Maintenance of serum albumin levels in pediatric burn patients: a prospective, randomized trial

Recombinant human growth hormone treatment in pediatric burn patients and its role during the hepatic acute phase response

OBJECTIVE

Recombinant human growth hormone (rHGH) has been shown to increase mortality in adult trauma patients; however, little has been reported on its side effects in children. The acute phase response has been suggested to be a contributing factor to trauma mortality. Therefore, the purpose of this study was to examine the effects of exogenous rHGH on the acute phase response in pediatric bum patients.

DESIGN

Prospective, randomized, double-blind study.

SETTING

Shriners Hospital for Children.

PATIENTS

Thermally injured pediatric patients, ranging in age from 0.1 to 16 yrs.

INTERVENTIONS

Twenty-eight thermally injured children received either 0.2 mg/kg/day of rHGH or saline (placebo) within 3 days of admission and for at least 25 days.

MEASUREMENTS AND MAIN RESULTS

Measurements were patient demographics, incidence of sepsis, inhalation injury, mortality, serum constitutive proteins, acute phase proteins, proinflammatory cytokines and insulin-like growth factor-I (IGF-I), insulin-like growth factor binding protein (IGFBP)-1, and IGFBP-3. No differences could be demonstrated in age, gender, burn size, incidence in sepsis (20% vs. 26%), inhalation injury (46% vs. 27%), or mortality (8% vs. 7%) between those receiving rHGH or placebo. Serum IGF-I and IGFBP-3 increased with rHGH treatment, whereas serum IGFBP-1 decreased compared with placebo (p < .05). Burned children treated with rHGH required significantly less albumin substitution to maintain normal levels compared with placebo (p < .05). Those receiving rHGH demonstrated a decrease in serum C-reactive protein and serum amyloid-A and an increase in serum retinol-binding protein compared with placebo (p < .05). rHGH decreased serum tumor necrosis factor-alpha and interleukin (IL)-1beta, whereas no changes were found for serum IL-1alpha, IL-6, and IL-10 compared with placebo (p < .05). Free fatty acids were elevated in burned children who received rHGH (p < .05).

CONCLUSION

Data indicate that rHGH does not increase mortality. rHGH decreased acute phase proteins, tumor necrosis factor-alpha, and IL-1beta, which is associated with increases in constitutive hepatic proteins and IGF-I.

Burns resuscitation: what place albumin?

The Cochrane analysis of the use of albumin in critical illness has highlighted the need for more well-conducted studies on colloid use in burns. The lack of objectivity in the press regarding this material has compromised our ability to deliver those studies. The analysis provides no evidence that albumin is unsafe for the initial resuscitation of uncomplicated burns, and the fall in its use is more likely to be cost-related.

The appropriate role of colloids in managing fluid imbalance: a critical review of recent meta-analytic findings

Three meta-analyses have recently been reported on the relationship between choice of resuscitation fluid and risk of mortality in critically ill patients. The relative risk of death (1.16-1.19) in two of the meta-analyses was slightly higher in colloid than crystalloid recipients; however, this observation was not statistically significant. In the third meta-analysis, 6% (95% confidence interval [CI], 3-9%) pooled excess mortality was documented in patients receiving albumin for hypovolaemia, burns or hypoalbuminaemia. The mortality difference in hypovolaemia patients (4%; 95% CI, 0-8%) was not statistically significant. A variety of serious limitations apply to the three meta-analyses, suggesting that their findings be interpreted cautiously. More than one-half of the randomized controlled trials (RCTs) included in the meta-analyses were reported prior to 1990 and hence do not reflect current practice. Each meta-analysis included only a subset of relevant RCTs, and therefore the scope of inferences to be drawn from the meta-analytic results is limited. The meta-analyses combined RCTs that were notably heterogeneous with respect to patient characteristics, type of illness, administered fluids and physiologic endpoints. Differences in illness severity, concomitant therapies and fluid management approaches were not taken into account. Very few of the RCTs were blinded. The meta-analyses do not support the conclusion that choice of resuscitation fluid is a major determinant of mortality in critically ill patients, nor do they support changes to current fluid management practice. Changes such as exclusive reliance on crystalloids would necessitate a reassessment of the goals and methods of fluid therapy. Since the effect on mortality may be minimal or non-existent, choice of resuscitation fluid should rest on whether the particular fluid permits the intensive care unit to provide better patient care.

[Management of severe burns during the 1st 72 hours]

Early and efficient management of severely burned patients facilitates outcome improvement. Pre-hospital care includes fluid loading with 2 mL.kg-1/% burn over the first six hours, sedation and analgesia, prevention of hypothermia and ventilatory support for either critically burned patients or facial, cervical or pulmonary burn injury. The transient stay in a general hospital before transfer to a burn centre allows extension of initial care, the critical investigation for associated injuries (intoxication, multiple trauma) and to perform initial local treatment with sterile coverage or vaseline gauze after a revised assessment of the burned skin area, and possibly escharotomies. The main aim of care in the burn centre is to control hypovolaemia and to obtain maximal tissue perfusion and oxygen delivery to burned tissues, as well as to healthy organs. To manage the burn shock (initially hypovolemic and later on hyperdynamic) catecholamines are often indicated when appropriate fluid loading remains insufficient. Mechanical ventilation is indicated in case of either a deep extensive burn over 60% of total body surface area, or facial and cervical burns or severe pulmonary burn injury from smoke inhalation, carbon monoxide intoxication, tracheobronchial thermal injury and blast injury. Because of the severity of burn-related pain, and the stimulus linked to intensive care, continuous sedation is usually required. Early surgical treatment such as escharotomies, excision and grafting, which cause significant pain as well as blood loss, and hydrotherapy, often require general anaesthesia. Burn injury can modify the volume of distribution and the pharmacokinetics of anaesthetic agents. Finally, chemical or electrical burn, radiation, associated CO intoxication or multiple trauma, as well as burn injury in infants, raise specific problems. With improvement in early intensive care, the survival rate of the most severely burned patients is obviously improving. New techniques in skin substitution will probably further improve the final outcome.

Serum albumin: touchstone or totem?

A decrease in serum albumin concentrations is an almost inevitable finding in disease states, and is primarily mediated in the acute phase by alterations in vascular permeability and redistribution. This change is not disease specific but marked changes that persist are generally associated with a poorer prognosis. Critical appraisal of long-standing practices and the availability of alternative colloid solutions have led to a reduction in albumin replacement therapy, and a widespread tolerance of lower albumin concentrations in patients. The factors determining serum albumin concentrations, their measurement and the implications of hypoalbuminaemia are reviewed. The clinical value of serum albumin measurement is discussed.

Human albumin administration in critically ill patients: systematic review of randomised controlled trials

OBJECTIVE

To quantify effect on mortality of administering human albumin or plasma protein fraction during management of critically ill patients.

DESIGN

Systematic review of randomised controlled trials comparing administration of albumin or plasma protein fraction with no administration or with administration of crystalloid solution in critically ill patients with hypovolaemia, burns, or hypoalbuminaemia.

SUBJECTS

30 randomised controlled trials including 1419 randomised patients.

MAIN OUTCOME MEASURE

Mortality from all causes at end of follow up for each trial.

RESULTS

For each patient category the risk of death in the albumin treated group was higher than in the comparison group. For hypovolaemia the relative risk of death after albumin administration was 1.46 (95% confidence interval 0.97 to 2.22), for burns the relative risk was 2.40 (1.11 to 5.19), and for hypoalbuminaemia it was 1.69 (1.07 to 2.67). Pooled relative risk of death with albumin administration was 1.68 (1.26 to 2.23). Pooled difference in the risk of death with albumin was 6% (95% confidence interval 3% to 9%) with a fixed effects model. These data suggest that for every 17 critically ill patients treated with albumin there is one additional death.

CONCLUSIONS

There is no evidence that albumin administration reduces mortality in critically ill patients with hypovolaemia, burns, or hypoalbuminaemia and a strong suggestion that it may increase mortality. These data suggest that use of human albumin in critically ill patients should be urgently reviewed and that it should not be used outside the context of rigorously conducted, randomised controlled trials.

Physiologic hypoalbuminemia is well tolerated by severely burned children

BACKGROUND

Physiologic hypoalbuminemia, defined as a plasma albumin (pl-ALB) of 1.0 to 2.5 g/dL, is a component of the injury response. A consensus on the need for albumin supplementation in this setting is lacking.

METHODS

We examined 27 consecutive children (age, 7 +/- 6 years) with > 40% body surface burns (mean, 59 +/- 18%) during their initial 4 weeks of care. Patients were managed with an albumin-supplementation protocol that tolerated profound physiologic hypoalbuminemia. Intravenous albumin was administered by infusion of 1 to 2 g/kg/d when pl-ALB fell below 1.0 g/dL, or below 1.5 g/dL in the presence of enteral feeding intolerance or pulmonary dysfunction. Supplementation was stopped when pl-ALB reached 2.0 g/dL.

RESULTS

Mean pl-ALB was 1.7 g/dL overall. Infusion for pl-ALB < 1.0 g/dL was needed for 70% (n = 19) of the patients. Profound physiologic hypoalbuminemia was constant, that is, mean weekly pl-ALB never exceed 2.5 g/dL in any patient. Mean plasma globulin rose during the 4 week period from 2.3 +/- 0.1 at week 1 to 3.1 +/- 0.1 at week 4. Diarrhea was negligible (19 of 756 patient days), nasogastric feedings were well tolerated, PaO2/FiO2 ratios remained well above 150, wounds healed satisfactorily, and all children survived and have been discharged home.

CONCLUSIONS

Profound physiologic hypoalbuminemia (pl-ALB of 1.0-2.5 g/dL) does not have adverse effects on pulmonary or gut function, wound healing, or outcome in severely burned children, perhaps because of a compensatory increase in acute-phase proteins reflected in plasma globulin.