Need for Mechanical Ventilation in Pediatric Scald Burns: Why it Happens and Why it Matters

The Effect of Various, Everyday Practices on Glucose Levels in Critically Ill Children

BACKGROUND

To evaluate the effect of various, everyday intensive care unit (ICU) practices on glucose levels in critically ill pediatric patients with the use of a continuous glucose monitoring system.

METHODS

Seventeen sensors were placed in 16 pediatric patients (8 male). All therapeutic and diagnostic interventions were recorded and 15 minutes later, a flash glucose measurement was obtained by swiping the sensor with a reader. Glucose difference was calculated as the glucose value 15 minutes after the intervention minus the mean daily glucose value for each individual patient. Additionally, the consciousness status of the patient (awake or sedated) was recorded.

RESULTS

Two hundred and five painful skin interventions were recorded. The mean difference of glucose values was higher by 1.84 ± 14.76 mg/dL (95% CI: -0.19 to 3.87 mg/dL, P = .076). However, when patients were categorized regarding their consciousness level, mean glucose difference was significantly higher in awake state than in sedated patients (4.76 ± 28.07 vs -2.21 ± 15.77 mg/dL, P < .001). Six hundred forty-nine interventions involving the respiratory system were recorded. Glucose difference during washings proved to be significantly higher than the ones during simple suctions (4.74 ± 14.18 mg/dL vs 0.32 ± 18.22 mg/dL, P = .016). Finally, glucose difference in awake patients was higher by 3.66 ± 13.91 mg/dL compared to glucose difference of -2.25 ± 21.07 mg/dL obtained during respiratory intervention in sedated patients.

CONCLUSIONS

Diagnostic and therapeutic procedures in the ICU, especially when performed in an awake state, exacerbate the stress and lead to a significant rise in glucose levels.

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.

Emergency Care of Pediatric Burns

Although the overall incidence of and mortality rate associated with burn injury have decreased in recent decades, burns remain a significant source of morbidity and mortality in children. Children with major burns require emergent resuscitation. Resuscitation is similar to that for adults, including pain control, airway management, and administration of intravenous fluid. However, in pediatrics, fluid resuscitation is needed for burns greater than or equal to 15% of total body surface area (TBSA) compared with burns greater than or equal to 20% TBSA for adults. Unique to pediatrics is the additional assessment for non-accidental injury and accurate calculation of the percentage of total burned surface area (TBSA) in children with changing body proportions are crucial to determine resuscitation parameters, prognosis, and disposition.

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.