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Differences in Resuscitation in Morbidly Obese Burn Patients May Contribute to High Mortality

Rae, Lisa MD*; Pham, Tam N. MD*; Carrougher, Gretchen MN*; Honari, Shari BSN*; Gibran, Nicole S. MD*; Arnoldo, Brett D. MD; Gamelli, Richard L. MD; Tompkins, Ronald G. MD, ScD§; Herndon, David N. MD

doi: 10.1097/BCR.0b013e3182a2a771
Original Articles

The rising number of obese patients poses new challenges for burn care. These may include adjustments in calculations of burn size, resuscitation, ventilator wean, nutritional goals as well as challenges in mobilization. The authors have focused this observational study on resuscitation in the obese patient population in the first 48 hours after burn injury. Previous trauma studies suggest a prolonged time to reach end points of resuscitation in the obese compared to nonobese injured patients. The authors hypothesize that obese patients have worse outcomes after thermal injury and that differences in the response to resuscitation contribute to this disparity. The authors retrospectively analyzed data prospectively collected in a multicenter trial to compare resuscitation and outcomes in patients stratified by National Institutes of Health/World Health Organization body mass index (BMI) classification (BMI: normal weight, 18.5–24.9; overweight, 25–29.9, obese, 30–39.9; morbidly obese, ≥40). Because of the distribution of body habitus in the obese, total burn size was recalculated for all patients by using the method proposed by Neaman and compared with Lund–Browder estimates. The authors analyzed patients by BMI class for fluids administered and end points of resuscitation at 24 and 48 hours. Multivariate analysis was used to compare morbidity and mortality across BMI groups. The authors identified 296 adult patients with a mean TBSA of 41%. Patient and injury characteristics were similar across BMI categories. No significant differences were observed in burn size calculations by using Neaman vs Lund–Browder formulas. Although resuscitation volumes exceeded the predicted formula in all BMI categories, higher BMI was associated with less fluid administered per actual body weight (P = .001). Base deficit on admission was highest in the morbidly obese group at 24 and 48 hours. Furthermore, the morbidly obese patients did not correct their metabolic acidosis to the extent of their lower BMI counterparts (P values .04 and .03). Complications and morbidities across BMI groups were similar, although examination of organ failure scores indicated more severe organ dysfunction in the morbidly obese group. Compared with being normal weight, being morbidly obese was an independent risk factor for death (odds ratio = 10.1; confidence interval, 1.94–52.5; P = .006). Morbidly obese patients with severe burns tend to receive closer to predicted fluid resuscitation volumes for their actual weight. However, this patient group has persistent metabolic acidosis during the resuscitation phase and is at risk of developing more severe multiple organ failure. These factors may contribute to higher mortality risk in the morbidly obese burn patient.

From the *University of Washington Medicine Regional Burn Center at Harborview Medical Center, Seattle; University of Texas Southwestern Parkland Memorial Hospital, Dallas; Loyola University Medical Center, Maywood, Illinois; §Massachusetts General Hospital, Boston; and University of Texas Medical Branch, Galveston.

Supported by the Inflammation and the Host Response to Injury (“the Glue Grant”) Large-Scale Collaborative Project Award 2-U54-GM062119 from the National Institute of General Medical Sciences. The data set obtained from the Glue Grant program does not reflect the opinions or views of the Inflammation and Host Response to Injury investigators or the National Institutes of General Medical Sciences.

Address correspondence to Lisa Rae, MD, Harborview Medical Center, 325 Ninth Avenue, Box 359796, Seattle, Washington 98103-2499.

© 2013 The American Burn Association