The meta-analysis study explored the differences between burn ICU and general ICU patients. Also, the paper provided intervention measures to control burn-related complications experienced during the first 48 hours of treatment. The study evaluated more than 80 research articles and texts obtained from different data sources, such as PubMed, Cochrane Library, and CINAHL. However, only twenty were used in the meta-analysis.
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The findings of the study revealed that burn ICU patients have higher mortality rates compared to those in general ICU. Besides, death prevalence rates are higher among burn patients who experience complications, such as cardiopulmonary conditions, during the treatment period. Another finding is that burn ICU patients stay for longer periods in ICU. To counter the high mortality rates, several interventions were identified. The approaches include the effective use of ventilators, vasodilators, and early wound closure.
The intensive care unit is a special hospital department that caters to patients with severe and life-threatening illnesses. Such conditions require doctors and nurses to carry out close monitoring and support for patients using special medication and medical equipment. Some of the special apparatus used in ICU include mechanical ventilators, feeding, and nasogastric tubes (Kayambu, Boots, & Paratz, 2015).
The primary reason for using specialized equipment is to stabilize a patient’s normal bodily functions. Some of the conditions treated within ICU include severe burns, multiple organ failure, and ARDS. The level of care in ICU differs based on the condition presented. Burn patients, for example, differ significantly compared to general ICU patients.
The differences are brought about by the fact that the injuries of burn patients are both external and internal. As a result, they should be handled with extreme care and caution to avoid worsening the patient’s condition. Some of the complications associated with severe burns include hypothermia, compartment syndromes, and kidney failure (Fortner, 2012). Other problems are cardiogenic, distributive, and hypovolaemic shock. As a result, doctors and nurses need to carry out early interventions to manage some of the complications. Some of the measures taken include glucose control, wound closure, operative, and metabolic interventions.
In this paper, the author will focus on the differences between burn and general ICU patients. To bring out the variations, the writer will carry out a meta-analysis by reviewing more than 14 research sources. The paper consists of six sections. The first is an introduction. Section 2 constitutes a discussion of complications and types of intervention for burn ICU patients. Section 3 highlights the method of meta-analysis. Section 4 details the results of the studies. Section 5 and 6 provide a discussion and conclusion summarizing the findings.
Complications Associated with ICU Burn Patients
Severe burns lead to some complications, which can lead to death. The classification and severity of burns are based on the depth, extent, injury location, and etiological agents. Other factors considered include co-existing illnesses and age. According to the American Burn Association report, about 450,000 people suffer from burn annually.1 However, the statistics do not include burn cases treated in hospital clinics, community health centers, and private medical offices.
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Out of the 450,000 reported cases, approximately 3400 die from the burn injuries annually. Based on the statistics, it is apparent that burns are the third leading cause of death in homes. The findings are supported by research conducted by Osler, Glance, and Hosmer (2010). According to the scholars, a burn-related death occurs after every 170 minutes. On its part, a non-fatal burn injury occurs every 30 minutes. Complications resulting from severe burns are classified into two categories. The classifications include septic and burn shock phases.
Burn Shock Phase Complications
Patients with severe burns have a decreased pulmonary function. The problem is brought about by humoral facets. The facets include serotonin and histamine. Thromboxane is also associated with the problem. According to Choi, Lee, and Lee (2015), complication is associated with a reduction in pulmonary and tissue compliance. Among persons with burn injuries, patients with inhalation burns suffer more from pulmonary function problems.2
Damage to the lungs can affect patients in three ways. They include carbon monoxide intoxication, as well as inhalation injury above and below the glottis. According to Hoeksema et al. (2014) and Candice et al (2016), carbon monoxide intoxication is followed by deep hypoxia. The poisoning is associated with immediate death even before the patient gets to the hospital.
Inhalation injury above the glottis is caused by the thermal effect of smoke particles. The injury progresses to affect the respiratory tract due to the formation of laryngeal oedema. Fuchs et al. (2012) note that oedema and an increase in oral secretions caused by smoke irritation lead to breathing difficulties and cyanosis. The complications are experienced in the immediate post-burn period. Inhalation injury below the glottis leads to acute respiratory failure.3 The reason for this is due to the damage of bronchioles and alveoli. Some of the problems exhibited by patients include breathing difficulties, wheezing, and impaired gas exchange.
Thermal injuries result in decreased cardiac output and an increase in peripheral vascular resistance. As a result, burn patients can experience cardiac failure through direct and indirect action. Robert et al. (2016) and Ranieri et al. (2012) concur that direct action leads to cardiac failure due to the release of inflammatory cytokine tumor necrosis factor. On its part, indirect action of tissue arises due to a reduction in oxygen perfusion in peripheral tissues.
Kidney function complications are caused by early renal failure resulting from prolonged delay or inadequate fluid resuscitation. The problem can also be caused by substantial muscle breakdown. One of the primary signs of kidney failure among severe burn patients is reduced urine output. Villar, Sulemanjii, and Kacmarek (2014) support this argument by stating that burn patients pass out less urine despite getting adequate fluids. Other symptoms of the complication are an increase in serum creatinine and urea concentrations.
According to Laquanda, Lindsay, Danier, Bruce, and Antony (2016), the risk of hyponatremia is experienced during rehydration. The complication may result in post-burn encephalopathy disorder. Osler et al. (2010) report that brain injuries are present among patients with severe head and neck burns.
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Severe burn patients experience digestive tract complications in two forms. The modes include haemorrhagic syndrome and paralytic ileus. Robert et al. (2016) observe that haemorrhagic condition is caused by the reaction of gastric acids on the mucosa. The final stage of the hemorrhagic syndrome is associated with curling’s ulcers. On its part, paralytic ileus results from an alteration in the intestinal environment. The condition is experienced during the first 48hours of hypovolaemic shock. Patients with more than 25% TBSA exhibit gastroparesis as the first sign of digestive tract failure. Sheridan (2012) claims that in critical burn cases, the syndrome takes the clinical condition of ileus.
The complication experienced by burn patients is caused by acute erythrocyte hemolysis. According to Fortner (2012), the condition is caused by damage to red blood cells and direct heat effects. In severe burn cases, the mass of this blood component drops. A drop of between 3 and 15 percent may be experienced. The reduction leads to the destruction of the hemopoietic system.
Hyperdynamic and Hypercatabolic Phase (Septic) Complications
The lung is one of the major organs affected by burns. During the septic stage, pulmonary complications continue to be the main elements responsible for increased morbidity and death. During the first 48 hours to six days, patients experience five abnormalities that affect pulmonary function. The five conditions, according to Jeschke, Kamolz, and Shahrokhi (2013) and Herndon (2012), include decreased chest wall compliance and pulmonary oedema. Others are continued upper airways obstruction, tracheobronchitis, and surgery or anesthesia-induced lung dysfunction.
Other lung complications experienced during the septic phase include nososocomial pneumonia, hypermetabolic-induced respiratory fatigue, and adult respiratory distress syndrome. However, the abnormalities are experienced after the first-week post-burn. Nososocomial pneumonia is caused by the colonization of naso-oropharynx by pathogens. According to Kayambu, Boots, and Paratz (2013), the abnormality is also caused by the aspiration of infected tracheobronchial fluids and weakened immune systems.
The hypermetabolic complication is associated with such factors as shortness of breath, reduced tidal volume, hypercapnia, and increased respiratory rate. Hypermetabolic respiratory fatigue is marked by an increase in oxygen consumption and carbon dioxide production. Herndon (2012) notes that patients with more than 50% of TBSA burns have about a 50-100% increase in carbon dioxide.
Patients with severe burn are at risk of cardiac failure. The complication is caused by increased metabolism and action of toxins (Peck, 2011). Another condition prevalent among severe burn patients is hypertension. The complication is reported among adults and elderly persons. Huan et al. (2016) note that the problem can be managed if detected early.
Renal failure is the final symptom before the septic shock. The complication results in permanent impairments to the parenchyma. Choi et al. (2015) and Hoeksema et al. (2014) reveal that the treatment of the condition is often complex. The reason is the delicate nature of the complication.
The organ is also affected during severe burns. According to Candice et al. (2016), damage to the meningeal membrane is witnessed during the early periods of sepsis. On its part, damage to cerebral matter is evident in later stages. The complications generalize rapidly, leading to the death of most patients in ICU.
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Critical burn patients suffer from severe sepsis and gastrointestinal complications. The conditions are linked to septic diarrhea. Ompkins, Liang, Lee & Kazis (2012) and Fuchs et al. (2012) observe that the condition is a disorder of the normal intestinal bacterial flora. Deterioration of the client’s outcomes may lead to further complications. Such complications include paralytic ileus. The emergence of the complication is often a sign of septic shock (Osler et al., 2010).
Interventions to Manage Burn Injury Complications
The mortality and morbidity rates associated with burn injuries can be managed in some ways. According to Herndon (2012) and Robert et al. (2016), the best way of reducing burn-related deaths is by effectively treating every complication that affects a patient. Some of the intervention measures include wound and pain management, physiotherapy, and resuscitation formulae. Other measures entail endocrine and glucose monitoring, β-Blockade, enteral nutrition, and anabolic steroids.
Several interventions to improve the outcomes of mortality and morbidity rate are identified in line with respiratory care of hypoxemia. Hypoxemia is a complication characterized by low levels of oxygen in the blood. Villar et al. (2014) observe that the condition is an abnormal deficiency of oxygen in arterial blood. Huan et al. (2016) agree that measurements of arterial blood gas, which reveal the pressure of oxygen, show signs of hypoxemia when they are lower than normal. The normal pressure is between 80 and 100 mmHg. However, Villar et al. (2014) and Huan et al. (2016) fail to agree whether or not oxygen content in the blood, as opposed to the arteries, is what is needed to identify hypoxemia.
Burn patients with severe or acute hypoxemia exhibit symptoms similar to respiratory distress. Huan et al. (2016) note that burn patients with this complication record oxygen pressure levels of as low as 60 mmHg. Also, the oxygen saturation level in the body is less than 90%. Hypoxemia is considered to be severe if the percentage falls below 80. The main symptoms of the condition are an increased rate of breathing, lip pursing, and shortness of breath.
Among burn patients, hypoxemia is caused by some factors. They include hypoventilation, impairment of diffusion, venous-to-arterial shunting, and uneven distribution of alveolar gas and blood. Osler et al. (2010) and Jeschke et al. (2013) suggest that diffusion impairment and uneven distribution of alveolar gas and blood are the most common causes of hypoxemia among burn patients. Severe hypoxemia can be managed in several ways. The respiratory care measures include the use of inhaled vasodilators and extracorporeal membrane oxygenation.
Inhaled vasodilators are used to improve ventilation-perfusion matching and enhance pulmonary hypertension. According to Fortner (2012) and Herndon (2012), the mechanism works by initiating local vasodilatation in properly ventilated areas of lungs. There are several inhaled vasodilators used for managing hypoxemia in ICU. The equipment includes inhaled nitric oxide (iNO), inhaled prostaglandin, and inhaled prostacyclin.
Extracorporeal membrane oxygenation
The use of extracorporeal membrane oxygenation (EMCO) in treating severe hypoxemia is a new approach in the ICU department. The technique has various positive impacts and more information is emerging. Kayambu et al. (2015) and Sheridan (2012) show that EMCO entails removing blood from a patient’s body. The blood is then circulated to the rest of the body by the use of a mechanical pump connected to a membrane oxygenator. Observational studies by Peck (2011) and Laquanda et al. (2016) show that EMCO significantly improves the survival rate of burn patients with hypoxemia.
It involves the use of different ventilator modes. The primary reason for using the maneuvers is to enhance the gas exchange surface. Some of the ventilatory options available, according to Choi et al. (2015) and Candice et al. (2016), include high-frequency oscillation ventilation (HFOV), PEEP level, inverse inspiration expiration ratio, and pressure regulated ventilation modalities. Others are airway pressure release ventilation (APRV) and recruitment maneuvers.
PEEP level and recruitment maneuvers are the most common techniques in ICU settings. The two are used to create a bigger surface for gaseous exchange (Fortner, 2012). PEEP, for example, helps to apply continued pressure during ventilation through slow and progressive conscription. On its part, recruitment maneuver entails maintaining high pressures for short periods with the mobilization of as many collapsed alveoli as possible.
Despite the numerous advantages associated with mechanical ventilation, arguments exist on the time patients are required to be on the equipment. Jeschke et al. (2013) observe that the primary conflicting question affecting the technique is determining the best way to evaluate if a burn patient is ready to be transitioned back to unaided breathing.
Data Sources and Study Selection
To carry out a meta-analysis, it is important to design one’s metadata. The search strategy used to acquire information consisted of three stages. The phases included the use of universal research databases, seeking expert recommendations, and checking references in existing articles, texts, and personal files. Some of the universal databases searched include Cochrane Library, Embase, and PyschINFO. Others were PubMed and CINAHL.
The most recent search studies were carried out in 2016. To acquire extensive information from different experts and databases, there was no language restriction. Some terms used included severe burns, ICU burn patients, mechanical ventilation, respiratory failure, cardiopulmonary complications, and hypoxemia. To be included in the research, studies had to meet a set of criteria. The criteria include prospective observational cohorts and medical trials of adult burn patients admitted in ICUs, patients evaluated for hypoxemia using burn care assessment methods, and full length reports in peer-reviewed articles. Another consideration was the relationship between burn complications, such as hypoxemia, and such outcomes as long stay in ICU, death in ICU, and duration in ventilators.
During the search, all articles without a control group of patients suffering from severe burn injuries were excluded. Other studies not included were those without intervention measures treating critical burn patients and improving outcomes on mortality and morbidity rates. However, the authors of some of the articles were contacted to provide more information on their methodologies and findings.
Data Abstraction and Validity Assessment
Data were independently abstracted from the selected articles. The information recorded included study characteristics, patients’ traits, and outcomes. Study attributes assessed were period of enrolment, the number of patients admitted, types of ICUs, and methods used to determine burn complications. The patient’s characteristics recorded included sex, age, burn severity, and therapies used. Outcome information entailed data on deaths in ICU, duration in ventilators, and hospital in general.
The accuracy and validity of the abstracted data were verified by sampling 15% of the references chosen at each stage of the search. Besides, the abstracted information was assessed against the original reference. The primary reason for this was to note any discrepancies. Newcastle-Ottawa Scale was used to evaluate the quality of the texts and peer-reviewed articles used. According to Jeschke et al. (2013), the scale is validated for the evaluation of observational studies and meta-analyses.
The scale analyzes three features of study methods. The aspects include quality outcome ascertainment (0-3), compatibility of groups (0-1), and selection of study groups. The correct and appropriate methodology is marked by a range of 5 and above. The certified Cochrane Risk of Bias Tool was used to evaluate and rate the quality of randomized controlled trials applied for the study.
The primary purpose of conducting the meta-analysis was to determine the differences between burn ICU and general ICU patients. Also, the analysis aimed at providing interventions to improve mortality and morbidity rates. The author estimated the different traits and outcomes presented by both burn and general ICU patients. The characteristics included duration of stay in ICU, deaths in ICU, and time spent on life support machines. The strength of the relationship between burn complications and the mortality rate was presented as risk ratios with confidence intervals of 95%. The risk ratio was selected as a measure of the impact of patients’ deaths on ICUs.
Studies with zero events were also incorporated in the evaluation. The reason was to include useful information and avoid bias. Studies that reported no single death were evaluated by comparing inverse variance statistical techniques, random effects, 0.5 continuity correlation, and Mantel-Haenszel. Continuous outcomes were evaluated by computing weighted standard mean variation based on reported medians. On their part, standard deviations were calculated as summarized by Kayambu et al. (2013). Long term results of burn complications were collected from the studies used for the meta-analysis.
Heterogeneity was evaluated by the use of I2 statistics. The gauge was applied to show the level of heterogeneity between studies above the sampling disparity. Huan et al. (2016) note that in cases where I2 statistic presents significant heterogeneity, researchers are required to merge summary measures from all the studies accessed using the random-effects model.
Heterogeneity between studies used for the research was evaluated by approximating the impact of study-specific traits on effect variables. The approach employed was meta-regression with predictors such as the patient’s age and severity of burn injuries. The value predictors were averaged across groups of patients in burn ICU and general ICU. The outcome variable was the risk ratio of death with burn severity complications. The publication bias associated with peer-reviewed journal articles and texts was verified by assessing funnel plots. Another approach used entailed the use of a modified Egger test for binary information.
The search strategy yielded 100 citation titles. Eighty of the total citations were screened to determine their relevance to the research. After screening and thorough evaluation, 62 peer-reviewed articles and texts were excluded. In the end, only 18 resources met the inclusion criteria. Reasons for excluding some texts included duplication of information and wrong intervention and outcomes.
Effect Size Calculations
Effect size calculations were carried out for between and within-group evaluations. Studies with a between-group design were analyzed by calculating the difference between the intervention and control groups. On its part, the effect size for studies that only had a within-group was computed by comparing pre and post-burn treatment data. The mean of the control group was then subtracted from the mean of follow-up evaluations. The subtraction figure was then divided by the pooled group of standard deviation. The computations produced a Cohen’s d for all the studies included in the research.
The primary evaluation was carried out by using the weighted least squares (WSL) methodology. Osler et al. (2010) note that the technique measures each effect size by the inverse of its variance. As a result, the approach helps researchers to focus on studies with bigger sample sizes. A positive effect size shows the intervention used on patients is appropriate and will produce the desired outcomes. On its part, a negative effect size indicates that a given treatment will generate good results.
The mean effect sizes were computed by using a random effect methodology. The reason is that the approach offers a more conservative approximate of the mean effect size. The technique uses study-level and subject-level sampling errors. According to Laquanda et al. (2016), the random-effects model is the best approach when evaluating studies with small sample sizes.
Description of Included Studies
The study used 20 prospective observational cohorts and three randomized controlled trials. The size of study populations ranged from 40 to 70 patients. Nineteen studies were carried out in mixed burn and general ICUs. Seven studies evaluated burn ICUs and 3 investigated general ICU wards. Nine studies evaluated patients under mechanical ventilators. Most of the peer-reviewed journals and texts (20) examined the outcomes and complications experienced within 48 hours.
Ten of the studies assessed outcomes extending more than two days. Fifteen studies used multivariable techniques to determine the association between burn injury complications and mortality. Six studies examined active intervention patient support machines used within the first 48 hours and alerted doctors when patients exhibited abnormal vital signs.
Despite being included in the study, some articles provided varying levels of details. Three studies, for example, did not provide sufficient detail to classify the level and severity of burn injury complications. Also, others differed on the monitoring time per day by nurses and doctors. However, most articles and texts concluded that patients received continuous close monitoring for 12 to 24 hours per day. Physicians made rounds to assess patients based on the severity of burns every 1 to 3 hours.
Information on the methodological quality of the peer-reviewed journal articles and texts was presented based on the Newcastle Ottawa Scale. Besides, the data from three randomized trials was assessed using the five modules of the Cochrane tool. According to the interpretation of funnel plot findings, there was moderate publication bias on studies reporting deaths of burn ICU patients.
The overall study quality based on the Newcastle Ottawa Scale was found to be average. The reason for this is that the achieved scale was 5.5.
Primary and Secondary Outcomes
Pooled data from 18 studies (82 patients, 45 in life support machines) showed that early and accurate intervention techniques, such as the use of ventilators, reduced ICU mortality for burn patients. Death rates are reduced by up to 25%. According to the funnel plot and Peter’s regression test, the peer-reviewed articles and texts indicated that there was no publication bias. Also, moderate statistical heterogeneity was found in all the studies (I2 =75%).
Pooled data from five studies (35 patients, 12 in life support machines) showed a statistically big difference in the duration of stay in ICU among burn patients. Patients who developed more complications, such as hypoxemia, during the first 48 hours, stayed longer in the ICU (standardization mean difference 1.42, 95% confidence interval 0.97 to 1.75; p>0.001) compared to those without conditions arising during the first 48 hours. The statistics reveal that patients with hypoxemia had a mean length of stay in the ICU that was 2 days longer than patients without hypoxemia.
Five studies reported the length of time taken in ventilators. The study’s approximations revealed that patients with complications, such as hypoxemia, stayed longer in mechanical ventilators compared to those without (1.75, 0.28 to 3.21; p<0.001). Based on the statistics, the mean length of time spent on the machines was found to be 1.75 days longer. Subgroup Analyses Effect of ventilators on ICU mortality was similar in higher-quality studies (RR, 0.76; 94% CI, 0.65 to 1.02; p=0.06; 8 studies, 45 patients, 16 in ventilators) and lower quality studies (RR, 0.64; 94% CI, 0.38 to 1.17; p=0.16, four studies, 21 patients, 9 in ventilators). In statistical terms, the RRs were not different (p=0.48 for test interaction). Active or high-intensity passive therapies and machine-based interventions, which involved continuous monitoring during the first 48 hours, significantly reduced mortality rates among burn patients in ICU (RR, 0.74; 95% CI, 0.60 to 0.95; p=0.01; 9 studies, 50 patients, 15 under therapies, and machines). Passive therapies and machine-based interventions did not prove to be highly effective (RR, 0.60; 95% CI, 0.18 to 2.04; p=0.40; 5 studies, 23 patients 9 in therapies and machine-based interventions). Studies, which analyzed only active interventions, showed the measures had no effect on mortality rates in ICU (RR, 0.82; 95% CI, 0.67 to 1.00; p=0.08, five studies 27 patients, 10 in ventilators). Discussion Principle Findings The meta-analysis synthesized data on the mortality rates between burn ICU and general patients. The research also evaluated the respiratory care for hypoxemia and interventions, which can improve outcomes on mortality and morbidity rates. More than 80 studies with more than 200 patients were identified for the study. It was found that burn patients suffer from more complications during the first 48 hours compared to general ICU patients. Besides, patients with cardiopulmonary conditions, such as hypoxemia are at higher risk of succumbing to their injuries (Herndon, 2012). Another finding is that such patients stay for longer periods in the ICU compared to other patients. Despite the delicate nature of burn injuries and associated complications, several intervention measures were evaluated and found to be effective. The management approaches include the use of ventilators, inhaled vasodilators, and extracorporeal membrane oxygenation. The effective use of the intervention measures during the first 48 hours was found o reduce mortality rates by up to 25% (Peck, 2011). Strengths and Limitations of the Study The study indicates that complications experienced during the first 48 hours are associated with the most adverse outcomes. The findings are consistent with the results of other studies by such scholars as Kayambu et al. (2013) and Choi et al. (2015). However, the data does not clarify whether or not some setbacks and cardiopulmonary complications are linked to adverse effects of burns at the moment or in later stages during patient care. Despite the ambiguities, the meta-analysis results and findings have significant implications. The reason is that they offer evidentiary intervention and recommendations for managing burn-related complications. Complications associated with burn injuries are prevalent and have adverse effects on both the patients and their families (Villar et al., 2014). As a result, the meta-analysis study highlights the need for future cohort studies with standardized approaches to determine ways of reducing mortality rates associated with manageable burn complications. The studies need to be stringent when identifying factors that lead to the impediments during the first 48 hours of treatment for burn patients in ICUs. Another aspect identified by the study is the need to identify endpoint interventions that are relevant from a clinical, biological, and care processes point of view. Besides, large and well-formulated clinical trials are needed in the future. The aim is to examine the efficacy and safety of interventions used to manage burn-related complications. Despite the numerous strengths, the meta-analysis had several limitations. One of the restraints is the presence of considerable heterogeneity in the study. The limitation was illustrated by I2 statistics. The primary reason associated with the heterogeneity was differences among studies (Huan et al., 2016). The disparity was in terms of the patient population used, methodologies applied to detect burn-related complications, and mortality timeframes. Another limitation of the study was the possibility of bias in publications used for the meta-analysis. The presence of bias was noted by the use of a funnel plot asymmetry technique. However, the preconception levels were moderate. As a result, the impact on the bias on conclusions made was minimal. Another limitation was the lack of statistical power in the analysis. The reason is that the intervention measures used in the studies may have been misclassified. One of the main reasons for misclassification is the lack of a universally adopted theoretical structure and terminology. The aspects are needed to describe intervention approaches, the intensity of deployment, and clinical actions associated with chosen measures.4 Another limitation in the study is the possibility of unmeasured cofounders, such as variations in timing and frequency of assessment of burn-related complications during the first 48 hours. Numerous advances have been made to detect burn injury-related impediments. However, the currently used assessment tools for complications associated with severe burns do not sufficiently reveal the range of alterations experienced in ICU (Kayambu et al., 2015). As a result, some of the conclusions made in the meta-analysis could be inaccurate. Conclusion Burn ICU patients register high mortality rates compared to those in general ICU. The high numbers are linked to complications experienced during the first 48 hours of treatment. Some intervention measures have been developed to address the issue. The approaches have proved to be effective in improving survival rates, duration was taken in ICU, and mortality rates. Some of the identified measures for managing burn complications include infection control, resuscitation procedures, early enteral nutrition, and enhanced respiratory support. However, for the impediments to be properly managed, doctors, nurses, and clinicians working in ICUs should classify the complications in two forms. The clusters are septic and shock phase. References Candice, L., Christina, P., James, E., Walter, J., Rune, J., Oscar, E., & Kenneth, J. (2016). The multicenter benchmarking study of burn injury: A content analysis of the outcome measures using the international classification of functioning, disability and health. Burns, 42(7), 1396-1403. Choi, M., Lee, H., & Lee, J. (2015). Early intervention for low-temperature burns: Comparison between early and late hospital visit patients. Archives of Plastic Surgery, 42(2), 173-178. Fortner, P. (2012). Burn care update. Philadelphia, PA: Saunders. Fuchs, M., Briel, M., Daikeler, T., Walker, U., Rasch, H., & Berg, S. (2012). The impact of 18F-FDG PET on the management of patients with suspected large vessel vasculitis. European Journal of Nuclear Medicine and Molecular Imaging, 39(2), 344-353. Herndon, D. (2012). Total burn care (4th ed.). Edinburgh: Saunders Elsevier. Hoeksema, H., Baker, R., Holland, A., Perry, T., Jeffery, S., & Verbelen, J. (2014). A new, fast LDI for assessment of burns: A multi-centre clinical evaluation. Burns, 40(7), 1274-1282. Huan, D., Jian, C., Frank, L., Cecilia, W., Qiushi, L., Xiaohong,…Jun, W. (2016). Effects of mobility training on severe burn patients in the BICU: A retrospective cohort study. Burns, 42(7), 1404-1412. Jeschke, M., Kamolz, L., & Shahrokhi, S. (2013). Burn care and treatment: A practical guide. Wien: Springer. Kayambu, G., Boots, R., & Paratz, J. (2015). Early physical rehabilitation in intensive care patients with sepsis syndromes: A randomized controlled trial. Physiotherapy, 41(5), 865-874. Kayambu, G., Boots, R., & Paratz, J. (2013). Physical therapy for the critically ill in the ICU: A systematic review and meta-analysis. Critical Care Medicine, 41(6), 1543-1554. Laquanda, K., Lindsay, S., Danier, M., Bruce, C., & Anthony, C. (2016). The measured effect magnitude of co-morbidities on burn injury mortality. Burns, 42(7), 1433-1438. Ompkins, R., Liang, M., Lee, A., & Kazis, L. (2012). The American Burn Association/Shriners Hospitals for Children Burn Outcomes Program: A progress report at 15 years. Journal of Trauma and Acute Care Surgery, 73(3), 173-178. Osler, T., Glance, L., & Hosmer, D. (2010). Simplified estimates of the probability of death after burn injuries: Extending and updating the Baux score. The Journal Trauma, 68(3), 690-697. Peck, M. (2011). Epidemiology of burns throughout the world, Part I: Distribution and risk factors. Burns, 37(7), 1087-1100. Ranieri, V., Rubenfeld, G., Thompson, B., Ferguson, N., Caldwell, E., & Fan, E. (2012). Acute respiratory distress syndrome: The Berlin definition. The Journal of the American Medical Association, 307(23), 2526-2533. Robert, C., Zeyu. L., Steven, H., Stefania, S., Donna, W., Karen, C., & Fernando, C. (2016). The Acute Respiratory Distress Syndrome (ARDS) in mechanically ventilated burn patients: An analysis of risk factors, clinical features, and outcomes using the Berlin ARDS definition. Burns, 42(7), 1423-1432. Sheridan, R. (2012). Burns: A practical approach to immediate treatment and long-term care. London: Manson Publishing. Villar, J., Sulemanjii, D., & Kacmarek, R. (2014). The acute respiratory distress syndrome: Incidence and mortality: Has it changed?. Current Opinion in Critical Care, 20(1), 3-9. Endnotes Most studies conducted on burns focus on the care provided to patients within the first 48hrs. See Hoeksema et al. (2014) for more information on how burns impair the pulmonary system. Kayambu et al. (2015) focus on inhalation injuries caused by burns… See Laquanda et al. (2016) for research methodologies used on burn patients admitted to ICU.