Extracorporeal membrane oxygenation as a lifesaving modality in the treatment of pediatric patients with burns and respiratory failure

Risk Factors of Mortality and Long-Term Survival in Burn Patients With/Without Extracorporeal Membrane Oxygenation: A 16 Year Real-World Study

Burn patients face cardiopulmonary failure risks, with recent observational studies suggesting promising outcomes for extracorporeal membrane oxygenation (ECMO). However, the effectiveness and long-term survival remain unclear. Our study aims to assess mortality risk factors and long-term survival in burn patients with and without ECMO. This study used Taiwan's National Health Insurance Research Database and designed a case-control with onefold propensity score matching across variables including sex, age, total body surface area (TBSA) burned, and index date. We analyzed mortality and survival risk factors in each stratified group with/without ECMO. Finally, we analyze the mortality according to ECMO and TBSA burned, and the cause of death and long-term survival. From 2000 to 2015, 4,556 burn patients with ECMO compared to an equivalent number without ECMO. Primary mortality include male, age >65, TBSA ≥30%, escharotomy, hemodialysis, and bacteremia. The ECMO group showed lower survival across all stratified risk factors, with the primary cause of death being burn-related issues, followed by respiratory and heart failure. The overall mortality rate was 54.41% with ECMO and 40.94% without ECMO (p < 0.001). Additionally, long-term survival is lower in the group with ECMO. This research provides a valuable real-world gross report about ECMO efficacy and long-term survival among burn patients with/without ECMO.

Pediatric venoarterial and venovenous ECMO

Extracorporeal membrane oxygenation (ECMO) is an invaluable resource in the treatment of critically ill children with cardiopulmonary failure.  To date, over 36,000 children have been placed on ECMO and the utilization of this life saving treatment continues to expand with advances in ECMO technology.  This article offers a review of pediatric ECMO including modes and sites of ECMO cannulation, indications and contraindications, and cannulation techniques.  Furthermore, it summarizes the basic principles of pediatric ECMO including circuit maintenance, nutritional support, and clinical decision making regarding weaning pediatric ECMO and decannulation.  Finally, it gives an overview of common pediatric ECMO complications including overall mortality and long-term outcomes of ECMO survivors. The goal of this article is to provide a comprehensive review for healthcare professionals providing care for pediatric ECMO patients.

Extracorporeal Membrane Oxygenation in Pediatric Burn Patients Without Inhalation Injury: A Unique Population?

Prolonged mechanical ventilation (MV) before the initiation of extracorporeal membrane oxygenation (ECMO) is associated with decreased survival. Pediatric burn patients without inhalational injury are a unique population as they may be intubated for longer durations due to frequent interventions such as dressing changes and burn excisions. This study utilized the Extracorporeal Life Support Organization registry and evaluated patients 0 to 18 years old placed on ECMO and with a burn injury from January 2010 to December 2020. Inhalation injury was excluded. Descriptive statistics and bivariate analyses were performed. Multivariable logistic regression was used to assess the association between mortality and precannulation MV duration before ECMO cannulation, and odds ratios and predicted probabilities of mortality were estimated. Our cohort of 47 patients had a median age of 2.7 years old. Mortality occurred in 48.9% of the cohort. The overall median number of days on ECMO was 6.3 days, with no difference between survivors and non-survivors (6.8 days vs 6.3 days; P = .67). Survivors were ventilated for 4.1 days and non-survivors for 4.8 days before cannulation (P = .25). Regression modeling demonstrated that with each additional day on MV before ECMO cannulation, the odds of mortality increases by 12% (P = .03). Our study suggests that, similar to pediatric patients without thermal injury, increasing precannulation MV duration is associated with an increasing risk of mortality in pediatric burn patients without inhalational injury. Though the pediatric burn population is unique, evaluation of burn patients with respiratory failure for ECMO should be similar to the general population.

Efficacy and safety of extracorporeal membrane oxygenation for burn patients: a comprehensive systematic review and meta-analysis

BACKGROUND

Respiratory and circulatory dysfunction are common complications and the leading causes of death among burn patients, especially in severe burns and inhalation injury. Recently, extracorporeal membrane oxygenation (ECMO) has been increasingly applied in burn patients. However, current clinical evidence is weak and conflicting. This study aimed to comprehensively evaluate the efficacy and safety of ECMO in burn patients.

METHODS

A comprehensive search of PubMed, Web of Science and Embase from inception to 18 March 2022 was performed to identify clinical studies on ECMO in burn patients. The main outcome was in-hospital mortality. Secondary outcomes included successful weaning from ECMO and complications associated with ECMO. Meta-analysis, meta-regression and subgroup analyses were conducted to pool the clinical efficacy and identify influencing factors.

RESULTS

Fifteen retrospective studies with 318 patients were finally included, without any control groups. The commonest indication for ECMO was severe acute respiratory distress syndrome (42.1%). Veno-venous ECMO was the commonest mode (75.29%). Pooled in-hospital mortality was 49% [95% confidence interval (CI) 41-58%] in the total population, 55% in adults and 35% in pediatrics. Meta-regression and subgroup analysis found that mortality significantly increased with inhalation injury but decreased with ECMO duration. For studies with percentage inhalation injury ≥50%, pooled mortality (55%, 95% CI 40-70%) was higher than in studies with percentage inhalation injury <50% (32%, 95% CI 18-46%). For studies with ECMO duration ≥10 days, pooled mortality (31%, 95% CI 20-43%) was lower than in studies with ECMO duration <10 days (61%, 95% CI 46-76%). In minor and major burns, pooled mortality was lower than in severe burns. Pooled percentage of successful weaning from ECMO was 65% (95% CI 46-84%) and inversely correlated with burn area. The overall rate of ECMO-related complications was 67.46%, and infection (30.77%) and bleedings (23.08%) were the two most common complications. About 49.26% of patients required continuous renal replacement therapy.

CONCLUSIONS

ECMO seems to be an appropriate rescue therapy for burn patients despite the relatively high mortality and complication rate. Inhalation injury, burn area and ECMO duration are the main factors influencing clinical outcomes.

Extracorporeal life support in pediatric burn care: A systematic review

A systematic review of the role of extracorporeal life support (ECLS) in pediatric patients with burn and smoke inhalation injury was undertaken. A systematic search of the literature according to a specific combination of keywords to ascertain the effectiveness of this treatment strategy was conducted. A total of 14 articles out of 266 were considered suitable for the analysis in pediatric patients. The PICOS approach and PRISMA flow chart were followed for the purpose of this review. Despite the limited number of studies on the subject, ECMO in burn and smoke inhalation injury provides an additional level of support in pediatric patients leading to positive outcomes. V-V ECMO demonstrated the best overall survival of all configurations, with similar outcomes to non-burned patients. Prolonged mechanical ventilation prior to ECMO decreases survival and increases mortality by 12% with each additional day off ECMO. Good outcomes have been described for scald burns, dressing changes, and pre-ECMO cardiac arrest.

The Use of Extracorporeal Membrane Oxygenation for Burns: A Systematic Review and Meta-Analysis

Burns are among the leading causes of trauma worldwide, and acute respiratory distress syndrome (ARDS) is a common cause of death in burn patients. Some patients develop hypoxemia refractory to conventional therapies and may be initiated on extracorporeal membrane oxygenation (ECMO) as rescue therapy. We conducted a meta-analysis for studies reporting on survival rates of patients receiving ECMO for burns or inhalation injuries, which was the primary outcome. Secondary outcomes included the hospital and intensive care unit length of stay and duration of ECMO. Random-effects (DerSimonian and Laird) were conducted. The pooled survival from 10 studies was 53.6% (95% confidence interval [CI]: 37.6-69.2%, high certainty). Survival was significantly associated with age (regression coefficient [B]: -0.0088, 95% CI: -0.0155 to -0.0021, p = 0.011) and the proportion of male patients (B: -1.0137 95% CI: -1.9695 to -0.0580, p = 0.038). Patients were cannulated on ECMO for a mean of 8.4 days (95% CI: 6.1-10.7) and remained in the ICU for a mean of 40.4 days (95% CI: 11.4-69.3). Mean hospital length of stay was 45.4 days (95% CI: 31.7-59.0). In conclusion, patients with burn and inhalation injuries who develop ARDS refractory to conservative management have a survival rate of 54% when placed on ECMO.

Extracorporeal Life Support for Severely Burned Patients with Concurrent Inhalation Injury and Acute Respiratory Distress Syndrome: Experience from a Military Medical Burn Center

BACKGROUND

Both inhalation injury and acute respiratory distress syndrome (ARDS) are risk factors that predict mortality in severely burned patients. Extracorporeal life support (ECLS) is widely used to rescue these patients; however, its efficacy and safety in this critical population have not been well defined. We report our experience of using ECLS for the treatment of severely burned patients with concurrent inhalation injury and ARDS.

METHODS

This was a retrospective analysis of 14 patients collected from a single medical burn center from 2012 to 2019. All patients suffered from major burns with inhalation injury and ARDS, and were treated with ECLS.

RESULTS

The median total body surface area of deep dermal or full thickness burns was 94.5%, ranging 47.7-99.0 %. The median revised Baux score was 122.0, ranging 90.0-155.0. All patients developed ARDS with a median partial pressure of arterial oxygen to a fraction of inspired oxygen ratio of 61.5, ranging 49.0-99.0. Indications for ECLS included sustained hypoxemia and unstable hemodynamics. The median interval for initiating ECLS was 2.5 days, ranging 1.0-156.0 days. The median duration of ECLS was 2.9 days, ranging 0.3-16.7 days. The overall survival to discharge was 42.8%. Causes of death included sepsis and multiple organ failure. ECLS-related complications included cannulation bleeding, catheter-related infection, and hemolysis. The incidence of risk factors reported in literature were higher in non-survivors, including Baux>120, albumin < 3.0 g/dL, and lactate > 8 mmol/L.

CONCLUSIONS

For severely burned patients with concurrent inhalation injury and ARDS, ECLS could be a salvage treatment to improve sustained hypoxemia. However, the efficacy of hemodynamic support was limited. Identifying definite ECLS indications and rigorous patient selection would contribute to better clinical outcomes.

A Systematic Review and Meta-Analysis of Extracorporeal Membrane Oxygenation in Patients with Burns

BACKGROUND

Severely burned patients are at high risk for cardiopulmonary failure. Promising studies have stimulated interest in using extracorporeal membrane oxygenation as a potential therapy for burn patients with refractory cardiac and/or respiratory failure. However, the findings from previous studies vary.

METHODS

In this study, the authors conducted a systematic review and meta-analysis using standardized mortality ratios to elucidate the benefits associated with the use of extracorporeal membrane oxygenation in patients with burn and/or inhalation injuries. A literature search was performed, and clinical outcomes in the selected studies were compared.

RESULTS

The meta-analysis found that the observed mortality was significantly higher than the predicted mortality in patients receiving extracorporeal membrane oxygenation (standardized mortality ratio, 2.07; 95 percent CI, 1.04 to 4.14). However, the subgroup of burn patients with inhalation injuries had lower mortality rates compared to their predicted mortality rates (standardized mortality ratio, 0.95; 95 percent CI, 0.52 to 1.73). Other subgroup analyses reported no benefits from extracorporeal membrane oxygenation; however, these results were not statistically significant. Interestingly, the pooled standardized mortality ratio values decreased as the selected patients' revised Baux scores increased (R = -0.92), indicating that the potential benefits from the treatment increased as the severity of patients with burns increased.

CONCLUSIONS

The authors' meta-analysis revealed that burn patients receiving extracorporeal membrane oxygenation treatment were at a higher risk of death. However, select patients, including those with inhalation injuries and those with revised Baux scores over 90, would benefit from the treatment. The authors suggest that burn patients with inhalation injuries or with revised Baux scores exceeding 90 should be considered for the treatment and early transfer to an extracorporeal membrane oxygenation center.

Extracorporeal membrane oxygenation combined with continuous renal replacement therapy for the treatment of severe burns: current status and challenges

Severe burns often cause various systemic complications and multiple organ dysfunction syndrome, which is the main cause of death. The lungs and kidneys are vulnerable organs in patients with multiple organ dysfunction syndrome after burns. Extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) have been gradually applied in clinical practice and are beneficial for severe burn patients with refractory respiratory failure or renal dysfunction. However, the literature on ECMO combined with CRRT for the treatment of severe burns is limited. Here, we focus on the current status of ECMO combined with CRRT for the treatment of severe burns and the associated challenges, including the timing of treatment, nutrition support, heparinization and wound management, catheter-related infection and drug dosing in CRRT. With the advancement of medical technology, ECMO combined with CRRT will be further optimized to improve the outcomes of patients with severe burns.

Extracorporeal Membrane Oxygenation Support for Pediatric Burn Patients: Is It Worth the Risk?

OBJECTIVES

Examine the outcomes of pediatric burn patients requiring extracorporeal membrane oxygenation to determine whether extracorporeal membrane oxygenation should be considered in this special population.

DESIGN

Retrospective cohort study.

SETTING

All extracorporeal membrane oxygenation centers reporting to the Extracorporeal Life Support Organization.

SUBJECTS

Pediatric patients (birth to younger than 18 yr) who were supported with extracorporeal membrane oxygenation with a burn diagnosis between 1990 and 2016.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 113 patients were identified from the registry by inclusion criteria. Patients cannulated for respiratory failure had the highest survival (55.7%, n = 97) compared to those supported for cardiac failure (33.3%, n = 6) or extracorporeal cardiopulmonary resuscitation (30%, n = 10). Patients supported on venovenous extracorporeal membrane oxygenation for respiratory failure had the best overall survival at 62.2% (n = 37). Important for the burn population, rates of surgical site bleeding were similar to other surgical patients placed on extracorporeal membrane oxygenation at 22.1%. Cardiac arrest prior to cannulation was associated with increased hospital mortality (odds ratio, 3.41; 95% CI, 0.16-1.01; p = 0.048). Following cannulation, complications including the need for inotropes (odds ratio, 2.64; 95% CI, 1.24-5.65; p = 0.011), presence of gastrointestinal hemorrhage (p = 0.049), and hyperglycemia (glucose > 240 mg/dL) (odds ratio, 3.42; 95% CI, 1.13-10.38; p = 0.024) were associated with increased mortality. Of patients with documented burn percentage of total body surface area (n = 19), survival was 70% when less than 60% total body surface area was involved.

CONCLUSIONS

Extracorporeal membrane oxygenation could be considered as an additional level of support for the pediatric burn population, especially in the setting of respiratory failure. Additional studies are necessary to determine the optimal timing of cannulation and other patient characteristics that may impact outcomes.

Exosomal miR-451 from human umbilical cord mesenchymal stem cells attenuates burn-induced acute lung injury

BACKGROUND

The aim of this study was to investigate the molecular mechanism of human umbilical cord mesenchymal stem cells (MSCs)-derived exosomes (hUCMSC-Exos) in regulating burn-induced acute lung injury (ALI).

METHODS

In this study, we initially isolated exosomes from hUCMSCs and identified them by transmission electron microscopy. The expression of the protein markers CD9 and CD63 in the exosomes was determined by western blot analysis. The expression of miR-451 in the hUCMSC-Exos was determined by qRT-PCR. The levels of TNF-α, IL-1β, and IL-6 in lung tissues and serum as well as the levels of malondialdehyde, myeloperoxidase, superoxide dismutase in lung tissues were detected by ELISA. Hematoxylin-eosin stain was used to observe the morphological changes of lung tissues after burn. Terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling assays were performed to detect apoptosis in lung tissues after burn. The expression of proteins related to the Toll-like receptor 4 (TLR4)/NF-κB signaling pathway in lung tissues after burn was analyzed by western blotting.

RESULTS

Our results showed that hUCMSC-Exos successfully decreased TNF-α, IL-1β, and IL-6 levels in rats after burn, and this reduction was reversed when the miR-451 expression in the hUCMSC-Exo group was inhibited. HUCMSC-Exo-derived miR-451 improves ALI via the TLR4/NF-κB pathway.

CONCLUSION

We demonstrated that exosomes derived from hUCMSCs mediate miR-451 to attenuate burn-induced ALI.

Extracorporeal membrane oxygenation in severe respiratory failure resulting from burns and smoke inhalation injury

Extracorporeal membrane oxygenation (ECMO) is one of the most frequent forms of extracorporeal life support (ECLS) and can be used as rescue therapy in patients with severe respiratory failure resulting from burns and/or smoke inhalation injury. Experience and literature on this treatment option is still very limited, consequently results are varied. We report a retrospective analysis of our experience with veno-venous (VV) ECMO in burn patients. All five patients, three male and two female (age: 28-37 years) had flame type burns and smoke inhalation injury. Their Murray scores ranged between 3.25 and 3.75, and their revised Baux scores between 62 and 102. The mean pre-ECMO conventional ventilation time was 7.4days (3-13). The mean ECMO duration was 18days (8-35). Three patients were cannulated with dual lumen, two with separate cannulae. One oxygenator had to be changed due to technical issues and two patients needed two parallel oxygenators. Four patients had renal replacement therapy. All patients needed vasoconstrictor support, antibiotics and packed red blood cells (5-62 units). Three had steroid treatment. All five patients were successfully weaned from ECMO. One patient died later from multi-organ failure in the ICU, the other four patients survived. VV-ECMO is a useful rescue intervention in patients with burns related severe respiratory failure. Patients in our institution benefit from having both burns and ECMO centres with major expertise in the field under one roof. The results from this small cohort are encouraging, although more cases are needed to draw more robust conclusions.

Extracorporeal Life Support Use in Adult Burn Patients

Burn-related cardiopulmonary failure causes significant morbidity and is associated with increased risk of death. Extracorporeal life support (ECLS) may be used to support burn patients, but its efficacy and safety in this population have not been well defined. This study examined survival rates and risk factors for death in adult burn patients who received ECLS. Retrospective data from the Extracorporeal Life Support Organization international registry were analyzed to determine clinical outcomes and risk factors for death in adult burn patients treated with ECLS. During the study period, we identified 58 adult burn patients who were treated with ECLS. Overall survival to hospital discharge was 43%. Survivors and nonsurvivors were similar in age, gender, body weight, mode of ECLS used, and duration of ECLS. Nonsurvivors had lower pH values (7.15 vs 7.30, P < .001) and higher pCO2 values (65.5 vs 50.5, P = .038) before initiation of ECLS. Nonsurvivors had higher rates of renal failure (49 vs 16%, P = .01) and renal replacement therapy (70 vs 36%, P = .016). Infection was documented in 21 patients; survival in this group was 43%. Multivariate logistic regression analysis identified acidosis (pH < 7.16) and the use of inotropic/vasopressor medications before ECLS as risk factors associated with increased risk of mortality. ECLS appears to be a viable treatment option for adult burn patients with cardiopulmonary failure. ECLS survival in adult burn victims is similar to that observed in nonburn patient populations treated with ECLS.

Pediatric inhalation injury

Smoke inhalation injury can cause severe physiologic perturbations. In pediatric patients, these perturbations cause profound changes in cardiac and pulmonary physiology. In this review, we examine the pathology, early management options, ventilator strategy, and long-term outcomes in pediatric patients who have suffered a smoke inhalation injury.

Extracorporeal membrane oxygenation support may be a lifesaving modality in patients with burn and severe acute respiratory distress syndrome: Experience of Formosa Water Park dust explosion disaster in Taiwan

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) has been reported to improve outcomes in patients with refractory respiratory failure. These successful experiences have stimulated interest in using ECMO as a potential therapy for patients with acute pulmonary failure resulting from burn and inhalation lung injury. Current literature has supported the use of ECMO in critically-ill, pediatric burn patients. On the other hand, it is controversial to apply ECMO in adult burn patients, and the evidence is limited by the shortcomings of small sample size. We share our successful experience of ECMO treatment in the casualties of the Formosa Water Park Dust Explosion Disaster.

METHODS

We investigated the data from the dust explosion event, which happened on June 27, 2015, in New Taipei, Taiwan. The medical records of five patients with severe acute respiratory distress syndrome receiving ECMO were evaluated.

RESULTS

The mean study subject age was 21.8 years, with a mean total body surface area burned of 82.9%. The average time to ECMO setup was 48.6 days. Survivors and non-survivors averaged four days and 77.7 days, respectively. The overall mortality rate was 40%. Three survivors were discharged without any ECMO-related complications or pulmonary sequelae after one year of follow up.

CONCLUSIONS

ECMO may be a lifesaving modality for burn patients with severe lung injury who are nonresponsive to maximal medical management, especially for young patients with early ECMO intervention.

Pathophysiology, research challenges, and clinical management of smoke inhalation injury

Smoke inhalation injury is a serious medical problem that increases morbidity and mortality after severe burns. However, relatively little attention has been paid to this devastating condition, and the bulk of research is limited to preclinical basic science studies. Moreover, no worldwide consensus criteria exist for its diagnosis, severity grading, and prognosis. Therapeutic approaches are highly variable depending on the country and burn centre or hospital. In this Series paper, we discuss understanding of the pathophysiology of smoke inhalation injury, the best evidence-based treatments, and challenges and future directions in diagnostics and management.

A Survey of Mechanical Ventilator Practices Across Burn Centers in North America

Burn injury introduces unique clinical challenges that make it difficult to extrapolate mechanical ventilator (MV) practices designed for the management of general critical care patients to the burn population. We hypothesize that no consensus exists among North American burn centers with regard to optimal ventilator practices. The purpose of this study is to examine various MV practice patterns in the burn population and to identify potential opportunities for future research. A researcher designed, 24-item survey was sent electronically to 129 burn centers. The χ, Fisher's exact, and Cochran-Mantel-Haenszel tests were used to determine if there were significant differences in practice patterns. We analyzed 46 questionnaires for a 36% response rate. More than 95% of the burn centers reported greater than 100 annual admissions. Pressure support and volume assist control were the most common initial MV modes used with or without inhalation injury. In the setting of Berlin defined mild acute respiratory distress syndrome (ARDS), ARDSNet protocol and optimal positive end-expiratory pressure were the top ventilator choices, along with fluid restriction/diuresis as a nonventilator adjunct. For severe ARDS, airway pressure release ventilation and neuromuscular blockade were the most popular. The most frequently reported time frame for mechanical ventilation before tracheostomy was 2 weeks (25 of 45, 55%); however, all respondents reported in the affirmative that there are certain clinical situations where early tracheostomy is warranted. Wide variations in clinical practice exist among North American burn centers. No single ventilator mode or adjunct prevails in the management of burn patients regardless of pulmonary insult. Movement toward American Burn Association-supported, multicenter studies to determine best practices and guidelines for ventilator management in burn patients is prudent in light of these findings.

Extracorporeal membrane oxygenation for neonatal and pediatric respiratory failure: an evidence-based review of the past decade (2002-2012)

OBJECTIVE

To provide a comprehensive evidence-based review of extracorporeal membrane oxygenation for neonatal and pediatric respiratory failure.

DATA SOURCE

A thorough computerized bibliographic search of the clinical literature regarding the use of extracorporeal membrane oxygenation in the neonatal and pediatric populations.

STUDY SELECTION

Clinical trials published between January 1, 2002, and October 1, 2012, including "extracorporeal membrane oxygenation" or "ECMO" and limited to studies involving humans aged 0-18 years. Trials focused on extracorporeal membrane oxygenation for cardiac indications were excluded from this study, unless the study was evaluating ancillary therapies in conjunction with extracorporeal membrane oxygenation.

DATA EXTRACTION

Studies were evaluated for inclusion based on reporting of patient outcomes and/or strategic considerations, such as cannulation strategies, timing of extracorporeal membrane oxygenation utilization, and ancillary therapies.

DATA SYNTHESIS

Pertinent data are summarized, and the available data are objectively classified based on the value of the study design from which the data are obtained.

CONCLUSIONS

Despite a large number of published extracorporeal membrane oxygenation studies, there remains a paucity of high-quality clinical trials. The available data support continued use of extracorporeal membrane oxygenation for respiratory failure refractory to conventional therapy for neonatal and pediatric patients without significant comorbidities. Further research is needed to better quantify the benefit of extracorporeal membrane oxygenation and the utility of many therapies commonly applied to extracorporeal membrane oxygenation patients.

Review of burn research for the year 2010

Like the previous year, 2010 was another active year for research in burn care. For this year, more than 1200 burn-related articles were published on a diverse array of topics. In this review, we focus on innovative and impactful burn injury-related research. As in the previous review, we group articles according to the following categories: critical care, infection, inhalation injury, epidemiology, psychology, wound characterization and treatment, nutrition and metabolism, pain and itch management, burn reconstruction, and rehabilitation. We have found that burn research continues to be prolific throughout the world and reflects the wide-ranging and complex care requirements of burn survivors.

Pediatric burn injuries

Pediatric burns comprise a major mechanism of injury, affecting millions of children worldwide, with causes including scald injury, fire injury, and child abuse. Burn injuries tend to be classified based on the total body surface area involved and the depth of injury. Large burn injuries have multisystemic manifestations, including injuries to all major organ systems, requiring close supportive and therapeutic measures. Management of burn injuries requires intensive medical therapy for multi-organ dysfunction/failure, and aggressive surgical therapy to prevent sepsis and secondary complications. In addition, pain management throughout this period is vital. Specialized burn centers, which care for these patients with multidisciplinary teams, may be the best places to treat children with major thermal injuries. This review highlights the major components of burn care, stressing the pathophysiologic consequences of burn injury, circulatory and respiratory care, surgical management, and pain management of these often critically ill patients.

Extracorporeal membrane oxygenation in burn and smoke inhalation injury

A systematic review and meta-analysis was conducted to assess the level of evidence for the use of extracorporeal membrane oxygenation (ECMO) in hypoxemic respiratory failure resulting from burn and smoke inhalation injury. We searched any article published before March 01, 2012. Available studies published in any language were included. Five authors rated each article and assessed the methodological quality of studies using the recommendation of the Oxford Centre for Evidence Based Medicine (OCEBM). Our search yielded 66 total citations but only 29 met the inclusion criteria of burn and/or smoke inhalation injury. There are no available systematic reviews/meta-analyses published that met our inclusion criteria. Only a small number of clinical trials, all with a limited number of patients, were available. The overall data suggests that there is no improvement in survival for burn patients suffering acute hypoxemic respiratory failure, with the use of ECMO. ECMO run times of less than 200 h correlate with higher survival compared to 200 h or more. Scald burns show a tendency of higher survival than flame burns. In conclusion, the presently available literature is based on insufficient patient numbers; the data obtained and level of evidence generated are limited. The role of ECMO in burn and smoke inhalation injury is therefore unclear. However, ECMO technology and expertise have improved over the last decades. Further research on ECMO in burn and smoke inhalation injury is warranted.

Current status of pediatric/neonatal extracorporeal life support: clinical outcomes, circuit evolution, and translational research

Extracorporeal life support (ECLS) offers lifesaving mechanical circulatory support for patients afflicted with respiratory and/or cardiac failure. Neonatal respiratory patients have higher survival rates compared to pediatric patients, while, for cardiac cases, pediatric patients are more likely to survive. The indications for ECLS have been expanded due to the improved technology and favorable outcomes. However, the rate of mortality and morbidity for ECLS patients remains significant. Mechanical complications still comprise a large percentage of ECLS complications, leaving definite room for improvement in ECLS circuit technology in the future. As a pre-clinical evaluating tool, translational research will provide more useful information for the selection of ECLS devices, encourage further development of ECLS technology, and, ultimately, benefit the patients.