The seriously burned child: resuscitation through reintegration--2

Pediatric burn-trauma patients have increased length of stay compared to trauma-only patients: A propensity matched analysis

BACKGROUND

Trauma is the leading cause of mortality in children. Burn injury involves intensive resources, especially in pediatric patients. We hypothesized that among pediatric trauma patients, combined burn-trauma (BT) patients have increased length of stay (LOS) and mortality compared to trauma-only (T) patients.

METHODS

The Pediatric Trauma Quality Improvement Program (2014-2016) was queried and BT patients were 1:2 propensity-score-matched to T patients based on age, gender, hypotension on admission, injury type and severity.

RESULTS

93 BT patients were matched to 186 T patients. There were no differences in matched characteristics. BT patients had a longer median LOS (4 vs 2 days, p<0.001) with no difference in mortality (1.1% vs 1.1%, p=1.00), intensive care unit (ICU) LOS (3 vs 3 days, p=0.55), or complications including decubitus ulcer (0% vs 1.1%, p=0.32), deep vein thrombosis (0% vs 0.5%, p=0.48), extremity compartment syndrome (1.1% vs 0%, p=0.16), and urinary tract infection (1.1% vs 1.1%, p=1.00).

CONCLUSION

Pediatric BT patients had twice the LOS compared to a matched group of pediatric T patients. There was no difference between the cohorts in ICU LOS, complications or mortality rate. When evaluating risk-stratified quality metrics such as LOS, concomitant burn injury should be incorporated.

Predictors of mortality of pediatric burn injury in the Douala General Hospital, Cameroon

Introduction

Burn injuries are a major cause of hospitalization and are associated with significant morbidity and mortality, particularly in children aged four years or below. In Cameroon, the mortality rate of pediatric severe burns was estimated at 41.2%. There is need to determine the predictors of such mortality in order to guide appropriate management.

Methods

This study is aimed at assessing the predictors of mortality of pediatric patients who sustained a burn injury over a period of 11 years (between 1^st of January 2006 and 31^st of December 2016) in Douala General Hospital (DGH). The data for this study was entered in an electronic questionnaire and analyzed using Epi info version 7. All variables thought to be associated with mortality were entered in a multiple binary logistic regression model. The magnitude or risk was measured by odds ratio, and the 95% confidence interval was estimated.

Results

A total of 125 cases of pediatric burns were recorded over the study period. A total of 69 (55.65%) were males, giving a male to female ratio of 1.25:1. The median age was 4 years. Most pediatric burns resulted from accidents. Most patient 78 (69%) came before 8 hours following injury. Scalding was the predominant mechanism of injury in 56 (45.5%) of patients. Most patients had partial thickness burn and most burns involved 1-9.9% body surface areas (BSA). The mean length of hospital stay in this study was 7 days, more than half of the patients had no complications during admission. Among those that developed complications, 19 (35%) developed sepsis.

Conclusion

Mortality rate of pediatric burns obtained in this study was 29%, mostly due to cardiac arrest. Flame burns (p=0.03) and BSA >25% (p=0.001) were statistically significant predictors of mortality.

Sepsis in pediatric burn patients

OBJECTIVE

To review the specific infections common in pediatric burns, including their categorization, diagnosis, and treatment.

DESIGN

Review of the literature and expert opinion.

RESULTS

Children with serious burns are prone to a host of septic complications. This proclivity to infection is secondary to the immunosuppressive effect of burn injury, the loss of the skin and mucosal physical barriers, and the requirement for invasive support devices.

CONCLUSION

Sepsis is common in the pediatric burn patient and can markedly increase morbidity and mortality. Anticipation, prompt diagnosis of infection, and effective therapy can result in successful outcomes for many of these children.

Management of background pain and anxiety in critically burned children requiring protracted mechanical ventilation

Optimal control of pain and anxiety is an elusive but important goal in children with protracted critical illness. This review represents an effort to document the doses of background medication required to achieve this goal in a group of children managed under a pain and anxiety protocol that adjusts background infusions to comfort. The course of children with wounds involving at least 10% of the body surface and coincident respiratory failure requiring mechanical ventilation for more than 7 days managed 1 Jan 97 to 31 Dec 98 was reviewed. A pain and anxiety protocol was used, including background infusions of morphine and midazolam adjusted to comfort. These 28 children had a mean (+/- standard deviation) age of 5.3 +/- 4.6 years, wound size of 48.3 +/- 28.4%, and were intubated for 25.0 +/- 23.9 days. Neuromuscular blocking drugs were administered for 65 of 447 (14.5%) ventilator days. To maintain comfort, drugs were required at doses substantially above standard dosing schemes. The highest daily background infusion of morphine sulfate averaged 0.40 mg/kg/hr +/- 0.24 mg/kg/hr (usual starting dose was 0.05 to 0.1 mg/kg/hr) and was reached 14.1 +/- 12.8 days after admission. The highest daily background infusion of midazolam averaged 0.15 +/- 0.07 mg/kg/hr (usual starting dose was 0.04 mg/kg/hr) and was reached 14.0 +/- 3.8 days after admission. Morphine infusions at extubation averaged 0.22 +/- 0.17 mg/kg/hr and midazolam infusions 0.10 +/- 0.12 mg/kg/hr. All children survived to discharge and there was no perceived morbidity related to these high doses of medication. Children with serious burns and respiratory failure will require high doses of background opiates and benzodiazepines to remain comfortable, because they develop drug tolerance during protracted critical illness. Infusions can be continued at a reduced dose through extubation, do not result in addiction or other apparent morbidity if adjusted to desired level of comfort, and may contribute to a reduced incidence of treatment-related stress disorders.