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Injury Characteristics and von Willebrand Factor for the Prediction of Acute Respiratory Distress Syndrome in Patients With Burn Injury

Development and Internal Validation

Afshar, Majid, MD, MSCR*,†,‡; Burnham, Ellen L., MD, MS§,¶; Joyce, Cara, PhD; Gagnon, Robin, BS*; Dunn, Robert, BS*; Albright, Joslyn M., MD||; Ramirez, Luis, BS*; Repine, John E., MD**; Netzer, Giora, MD, MSCE††; Kovacs, Elizabeth J., PhD§,‡‡,§§

doi: 10.1097/SLA.0000000000002795
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Objective: To derive and validate a prediction model for the development of ARDS in burn-injured patients.

Summary Background Data: Burn injury carries the highest incidence of acute respiratory distress syndrome (ARDS) among all predisposing conditions, but few studies exist on risk factors in these patients. Studies employing biomarkers and clinical risk factors for predicting ARDS mortality have recently been examined but none exist for onset of ARDS nor in patients with burn injury.

Methods: This was a prospective multicenter study of 113 patients with isolated burn injury or inhalation injury. Clinical variables and plasma biomarkers representative of endothelial injury, epithelial injury, or inflammation were collected within 24 hours of admission. The most parsimonious model was chosen by considering discrimination, calibration, and model fit.

Results: Among the biomarkers measured in patients with burn injuries, a one-standard deviation increase in log-transformed levels of the A2 domain of von Willebrand factor in the first 24 hours was most strongly associated with the development of ARDS (OR 7.72; 95% CI: 1.64–36.28, P = 0.03). Of candidate models, a 3-variable model with %TBSA, inhalation injury, and von Willebrand factor-A2 had comparable discrimination to more complex models (area under the curve: 0.90; 95% CI 0.85–0.96). The 3-variable model had good model fit by Hosmer–Lemeshow test (P = 0.74) and maintained similar discrimination after accounting for performance optimism (Bootstrapped area under the curve: 0.90; 95% CI: 0.84–0.95).

Conclusions: The 3-variable model with %TBSA, inhalation injury, and von Willebrand factor could be used to better identify at-risk patients for both the study and prevention of ARDS in patients with burn injury.

*Burn and Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Health Sciences Campus, Maywood, IL

Division of Pulmonary and Critical Care Medicine, Loyola University Medical Center, Maywood, IL

Department of Public Health Sciences, Stritch School of Medicine, Loyola University Chicago Health Sciences Campus, Maywood, IL

§Colorado Pulmonary-Alcohol Research Consotrium (CoPARC), University of Colorado School of Medicine, Aurora, CO

Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO

||Department of Surgery, Advocate Christ Medical Center, Oak Lawn, IL

**Webb-Waring Center Division of Experimental Research, University of Colorado, Aurora, CO

††Division of Pulmonary and Critical Care, University of Maryland, Baltimore, MD

‡‡Department of Surgery, Division of GI, Trauma and Endocrine Surgery, University of Colorado School of Medicine, Aurora, CO

§§Burn Research Program, University of Colorado School of Medicine, Aurora, CO.

Reprints: Majid Afshar, MD, MSCR, Loyola University Chicago, Center for Translational Research and Education, Room 447, 2160 South First Avenue, Maywood, IL 60153. E-mail: majid.afshar@lumc.edu.

This research was supported by the National Institute of General Medical Sciences R01GM115257 (EJK), and the National Institute of Alcoholism and Alcohol Abuse, R24AA019661 (ELB), and K23AA024503 (MA).

No reprints will be ordered.

The authors report no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.annalsofsurgery.com).

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.annalsofsurgery.com).

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