Fluid resuscitation in thermally injured children

Characteristics and predictors of mortality in-hospital mortality following burn injury in infants in a resource-limited setting

PURPOSE

Burn outcome data in infants is lacking from sub-Saharan Africa. We, therefore, sought to assess the characteristics and predictors of in-hospital burn mortality in a resource-limited setting.

METHODS

We performed a retrospective study of the prospectively collected Burn Injury Surveillance database from June 2011 to December 2019. We performed bivariate analysis and Poisson regression to assess risk factors for mortality in our infant burn population.

RESULTS

115 (7.3%) infants met inclusion criteria. The median age of 8 months (IQR: 6-10) and primarily male (n = 67, 58.8%). Most burns were from scald (n = 62, 53.9%). Infant burn mortality was 12.2%. Poisson multivariable regression to determine burn mortality risk in infants showed that increased %TBSA burns (RR 1.04, 95% CI 1.01-1.07) and flame burns (RR 3.08, 95%CI 1.16-8.16) had a higher risk of mortality. Having surgery reduced the relative risk of death for infants with burns.

CONCLUSION

We show that factors that increase infant burn mortality risk include percent total body surface area burn, flame burn mechanism, and lack of operative intervention. Increasing burn operative capability, particularly for infants and other children, is imperative.

Role of resuscitation ratio in monitoring burn patients

INTRODUCTION

Efforts with the utilization of an Input/Output ratio (I/O ratio) are done with success for analyzing and moving forward the treatment in the resuscitation phase of the burn patient. The need for conducting this research is to apply the I/O ratio in our cohort as a helpful index for classifying the resuscitation response of the burn patients. Our prespecified hypothesis is if it matters the analysis of the I/O ratio at 8 h of fluid resuscitation period.

MATERIAL AND METHOD

This prospective observational study was performed in 50 patients (22 adults and 28 children) admitted in the Intensive Care of the Service of Burns in Tirana, Albania in the period January to December 2016. We calculated the I/O ratio at 8 h and the end of the 1st 24 h based on the stratification of patients according to the ratio in respective groups. In the adult population we did an analysis whereby the ratio I/O at 8 h has a relationship with the 24 h results as well as with ICU-free days.

RESULTS

The 24 h fluid resuscitation was done with the majority clustered in the range 2-4 ml/kg/% TBSA with fluid-weight score (ml/kg) correlated with % TBSA. After calculation of the I/O ratio at 8 h, 29 patients were assigned in over-responders (<0.166), 16 patients in the expected group(0.166-0.334), and 5 patients were assigned in under-responders (>0.334). There is a strong correlation between the I/O ratio at 8 h and the I/O ratio at 24 h and I/O ratio predict better the longer ICU-free days.

CONCLUSIONS

The I/O ratio is a very useful parameter not only at 12 h and 24 h but also at 8 h after burns. By classifying the patients into outcome groups that reflect not only the volume given but moreover the physiologic reactions to the resuscitation volume gotten, we were more attentive to patients in under-responders at 8 h. This parameter fulfills the criteria for better classifying patients and a better understanding of the physiology of burns.

Management of severe thermal burns in the acute phase in adults and children

OBJECTIVES

To provide recommendations to facilitate the management of severe thermal burns during the acute phase in adults and children.

DESIGN

A committee of 20 experts was asked to produce recommendations in six fields of burn management, namely, (1) assessment, admission to specialised burns centres, and telemedicine; (2) haemodynamic management; (3) airway management and smoke inhalation; (4) anaesthesia and analgesia; (5) burn wound treatments; and (6) other treatments. At the start of the recommendation-formulation process, a formal conflict-of-interest policy was developed and enforced throughout the process. The entire process was conducted independently of any industry funding. The experts drew up a list of questions that were formulated according to the PICO model (Population, Intervention, Comparison, and Outcomes). Two bibliography experts per field analysed the literature published from January 2000 onwards using predefined keywords according to PRISMA recommendations. The quality of data from the selected literature was assessed using GRADE® methodology. Due to the current paucity of sufficiently powered studies regarding hard outcomes (i.e. mortality), the recommendations are based on expert opinion.

RESULTS

The SFAR guidelines panel generated 24 statements regarding the management of acute burn injuries in adults and children. After two scoring rounds and one amendment, strong agreement was reached for all recommendations.

CONCLUSION

Substantial agreement was reached among a large cohort of experts regarding numerous strong recommendations to optimise the management of acute burn injuries in adults and children.

Fluid resuscitation in paediatric burns: how do we get it right? A systematic review of the evidence

BACKGROUND

Optimal fluid resuscitation in children with major burns is crucial to prevent or minimise burn shock and prevent complications of over-resuscitation.

OBJECTIVES

To identify studies using endpoints to guide fluid resuscitation in children with burns, review the range of reported endpoint targets and assess whether there is evidence that targeted endpoints impact on outcome.

DESIGN

Systematic review.

METHODS

Medline, Embase, Cinahl and the Cochrane Central Register of Controlled Trials databases were searched with no restrictions on study design or date. Search terms combined burns, fluid resuscitation, endpoints, goal-directed therapy and related synonyms. Studies reporting primary data regarding children with burns (<16 years) and targeting fluid resuscitation endpoints were included. Data were extracted using a proforma and the results were narratively reviewed.

RESULTS

Following screening of 777 unique references, 7 studies fulfilled the inclusion criteria. Four studies were exclusively paediatric. Six studies used urine output (UO) as the primary endpoint. Of these, one set a minimum UO threshold, while the remainder targeted a range from 0.5-1.0 mL/kg/hour to 2-3 mL/kg/hour. No studies compared different UO targets. Heterogeneous study protocols and outcomes precluded comparison between the UO targets. One study targeted invasive haemodynamic variables, but this did not significantly affect patient outcome.

CONCLUSIONS

Few studies have researched resuscitation endpoints for children with burns. Those that have done so have investigated heterogeneous endpoints and endpoint targets. There is a need for future randomised controlled trials to identify optimal endpoints with which to target fluid resuscitation in children with burns.

Positive cumulative fluid balance at 72h is associated with adverse outcomes following acute pediatric thermal injury

OBJECTIVE

To determine the association between fluid resuscitation volume following pediatric burn injury and impact on outcomes.

METHODS

A retrospective chart review of pediatric patients (0-18 years) sustaining ≥15% TBSA burn, admitted to an American Burn Association verified pediatric burn center from 2010 to 2015.

RESULTS

Twenty-seven patients met inclusion criteria and had complete data available for analysis. Fifteen (56%) patients received greater than 6ml/kg/total body surface area burn in first 24h and twelve (44%) patients received less than 6ml/kg/percent total body surface area burn in first 24h. There were no differences between groups in median number of mechanical ventilator days (4 vs 8, p=0.96), intensive care unit length of stay (10 vs 13.5, p=0.75), or hospital length of stay (37 vs 37.5, p=0.56). Secondary analysis revealed that patients with a higher mean cumulative fluid overload (>253ml/kg, n=16) had larger burn size, higher injury severity scores, and were more likely to receive mechanical ventilation and invasive support devices. Controlling for burn size, odds of longer PICU length of stay and duration of mechanical ventilation were 20.33 [95% CI (1.7-235.6) p=0.02] and 27.9 [95% CI (2.1-364.7) p=0.01], respectively, among patients with a high cumulative fluid overload on day 3 compared to low cumulative fluid overload.

CONCLUSIONS

Resuscitation volume in the first 24h was not associated with adverse outcomes. Persistent cumulative fluid overload at day 3 and beyond was independently associated with adverse outcomes.

Pediatric burn resuscitation: past, present, and future

Burn injury is a leading cause of unintentional death and injury in children, with the majority being minor (less than 10%). However, a significant number of children sustain burns greater than 15% total body surface area (TBSA), leading to the initiation of the systemic inflammatory response syndrome. These patients require IV fluid resuscitation to prevent burn shock and death. Prompt resuscitation is critical in pediatric patients due to their small circulating blood volumes. Delays in resuscitation can result in increased complications and increased mortality. The basic principles of resuscitation are the same in adults and children, with several key differences. The unique physiologic needs of children must be adequately addressed during resuscitation to optimize outcomes. In this review, we will discuss the history of fluid resuscitation, current resuscitation practices, and future directions of resuscitation for the pediatric burn population.

A noninvasive computational method for fluid resuscitation monitoring in pediatric burns: a preliminary report

The fluid resuscitation needs of children with small area burns are difficult to predict. The authors hypothesized that a novel computational algorithm called the compensatory reserve index (CRI), calculated from the photoplethysmogram waveform, would correlate with percent total body surface area (%TBSA) and fluid administration in children presenting with ≤20% TBSA burns. The authors recorded photoplethysmogram waveforms from burn-injured children that were later processed by the CRI algorithm. A CRI of 1 represents supine normovolemia; a CRI of 0 represents the point at which a subject is predicted to experience hemodynamic decompensation. CRI values from the first 10 minutes of monitoring were compared to clinical data. Waveform data were available for 27 children with small to moderate sized burns (4-20 %TBSA). The average age was 6.3 ± 1.1 years, the average %TBSA was 10.4 ± 0.8%, and the average CRI was 0.36 ± 0.03. CRI inversely correlated with the %TBSA (P < .001). Twenty children were transferred with an average reported %TBSA of 16.5 ± 1.4%, which was significantly higher than the actual %TBSA (P < .001). CRI correlated better with actual %TBSA compared to reported %TBSA (P = .02). CRI correlated with the amount of fluid resuscitation given at the time of CRI measurement (P = .02) and was inversely related to total fluids given per 24 hours for children with adequate urine output (>0.5 ml/kg/hr) (P < .001). The CRI is decreased in children with small to moderate size burns, and correlates with %TBSA and fluid administration. This suggests that the CRI may be useful for fluid resuscitation guidance, warranting further study.

Special considerations in paediatric burn patients

Burn injuries are a major cause of morbidity and mortality in children. In India, the figure constitutes about one-fourth of the total burn accidents. The management of paediatric burns can be a major challenge for the treating unit. One has to keep in mind that “children are not merely small adults”; there are certain features in this age group that warrant special attention. The peculiarities in the physiology of fluid and electrolyte handling, the uniqueness of the energy requirement and the differences in the various body proportions in children dictate that the paediatric burn management should be taken with a different perspective than for adults. This review article would deal with the special situations that need to be addressed while treating this special class of thermal injuries. We must ensure that not only the children survive the initial injury, but also the morbidity and complications are minimized. If special care is taken during the initial management of paediatric burn injuries, these children can be effectively integrated into the society as very useful and productive members.

Colloid normalizes resuscitation ratio in pediatric burns

Fluid resuscitation of burned children is challenging because of their small size and intolerance to over- or underresuscitation. Our American Burn Association-verified regional burn center has used colloid "rescue" as part of our pediatric resuscitation protocol. With Institutional Review Board approval, the authors reviewed children with ≥15% TBSA burns admitted from January 1, 2004, to May 1, 2009. Resuscitation was based on the Parkland formula, which was adjusted to maintain urine output. Patients requiring progressive increases in crystalloid were placed on a colloid protocol. Results were expressed as an hourly resuscitation ratio (I/O ratio) of fluid infusion (ml/kg/%TBSA/hr) to urine output (ml/kg/hr). We reviewed 53 patients; 29 completed resuscitation using crystalloid alone (lactated Ringer's solution [LR]), and 24 received colloid supplementation albumin (ALB). Groups were comparable in age, gender, weight, and time from injury to admission. ALB patients had more inhalation injuries and larger total and full-thickness burns. LR patients maintained a median I/O of 0.17 (range, 0.08-0.31), whereas ALB patients demonstrated escalating ratios until the institution of albumin produced a precipitous return of I/O comparable with that of the LR group. Hospital stay was lower for LR patients than ALB patients (0.59 vs 1.06 days/%TBSA, P = .033). Twelve patients required extremity or torso escharotomy, but this did not differ between groups. There were no decompressive laparotomies. The median resuscitation volume for ALB group was greater than LR group (9.7 vs 6.2 ml/kg/%TBSA, P = .004). Measuring hourly I/O is a helpful means of evaluating fluid demands during burn shock resuscitation. The addition of colloid restores normal I/O in pediatric patients.

Effect of early enteral nutrition on morbidity and mortality in children with burns

Burns increase the metabolic demands of the body and can lead to severe weight loss and increased risk of death. Early enteral support is believed to improve gastrointestinal, immunological, nutritional and metabolic responses to critical injury; however, this premise is in need of further substantiation by definitive data. This research aimed to examine the effectiveness and safety of early enteral feeding in paediatric patients suffering from burns.

MATERIALS AND METHODS

This clinical trial was carried out with a total number of 688 children with burns hospitalised in the Burn Department across a 2-year period (September 2002-September 2004). The subjects were randomised into two groups. A total of 322 patients received only intravenous resuscitation, in accordance with current treatment protocols, in the first 48 h and were considered as the late enteral nutrition group (LEN group); 366 patients were nourished early enteral nutrition group (EEN group), such that both groups received similar amounts of fluid in the first 48 h. Initiation of enteral nutrition commenced between 3 and 6 h following the burn. The patients were kept in the unit until they were discharged. Wound management did not vary between groups.

RESULTS

In our study, the mean age was 5±3 years in the LEN group and 5±3.5 years in the EEN group. Hot liquids were the most common cause of burns in both groups. The mean percentage of burn was reported as 20±13 in the LEN group and 22±15 in the EEN group. Mean duration of hospitalisation was 16.4±3.7 days in the LEN group and 12.6±1.3 in the EEN group for cured patients (P<0.05). A total of 40 patients (12%) in the LEN group and 31 patients (8.5%) in the EEN group expired (P<0.05).

CONCLUSION

Our research showed that EEN decreases duration of hospitalisation and mortality in children with burns.

Comparison of hypertonic vs isotonic fluids during resuscitation of severely burned patients

BACKGROUND

The hypertonic lactate saline (HLS) solutions with mild concentration of sodium have been used in some burn centers to maintain plasma volume without infusing larger fluids volumes. To evaluate the fluid requirements during resuscitation with lactated Ringer's solution and to realize resuscitation with HLS, we suggest the following clinical trial. Specific objectives include fluid loads, sodium loads, and fluid accumulation.

METHOD

This prospective study included 110 patients with severe burns. The first group included patients resuscitated in the beginning with lactated Ringer's solution, according to Parkland formula for adults and Shriner formula for children. In the other group, the patients were resuscitated with HLS solution. Patients are divided in 2 groups for comparison.

RESULTS

There is difference between sodium loads (P = .03), fluid load in the first hour (P = .001), sodium load in the first hour (P = .001), and net fluid accumulation (P = .0025). There is a difference regarding plasma sodium and plasma osmolality in the first hour (P = .003, P = .002). There is difference regarding sodium given (P = .001) and sodium excreted (P = .001) in 2 groups.

CONCLUSIONS

Hypertonic resuscitation consists in giving a higher fluid and sodium load in the first hour of therapy that is accompanied with a decrease in fluid requirements and fluid accumulation for the first 24 hours of burn shock.

Factors affecting fluid requirement on the first day after severe burn trauma

BACKGROUND

Parkland formula (PF) is the most often used schema for calculating intravenous resuscitation fluid requirement in burn patients. Some studies have reported that PF underestimates the fluid requirement in 45-63% of patients. The aim of this retrospective study was to analyse factors influencing first-day intravenous fluid replacement set for a targeted urinary output in severely burnt patients.

METHODS

Data of 47 patients with burn injury affecting equal or more than 15% of body surface area were retrieved from the archived files. The local intensive care protocol rendered the infusion rate of lactated Ringer's solution to achieve a urinary output of 0.5-1.0 mL/kg per hour in the first 24 h after burn trauma.

RESULTS

First-day i.v. infusion volume was significantly higher than PF preferred. In the first 24 h the hourly volume of intravenous fluid resuscitation per bodyweight per burnt surface area showed significant negative correlation to the burnt body surface area and body mass index, (r = -0.553, P < 0.001; r = -0.570, P < 0.001, respectively) no correlation was found to bodyweight, height or patient age. Patients having deep-burn injury required higher intravenous fluid resuscitation rate than patients having superficial injury only (P < 0.01).

CONCLUSION

Our data suggest that fluid requirement is higher than predicted by PF if the extent of burn or body mass index is low and less if the extent of burn or body mass index is high. The presence of deep burn increases fluid requirement.

Enteral resuscitation and early enteral feeding in children with major burns--effect on McFarlane response to stress

AIM

Early enteral feeding has become standard practice for burned patients. The aim of this study was to determine whether early enteral feeding could be used as an avenue for resuscitation and feeding and the effect it would have on the induction/amelioration of the hormonal stress response.

METHOD

Eighteen children with <20% TBSA were randomly assigned to either early enteral feeding and resuscitation, or intravenous resuscitation with the induction of enteral feeding delayed. The enteral fluid volume was incrementally increased every 3h with a simultaneous equal reduction in the intravenous volume until all the calculated intravenous fluid requirements for resuscitation and maintenance could be administered enterally. In the second group, intravenous resuscitation continued for 48 h when enteral feeding was introduced. Parameters measured were the clinical responses and outcome as well as the concentrations of insulin, insulin-like growth factor 1, glucagon, cortisone and growth hormone. The estimated and calculated energy expenditure was measured calorimetrically and bowel permeability was assessed using a dual sugar absorption test.

RESULTS

Three children were excluded from the study because of early death from organ failure or carbon monoxide poisoning. Early enteral resuscitation and feeding (ER/EEF) was initiated within a median of 10.7h post-burn in nine children and late enteral feeding introduced on an average 54 h post-burn. The ER/EEF group showed an anabolic response with significantly higher insulin concentrations (p=0.008) and insulin: glucagon ratios (p=0.043). Although blood glucose concentrations were initially slightly elevated (EEF: 10.3g/l, LEF: 8.1g/l), they rapidly returned to within the normal range. The cortisol and IGF1 concentrations did not differ significantly between the two treatment groups. Growth hormone concentrations were significantly higher in the late enteral feeding (LEF) group (p=0.03). The estimated energy expenditure was not different amongst the groups. Small bowel permeability [lactulose:rhamnose (L:R) ratios] decreased significantly over time (p=0.02) in both study groups. No pulmonary aspiration was found. Diarrhoea in the ER/EEF settled quickly (2-4 days), whereas in the LEF group it persisted for longer than a week. The LEF group lost a median of 7.75% (acceptable range=<or=5%) of admission body weight, whereas the ER/EEF group lost a median of 3.01%. Patients in the LEF group required antibiotic treatment for a longer period (p=0.08) and their hospital stay was longer, though not significant.

CONCLUSIONS

Enteral resuscitation and early enteral feeding is a safe and effective method and particularly suited for children in developing countries. It resulted in the amelioration of the hormonal stress response and improved outcome. Enteral resuscitation should not be introduced in a patient in shock or with existing gastrointestinal disease. Complications were minimal.

CHILDREN UNDER 4 YEARS ARE AT GREATER RISK OF MORTALITY FOLLOWING ACUTE BURN INJURY

It is important to have an accurate understanding of mortality risk in children to make sound treatment decisions and to advise parents and families. Several studies have found that children younger than 4 years are at greater risk for mortality from burn injury than older children, although other studies have found no difference. All of these studies, however, have been limited by small sample sizes from single burn centers. The objective of this study was to assess age-related mortality risk in a sample of more than 12,000 children from a national burn registry who were admitted to 43 burn centers in the United States from 1992 to 2002. The study showed that, compared with older children, children younger than 4 years were significantly more likely to be admitted with scalds rather than flame burns, had smaller burn injuries, and were less likely to have an inhalation injury. Logistic regression analysis was used to assess age-related mortality risk. After adjusting for sex, burn size, inhalation injury, and type of burn (flame versus scald), the risk of mortality was substantially higher for children aged 0 to 1.9 years (odds ratio, 2.70; P<0.001) and for children aged 2.0 to 3.9 years (odds ratio, 2.00; P<0.01) as compared with children aged 4 years or older. This study provides strong evidence that when comparing children based on burn injuries of similar size and etiology, children younger than 4 years are at substantial risk for death as compared with older children.

Etiology and outcome of pediatric burns in Tabriz, Iran

A 3-year prospective study of burn victims hospitalized at a major burn center was conducted to determine the etiology and outcome of pediatric burns. One thousand one hundred sixty patients under the age of 14 years identified and stratified by age, sex, burn size, presence or absence of inhalation injury, and cause of burn. The mean patient age was 2.2 years, and the male:female ratio was 1.6:1. There were 74 deaths overall (6.4%), the majority of which (44) were among children under 5 years of age. Except for burn incidence, there were no significant differences between males and females. The mean burn size was 19%, and was significantly larger for nonsurvivors than survivors (50.3% versus 16.8%; P<0.001). Inhalation injuries were strongly associated with large burns, and were present in all flame-burn fatalities. Scalds were the most common type of burn among children under 5 years of age; flame burns predominated in older children. There were 39 deaths related to scalds. Large burn size was the strongest predictor of mortality followed by the presence of inhalation injury and the length of time to intravenous access.

Predicting increased fluid requirements during the resuscitation of thermally injured patients

BACKGROUND

We determined whether factors present soon after burn predict which patients will receive more than 4 mL/kg/% burn during the first 24 hours, and whether total fluid intake during the first 24 hours (VOL) contributes to in-hospital mortality (MORT).

METHODS

We reviewed the records of patients admitted during 1987-97. The modified Brooke resuscitation formula was used. One hundred four patients met inclusion criteria: total body surface area burned (TBSA) > or = 20%; admission directly from the field; weight > 30 kg; no electric injury, mechanical trauma, or blood transfusions; and survival > or = 24 hours postburn. Eighty-nine records were complete.

RESULTS

Mean TBSA was 43%, mean full-thickness burn size was 21%, mean age was 41 years, mean VOL was 4.9 mL/kg/% burn, and mean lactated Ringer's volume was 4.4 mL/kg/% burn; 53% had inhalation injury. MORT was 25.8%. Mean urine output was 0.77 mL/kg/h. By linear regression, VOL was associated with weight (negatively) and full-thickness burn size (r2 = 0.151). By logistic regression, receipt of over 4 mL/kg/% burn was predicted at admission by weight (negatively) and TBSA; by 24 hours postburn, mechanical ventilation replaced TBSA. With respect to MORT, logistic regression of admission factors yielded a model incorporating TBSA and an age function; by 24 hours postburn, the worst base deficit was added.

CONCLUSION

Burn size and weight (negatively) were associated with greater VOL. However, a close linear relationship between burn size and VOL was not observed. Mechanical ventilation supplanted TBSA by 24 hours as a predictor of high VOL. Worst base deficit, TBSA, and an age function, but not VOL, were predictors of MORT.

Trends in burn resuscitation: shifting the focus from fluids to adequate endpoint monitoring, edema control, and adjuvant therapies

Bum shock is a complex process involving a series of intertwined physiologic responses to injury that require more rigorous intervention than simply a change in fluid tonicity, fluid composition, or fluid resuscitation volume. Controversy ensues over monitoring techniques and resuscitation goals, in part because the identification of true markers of perfusion is clouded by intradependence of endpoints on other metabolic processes. The persistence of cellular hypoperfusion in patients who have been deemed adequately resuscitated by global indices supports the growing realization that failure of conventional endpoint-monitoring strategies to detect compensated bum shock can lead to significant organ injury from SIRS or MODS. Current endpoints should be interpreted in the aggregate, because none have yet been demonstrated to reflect tissue perfusion status independently and accurately. Numerous technologically advanced endpoints to predict patient outcome, which may be useful in determining futility of treatment or end-of-life decisions, are now available. Still lack-ing, however, is a reliable tool proven to improve outcome that can guide bum shock resuscitation therapies successfully. Exciting new research in tissue oxygenation and perfusion has revealed that damaging mediator cascades and irreversible microvascular changes may preclude complete resolution of bum shock solely through restoration of oxygen delivery. Because bum patients now frequently survive the early resuscitation phase. the focus should be on controlling derangements in oxygen use and correcting occult hypoperfusion to reduce later adverse patient outcomes from SIRS, sepsis, and MODS. Bum-specific research on resuscitation endpoints and monitoring strategies lags behind research in other patient populations. Present standards and monitoring guidelines for bum shock resuscitation should be critically evaluated and based on true, scientifically validated data rather than on observational studies or personal beliefs. Thus the continuing challenge for clinicians and researchers:burn centers must collaborate to perform large, multi-center studies to evaluate critically and to prove resuscitation endpoints and therapies. Future technologies targeted at microcirculatory perfusion and cellular oxygenation offer an exciting promise for less invasive, easily accessible, more accurate endpoints and treatments for bum shock resuscitation.

The systemic stress response to thermal injury in children

OBJECTIVE

Thermal injury is extremely stressful, but data characterizing the endocrine stress response to this injury in children are sparse. The objective of this study was to measure the effects of thermal injury on the levels of stress hormones in children and to assess the temporal changes associated with them.

PATIENTS

Twenty-three children, 13 girls and 10 boys aged between 5 months and 12 years 3 months (mean, 2 years 11 months), with burns covering 10-61% of their body surface (mean, 20.5%) were studied during the first 5 days following injury.

MEASUREMENTS

The levels of arginine vasopressin, angiotensin II, cortisol, adrenaline, noradrenaline and dopamine were measured in sequential blood samples obtained from thermally injured children on admission and at specified time intervals during the 5 days of the investigation.

RESULTS

At admission the concentrations of all the hormones were high, and varied widely between individual patients. The geometric mean and 95% confidence intervals of admission hormone levels were as follows: arginine vasopressin 18.3 (8.3-40.7) pmol/l; angiotensin II 122.0 (56.0-266.2) pmol/l; cortisol 650.6 (473.0-895.0) nmol/l; dopamine 1.0 (0.1-8.0) nmol/l; adrenaline 6.4 (3.2-12.5) nmol/l and noradrenaline 2.3 (1.3-4.3) nmol/l. Although the concentrations of arginine vasopressin and cortisol returned to normal 24 to 36 h after admission, the levels of angiotensin II, adrenaline and dopamine fluctuated and remained higher than normal throughout the study (108 h).

CONCLUSIONS

Thermal injury results in the release of abnormally high levels of stress hormones in children. Although there are similarities between some of the data reported here and those reported in adults, higher levels of adrenaline and lower levels of noradrenaline than reported in adults suggest important differences too. These differences may need to be taken into account in the management of burn-injured children.

Anesthesia and pain management in pediatric burn patients

Patients with severe burn injury are a challenge for the pediatric anesthesiologist. Today with adequate care many children survive their trauma and have a good chance for complete functional and psychological rehabilitation. The anesthesiologist has to provide excellent care even for patients in suboptimal or unstable condition to enable wound debridement and grafting, because only rapid skin closure will stabilize the patient. Adequate pain treatment during all phases of burn treatment is mandatory.

Burn management in children

Pediatric burn care consists of a coordinated program to provide acute physiological support during the shock phase, prompt wound closure, aggressive ancillary care, and appropriate postdischarge management. Adherence to predetermined burn care guidelines will produce the most optimal results in survival and return to function.

Etiology and outcome of pediatric burns

A 6-year retrospective review of burn victims hospitalized at a major burn center was conducted to determine the etiology and outcome of pediatric burns. Four hundred forty-nine patients under age 16 years were identified and stratified by age, sex, burn size, presence or absence of inhalation injury, cause of burn, and county of residence. The mean patient age was 4.3 +/- 0.2 years, and the male:female ratio was 1.9:1. There were 21 deaths overall (4.7%), the majority of which (18) were among children under 4 years of age. With respect to large burns, defined as > and = 30% total body surface area (TBSA), the mortality rate for children under age 4 was significantly higher than that for older children (46.9% v 12.5%; P < .01), despite the nearly identical mean burn size of the two groups. Except for burn incidence, there were no significant differences between males and females. The mean burn size was 15.1% +/- 0.7%, and was significantly larger for nonsurvivors than survivors (55.3% +/- 5.7 v 13.1% +/- 0.5%; P < .01). Inhalation injuries were strongly associated with large burns and were present in all 15 flame-burn fatalities. Scalds were the most common type of burn among children under 4 years of age; flame burns predominated in older children. There were 6 deaths related to scalds, all of which occurred in children under 4. Burn type, size, and mortality rate did not differ between children from urban and rural counties. Large burn size was the strongest predictor of mortality, followed by (in order) age less than 4 and the presence of inhalation injury. Infants and young children have the highest risk of death from burn injury. Burns smaller than 30% TBSA without an inhalation injury (such as small scald injuries) occasionally are lethal in infants and small children, despite modern therapy.

Rapid isotonic fluid resuscitation in pediatric thermal injury

Intravenous fluid resuscitation within the first 24 hours after a burn is critical to prevent shock and maintain organ function. The Parkland burn resuscitation formula suggests that one half of the first 24-hour fluid requirement be given in the first 8 hours. Results of recent studies in animals suggest that compression of the first half of the initial resuscitation from 8 to 4 hours may have a physiological benefit. We reviewed the medical records of 44 children under 12 years of age who had burns of greater than 29% of total body surface. Twenty-two children received a standard resuscitation of one-half volume given over the first 8 hours, followed by one-half volume over the next 16 hours. Twenty-two children received a rapid isotonic fluid resuscitation of one-half volume over 4 hours or less, followed by the remainder given over 20 hours. Vital signs, urine output, urine specific gravity, blood gases (acidosis), ventilator need, morbidity, and mortality were compared between the two groups. The rapid group had increased normalization of vital signs (P < .001), increased urine output and normalization of urine specific gravity (P < .01), and decreased requirement for ventilator support (P < .05). The authors conclude that rapid isotonic fluid resuscitation is well tolerated by pediatric patients and may be better than the standard burn resuscitation technique.

Burn shock resuscitation

The goal of fluid resuscitation in the burn patient is maintenance of vital organ function at the least immediate or delayed physiological cost. To optimize fluid resuscitation in severely burned patients, the amount of fluid should be just enough to maintain vital organ function without producing iatrogenic pathological changes. The composition of the resuscitation fluid in the first 24 hours postburn probably makes very little difference; however, it should be individualized to the particular patient. The utilization of the advantages of hypertonic, crystalloid, and colloid solutions at various times postburn will minimize the amount of edema formation. The rate of administration of resuscitation fluids should be that necessary to maintain satisfactory organ function, with maintenance of hourly urine outputs of 30 cc to 50 cc in adults and 1-2 cc/kg/% burn in children. When a child reaches 30 kg to 50 kg in weight, the urine output should be maintained at the adult level. With our current knowledge of the massive fluid shifts and vascular changes that occur, mortality related to burn-induced hypovolemia has decreased considerably. The failure rate for adequate initial volume restoration is less than 5% even for patients with burns of more than 85% of the total body surface area. These improved statistics, however, are derived from experience in burn centers, where there is substantial knowledge of the pathophysiology of burn injury. Inadequate volume replacement in major burns is, unfortunately, common when clinicians lack sufficient knowledge in this area.

Differences in mortality from thermal injury between pediatric and adult patients

Children differ from adults in their responses to thermal injury, as reflected by higher reported mortality rates for equivalent major injuries. The age at which children's survival rates equal those of young adults has not been well defined, and some investigators have recently claimed that pediatric and adult burn mortality do not differ. We evaluated age-related mortality among 1,443 consecutive patients without inhalation injury treated from 1978 to 1988, inclusively. The sample consisted of 595 children aged 12 years or less, 243 children aged 13 to 20 years, and 605 young adults aged 21 to 40 years who served as a comparison group of patients with the best predicted survival. We separately examined mortality in patients with burns exceeding 30% total body surface area. There were no significant differences in mortality between age groups for the study sample as a whole, but among patients with large burns, children aged 0 to 48 months had higher mortality than comparably injured adults (31% v 12%, P less than .05 by analysis of covariance). Improvements in survival were also demonstrated between the first and second halves of the study period for children aged 25 months to 8 years. These data indicate that children 48 months of age and younger do not tolerate large thermal injuries as well as adults. Improvements in pediatric burn survival are being achieved in most age groups.

Increased survival after major thermal injury. A nine year review

This study has reviewed the results of burn care in a burn center between 1978 and 1986. The total population included 1,458 patients. Mean burn size was 19 percent total body surface area, mean patient age was 24.4 years, and overall survival rate was 92 percent. We separately analyzed patients with burns of 30 percent total body surface area or greater during both halves of the study with respect to survival and length of hospital stay. Before 1982, patient survival was 59 percent and mean length of hospital stay was 28.1 days. Since that, the survival rate increased to 77 percent and mean length of hospital stay increased to 35.2 days. The early burn mortality rate remained nearly constant during the period of study (17 percent during the first half of the study and 16 percent during the second half), but the late mortality rate decreased significantly during the second half of the study (24 percent versus 8 percent, p less than 0.01). These data demonstrate increased survival rates after major thermal injury due to improvements in prevention and treatment of sepsis and other late complications of thermal injury.