Respiratory failure after pediatric scald injury

Retrospective outcomes analysis of tracheostomy in a paediatric burn population

INTRODUCTION

Previous analyses of tracheostomy in paediatric burns was hindered by a lack of multi-institution or nationwide analysis. This study aims to explore the effects of tracheostomy in paediatric burn patients in such an analysis. De-identified data was obtained from the TriNetX Research Network database.

METHODS

Two cohorts were identified using ICD and CPT codes: paediatric burn patients with tracheostomy (cohort 1) and paediatric burn patients without tracheostomy (cohort 2). Cohorts were matched according to age at diagnosis and pulmonary condition, specifically influenza and pneumonia, respiratory failure, acute upper respiratory infection, and pulmonary collapse. Cohorts were also matched for age at burn diagnosis and surface area burned. Several parameters including infection following a procedure, sepsis, volume depletion, respiratory disorders, laryngeal disorders, pneumonia, and other metrics were also compared.

RESULTS

A total of 152 patients were matched according to age and pulmonary condition. Cohort 1 and cohort 2 had a mean age of 4.45 ± 4.06 and 4.39 ± 3.99 years, respectively. Matched patients with tracheostomy had a higher risk for pneumonia, respiratory failure, other respiratory disorders, diseases of the vocal cord and larynx, sepsis, volume depletion, pulmonary edema, and respiratory arrest. The risk ratios for these outcomes were 2.96, 3.5, 3.13, 3.9, 2.5, 2.5, 3.3, and not applicable. Analysis of longitudinal outcomes of paediatric burn patients with tracheostomy vs. those without demonstrated the tracheostomy cohort suffered much worse morbidity and experienced higher health burden across several metrics.

CONCLUSION

The potential benefits of tracheostomy in paediatric burn patients should be weighed against these outcomes.

Weaning of Children With Burn Injury by Noninvasive Ventilation: A Clinical Experience

The aim of this study was to report the respiratory management of a cohort of infants admitted to a Pediatric Intensive Care Unit (PICU) over a 7-year period due to severe burn injury and the potential benefits of noninvasive ventilation (NIV). A retrospective review of all pediatric patients admitted to PICU between 2009 and 2016 was conducted. From 2009 to 2016, 118 infants and children with burn injury were admitted to our institution (median age 16 months [IQR = 12.2-20]); 51.7% of them had face burns, 37.3% underwent tracheal intubation, and 30.5% had a PICU stay greater than 7 days. Ventilated patients had a longer PICU stay (13 days [IQR = 8-26] vs 4.5 days [IQR = 2-13]). Both ventilation requirement and TBSA% correlated with PICU stay (r = .955, p < .0001 and r = .335, p = .002, respectively), while ventilation was best related in those >1 week (r = .964, p < .0001 for ventilation, and r = -.079, p = .680, for TBSA%). NIV was introduced in 10 patients, with the aim of shorten the invasive ventilation requirement. As evidenced in our work, mechanical ventilation is frequently needed in burned children admitted to PICU and it is one of the main factors influencing PICU length of stay. No difference was found in terms of PICU length of stay and invasive mechanical ventilation time between children who underwent NIV and children who did not, despite children who underwent NIV had a larger burn surface. NIV can possibly shorten the total invasive ventilation time and related complications.

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.

Airway compromise in children with anterior neck burns: Beware the scalded child

AIM

The aim of the study was to describe characteristics of children with anterior neck burns admitted to our Paediatric Intensive Care Unit (PICU) and to highlight potential airway complications associated with these injuries, especially in children with scalds.

METHODS

Retrospective review of children with anterior neck burns requiring admission to PICU January 2004-December 2013.

RESULTS

Fifty-two children with anterior neck burns were admitted; average age 6.6 years. Thirty sustained flame/explosion injuries; 22 scalds. Seventy-nine per cent were male. Mean total body surface area (TBSA) burn 21%. Forty-seven were intubated. Some primary reasons for intubation included unconsciousness, inhalational/ingestion/direct airway injury and large TBSA. Majority, however, required intubation for airway complications secondary to subcutaneous/soft tissue anterior neck oedema not associated with airway injury/ingestion/inhalational burns. The scalds subgroup mean age was 2.3 years. Eighty-two per cent were male. Mean TBSA 18%. There were no inhalational/ingestion/airway injuries. Nineteen children were intubated; average 9.3 h post-injury. Majority (63%) were intubated post-arrival in the Burn Unit, compared with flame/explosion group (32%). Primary reasons for intubation included large burns, although majority (74%) required intubation for airway complications secondary to subcutaneous and soft tissue anterior neck oedema. For the flame/explosion group this was the case in only 46%, with other primary reasons such as unconsciousness or inhalational injury being the immediate precedent.

CONCLUSION

These results demonstrate that subcutaneous and soft tissue oedema secondary to anterior neck burns may contribute to airway narrowing and compromise requiring intubation. When assessing children's airways, evolving oedema should be recognised and higher observation or early intubation considered regardless of the mechanism of injury.