Chunhong xiao

The first affiliated hospital of Anhui Medical University

Hefei, Anhui.

China

Submitted to:-

Professor Xulin Chen

 Red blood cell distribution width as an independent risk factor in the prognosis of

Commented [G1]: Inserted: the

acute respiratory distress syndrome after severe burn
Commented [G2]: Inserted: an

Abstract

Background: the occurrence of ARDS significantly increased the mortality and

morbidity of severe burn injury, fewer maker realistically testable predictions as of yet.

This study intended to investigate the relationship between CBC parameters and the

incidence of ARDS in severe burn patients.

Methods: This retrospective study recruited 610 severe burn cases. The patients
were divided into two groups according to the incidence of ARDS. A blood sample was

Commented [G3]: Inserted: for

taken for admission.

Results:

Conclusions:

Keywords: CBC; RDW; ARDS; severe burns

Introduction

Acute respiratory distress syndrome (ARDS) describes the severe respiratory

dysfunction by refractory hypoxemia and progressive respiratory distress. It

was reported approximately 40% severe burn injury patients with mechanical

ventilation developed ARDS within the first week after injury[1]. During the early phase

of severe burn injury, the cause of ARDS included pneumonia, inhalation lesions, fluid

overdose and polytrauma[2, 3]. However, ARDS remained the leading cause of

respiratory distress and mortality after severe burn injury, especially complicated with
inhalation lesions [3]. Nowadays, several studies indicated the mortality rate of

mechanical ventilated burn patients is claimed to be in the range of 14% - 48%[4-6].

Early diagnosis and effective treatment of ARDS knock down the mortality and

improved recovery. Therefore, it is important for severe burn patients at risk to develop

ARDS be discriminated earlier.

It is well established that the incidence of ARDS is associated with the massive

Commented [G4]: Inserted: the

systemic inflammatory response. The damaged of endothelial and epithelial layers

leading to hyaline membranes develop in the alveoli, the abundance of acute

inflammatory cells and red blood cells into the alveoli, and protein-rich pulmonary

edema, which then causes deteriorated gas exchange and the lung parenchyma injury[7] .

Complete blood count (CBC) is the most common available blood test worldwide,

Commented [G5]: Deleted:can

even the most humble of laboratories can yield more than ten measurements. Red blood

cell distribution width (RDW) is part of the routine blood parameters, and reflects the

degree of heterogeneity in erythrocyte volume. A number of studies have been

demonstrated that the RDW as an independent prognostic biomarker for mortality in

patients with coronary Disease, severe sepsis and septic shock, as well as critically ill

patients [8-10]. Previous studies have verified the relationship between risk factors and

ARDS, However, no study has examined the prognostic performance of RDW in severe

burn patients complicated ARDS.

The objective of this study is to investigate the relationship between RDW and the

incidence of ARDS after severe burn.

2 Methods
 2.1 Patients

This is a retrospective study of 652 severe burn patients admitted to the First

Affiliated Hospital of Anhui Medical University and Rui Jin Hospital of Shanghai Jiao

Tong University between January 2008 and December 2015. The personal information,

Commented [G6]: Inserted: the

baseline demographic data and injury characteristics of the patient were recorded on the

case history upon admission to the burn center routinely. All information was provided

Commented [G7]: Inserted: the

by the patient, family member or friend who knows the accurate condition of the patient.

The clinical and laboratory data were reviewed from the paper-based and electric

Commented [G8]: Inserted: ere

medical records. All data of the two hospitals were collected by the same team under
Commented [G9]: Deleted:as

the unified standard. This study was approved by the Human Subjects Review Board of

Anhui Medical University Hospital, Hefei, Anhui.

This study included adult (age of 18 years or older) patients who were diagnosed

severe burn (the total body surface area ≥ 30%), hospitalized in 24 hour after injury,

accepted standardized fluid resuscitation according to the China formula (1.5 ml/kg

body weight (BW) × TBSA% + 2000 ml dextrose solution) , and length of hospital stay

more than 3 days. Patients with cardiac disease, kidney disease, or other conditions

such as hemolytic anemia, bone marrow arrest, or other inflammatory diseases were

excluded from the study.

2.2 ARDS definition

Commented [G12]: Deleted:s

Since most ARDS occurred within 1 week after burn injury1. We classified all the

included patients by subjects that did not develop ARDS (NO-ARDS group) and

subjects that did develop ARDS (ARDS group) according to the Berlin definition2.
 Commented [G10]: Inserted: ly
Mechanical ventilation was conventionally performed on the patients that did develop

Commented [G13]: Deleted:ed

ARDS for provided effective gas exchange. All patients were a follow-up for up to 90

Commented [G11]: Inserted: a

days after injury. The main endpoint was the development of ARDS.

2.3 Clinical and laboratory parameter

The complete blood count (CBC) test include white blood cell (WBC), Neutrophils

(N), Lymphocytes (L), Red Blood Cell (RBC), Hemoglobin, erythrocyte mean

corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular

hemoglobin concentration (MCHC), red blood cell distribution width (RDW), platelet

Commented [G14]: Inserted: A b

(PLT). A blood sample was collected in the acute care hospital to avoid fluid overload.
Commented [G15]: Inserted: t

2.4 Statistical analysis Commented [G16]: Deleted:B

Commented [G17]: Deleted:f

Continuous numerical variables were presented as the mean ± standard deviation
Commented [G18]: Deleted:r
(SD) and compared using student’s t-test. Categorical Commented [G19]: Inserted: ere

Commented [G20]: Deleted:as

data were presented with frequency (%) and compared by chi-square test.
Commented [G21]: Inserted: ere
Univariate logistic regression analysis was conducted to evaluate the risk factors for the
Commented [G22]: Deleted:as

developed of ARDS of severe burn patients. Multivariate logistic regression was used

to estimate the clinical and laboratory parameters with the ARDS after major burn after

adjustment for potential factors

3 Results

3.1 Patients

A total of 652 patients were included retrospectively in our analysis. Among these

patients, Thus, in the final analysis, 610 patients were included in The study.
 A total of 184 patients were hospitalized with inhalation injury. 143 patients who

met the eligibility criteria and accepted the mechanical ventilation were diagnosed

ARDS during hospitalization. 88 patients died within 90 day due to burns.

3.2 Baseline characteristic

Commented [G23]: Inserted: i

Table 1 shows their baseline characteristics. Patients were divided into two groups
Commented [G24]: Inserted: s

according to ARDS status: The ARDS group and the NO –ARDS group. In the ARDS Commented [G28]: Deleted:e

group, there was found to be a higher proportion with a larger %TBSA and a longer

length of hospital stay, what’s more, the ARDS group had a higher mortality rate. 72.4%

no-ARDS patients had an operation during the first week after injury while just 27.6%

Commented [G25]: Inserted: of

of patients for ARDS group. There was no significant difference in age or gender
Commented [G26]: Inserted: an

between two groups. While WBC, Neutrophils, Lymphocytes, and RDW were Commented [G27]: Inserted: ,

considerably higher in ARDS patients than no-ARDS patients (WBC 22.55±11.10 vs.

18.48±6.93 p<0.01; Neutrophils 19.43±9.89 vs. 16.00±6.48 p<0.01; Lymphocytes

1.74±1.30 vs. 1.36±0.96 p<0.01; RDW 13.63±1.45 vs. 13.25±0.99 p<0.01). No

difference was found in RBC, Hemoglobin, MCV, MCH, MCHC, PLT.

3.3 regression analysis for the developed of ARDS

Univariate logistic regression analysis revealed that patients with higher %TBSA, %

deep II degree, % full thickness burn, WBC, Neutrophils, Lymphocytes, RDW and

Commented [G29]: Deleted:ly

inhalation injury had significant risk to developed ARDS. Every 1% increase in RDW

was associated with a 29% increase in the risk to developed ARDS,

Multivariate logistic regression analysis demonstrated that % deep II degree, % full

thickness burn, Inhalation injury and RDW were independent predictors of the
development of ARDS (table 3). The association of RDW and the development of

ARDS after severe burn injury remained significant after adjusting for TBSA %, %

Commented [G30]: Inserted: t

deep II degree, % full thickness burn, Inhalation injury, Surgery during the first week,
Commented [G32]: Deleted:ce

WBC, Neutrophils, and Lymphocytes. Commented [G31]: Inserted: ,

DISCUSSION

This study revealed that RDW is independently associated with the presence of

Commented [G33]: Inserted: ed

ARDS after severe burn injury
Commented [G34]: Deleted:ion

1. Cartotto R, Li Z, Hanna S, Spano S, Wood D, Chung K, Camacho F: 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 2016, 42(7):1423-1432.
2. Bersten AD EC, Hunt T, Moran J: Australian and New Zealand
Intensive Care Society Clinical Trials Group: Incidence and Mortality of
Acute Lung Injury and the Acute Respiratory Distress Syndrome in Three
Australian States. Am J Respir Crit Care Med 2002., 165( (4)):443-448. Commented [G35]: Deleted:.
3. Silva L., Garcia L., Oliveira B., Tanita M., Festti J., Cardoso L., Lavado E.,
C. G: Acute respiratory distress syndrome in burn patients: incidence and
risk factor analysis. Ann Burns Fire Disasters 2016, 29(3):178-182.
4. Liffner G BZ, Reske A, Sjoberg F.: Inhalation injury assessed by score
does not contribute to the development of acute respiratory distress
syndrome in burn victims. Burns 2005, 31:263–268.
5. Belenkiy SM BA, Cannon JW, Sine CR, Aden JK, Henderson JL, et al. :
Acute respiratory distress syndrome in wartime military burns:
application of the Berlin criteria. J Trauma Acute Care Surg 2014,
76:821–827.
6. Waters JA LJ, Aden JK, Sine CR, Buel AR, Henderson JL, et al. : A
comparison of acute respiratory distress outcomes between military and
civilian burn patients. . MilMed 2015, 180:56–59.
7. Jozwiak M TJ, Monnet X.: Extravascular lung water in critical care:
recent advances and clinical applications. Ann Intensive Care 2015, 5(1):38.
8. Jo YH, Kim K, Lee JH, Kang C, Kim T, Park H-M, Kang KW, Kim J,
Rhee JE: Red cell distribution width is a prognostic factor in severe sepsis
and septic shock. American Journal of Emergency Medicine 2013,
31:545–548.
 9. Bazick HS, Chang D, Mahadevappa K, Gibbons FK, Christopher KB:
Red cell distribution width and all-cause mortality in critically ill patients*.
Critical Care Medicine 2011, 39(8):1913-1921.
10. Tonelli M, Sacks F, Arnold M, Moye L, Davis B, Pfeffer M: Relation
Between Red Blood Cell Distribution Width and Cardiovascular Event
Rate in People With Coronary Disease. Circulation 2008, 117(2):163-168.

1 Ingrid Steinvall, Zoltan Bak, Folke Sjoberg. Acute respiratory distress syndrome is

as important as inhalation injury for the development of respiratory dysfunction in

major burns.
2 Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, Fan E,

et al. Acute respiratory distress syndrome: the Berlin Definition. JAMA.

2012;307:2526–33.