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Original Research |

Risk factors for in-hospital mortality in smoke inhalation-associated acute lung injury: Data from 68 United States hospitals

Sameer S. Kadri, MD, MS; Andrew C. Miller, MD; Samuel Hohmann, PhD; Stephanie Bonne, MD; Carrie Nielsen, MA; Carmen Wells, RN; Courtney Gruver, RN; Sadeq A. Quraishi, MD, MHA, MMSc; Junfeng Sun, PhD; Rongman Cai, PhD; Peter E. Morris, MD; Bradley D. Freeman, MD; James H. Holmes, MD; Bruce A. Cairns, MD; Anthony F. Suffredini, MD
Author and Funding Information

Summary of conflict of interest statements: Dr. Quraishi received consulting fees from Lungpacer, Inc. and Travena, Inc. Dr. Holmes IV has equity positions in ABT, ABBV, LLY, Permeaderm, Inc. and RegenMed Therapeutics. All other authors declare no conflicts of interest.

Funding source: Intramural Research Program, National Institutes of Health

1Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD

2Department of Medicine, Massachusetts General Hospital, Boston, MA

3Department of Emergency Medicine, West Virginia University, Morgantown, WV

4University HealthSystem Consortium, Chicago, IL

5Department of Health Systems Management, Rush University, Chicago, IL

6Department of Surgery, Washington University School of Medicine, St. Louis, MO

7North Carolina Jaycee Burn Center, University of North Carolina Hospital, Chapel Hill, NC

8Department of General Surgery, Wake Forest Medical Center, Wake Forest School of Medicine, Winston-Salem, NC

9Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA

10Department of Anesthesia, Harvard Medical School, Boston, MA

11Division of Pulmonary and Critical Care Medicine, Wake Forest Medical Center, Wake Forest School of Medicine, Winston-Salem, NC

Corresponding author: Sameer S. Kadri, MD, MS, Critical Care Medicine Department, National Institutes of Health Clinical Center, 10 Center Dr, Rm 2C145, Bethesda, MD 20892-1662


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016. doi:10.1016/j.chest.2016.06.008
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Abstract

Background  Mortality after smoke inhalation-associated acute lung injury (SI-ALI) remains substantial. Age and burn surface area are risk factors of mortality, while the impact of patient and center-level variables and treatments on survival are unknown.

Methods  We performed a retrospective cohort study of burn and non-burn centers at 68 United States academic medical centers from 2011-2014. Adult SI-ALI inpatients were identified using an algorithm based on a billing code for respiratory conditions from smoke inhalation who were mechanically ventilated by hospital day 4, with either a length-of-stay ≥ 5-days or death within 4 days of hospitalization. Predictors of in-hospital mortality were identified using logistic regression. The primary outcome was the odds ratio for in-hospital mortality.

Results  769 patients (52.9 ± 18.1 years) with SI-ALI were analyzed. In-hospital mortality was 26% in the SI-ALI cohort and 50% in patients with ≥20% surface burns. In addition to age > 60 years (OR 5.1, 95%CI 2.53-10.26) and ≥20% burns (OR 8.7, 95%CI 4.55-16.75), additional risk factors of in-hospital mortality included initial vasopressor use (OR 5.0, 95%CI 3.16-7.91), higher DRG-based risk-of-mortality assignment and lower hospital bed capacity (OR 2.3, 95%CI 1.23-4.15). Initial empiric antibiotics (OR 0.93, 95%CI 0.58-1.49) did not impact survival. These new risk factors improved mortality prediction (ΔAUC) by 9.9%(p<0.001).

Conclusions  In addition to older age and major surface burns, mortality in SI-ALI is predicted by initial vasopressor use, higher DRG-based risk-of-mortality assignment and care at centers with <500 beds, but not by initial antibiotic therapy.


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