetrating injuries (9.2%). The overall mortality is 239 out of 2208 (10.8%). Seventy-eight patients (32.6%) died due to central nervous system injury, 69 due to sepsis (28.9%) and 58 due to exsanguination (24.3%). After multivariate analysis, age (OR 1.026 (1.009 to 1.044), p=0.002), SBP (OR 0.985 (0.975 to 0.995), p=0.003) and temperature (OR 0.203 (0.076 to 0.543), p=0.001) were found to be the significant physiological parameters. Intra-abdominal injury and NISS were significant anatomic mortality predictors from exsanguination (p<0.001). Patients with intra-abdominal injury had four times higher risk of mortality from exsanguination (OR 3.948 (2.331 to 6.686), p<0.001).DiscussionIn a Malaysian trauma center, age, SBP, core body temperature, intra-abdominal injury and NISS were significant predictors of early death from exsanguination.Level of evidenceII.