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Abstract
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.
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Glas GJ, Horn J, van der Hoeven SM, Hollmann MW, Cleffken B, Colpaert K, Juffermans NP, Knape P, Loef BG, Mackie DP, Malbrain M, Muller J, Reidinga AC, Preckel B, Schultz MJ. Changes in ventilator settings and ventilation-induced lung injury in burn patients-A systematic review. Burns 2019; 46:762-770. [PMID: 31202528 DOI: 10.1016/j.burns.2019.05.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 03/20/2019] [Accepted: 05/21/2019] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Ventilation strategies aiming at prevention of ventilator-induced lung injury (VILI), including low tidal volumes (VT) and use of positive end-expiratory pressures (PEEP) are increasingly used in critically ill patients. It is uncertain whether ventilation practices changed in a similar way in burn patients. Our objective was to describe applied ventilator settings and their relation to development of VILI in burn patients. DATA SOURCES Systematic search of the literature in PubMed and EMBASE using MeSH, EMTREE terms and keywords referring to burn or inhalation injury and mechanical ventilation. STUDY SELECTION Studies reporting ventilator settings in adult or pediatric burn or inhalation injury patients receiving mechanical ventilation during the ICU stay. DATA EXTRACTION Two authors independently screened abstracts of identified studies for eligibility and performed data extraction. DATA SYNTHESIS The search identified 35 eligible studies. VT declined from 14 ml/kg in studies performed before to around 8 ml/kg predicted body weight in studies performed after 2006. Low-PEEP levels (<10 cmH2O) were reported in 70% of studies, with no changes over time. Peak inspiratory pressure (PIP) values above 35 cmH2O were frequently reported. Nevertheless, 75% of the studies conducted in the last decade used limited maximum airway pressures (≤35 cmH2O) compared to 45% of studies conducted prior to 2006. Occurrence of barotrauma, reported in 45% of the studies, ranged from 0 to 29%, and was more frequent in patients ventilated with higher compared to lower airway pressures. CONCLUSION This systematic review shows noticeable trends of ventilatory management in burn patients that mirrors those in critically ill non-burn patients. Variability in available ventilator data precluded us from drawing firm conclusions on the association between ventilator settings and the occurrence of VILI in burn patients.
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Affiliation(s)
- Gerie J Glas
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam Universitair Medische Centra, Amsterdam, The Netherlands; Department of Anesthesiology, Amsterdam Universitair Medische Centra, Amsterdam, The Netherlands.
| | - Janneke Horn
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam Universitair Medische Centra, Amsterdam, The Netherlands; Department of Intensive Care, Amsterdam Universitair Medische Centra, Amsterdam, The Netherlands
| | - Sophia M van der Hoeven
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam Universitair Medische Centra, Amsterdam, The Netherlands; Department of Intensive Care, Amsterdam Universitair Medische Centra, Amsterdam, The Netherlands
| | - Markus W Hollmann
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam Universitair Medische Centra, Amsterdam, The Netherlands; Department of Anesthesiology, Amsterdam Universitair Medische Centra, Amsterdam, The Netherlands
| | - Berry Cleffken
- Department of Intensive Care, Maasstad Hospital, Rotterdam, The Netherlands
| | - Kirsten Colpaert
- Department of Intensive Care, Ghent University Hospital, Ghent, Belgium
| | - Nicole P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam Universitair Medische Centra, Amsterdam, The Netherlands; Department of Anesthesiology, Amsterdam Universitair Medische Centra, Amsterdam, The Netherlands
| | - Paul Knape
- Department of Intensive Care, Red Cross Hospital, Beverwijk, The Netherlands
| | - Bert G Loef
- Department of Intensive Care, Martini Hospital, Groningen, The Netherlands
| | - David P Mackie
- Department of Intensive Care, Red Cross Hospital, Beverwijk, The Netherlands
| | - Manu Malbrain
- Department of Intensive Care, University Hospital Brussels, Jette, Belgium
| | - Jan Muller
- Department of Intensive Care, University Hospital Gasthuisberg, Leuven, Belgium
| | - Auke C Reidinga
- Department of Intensive Care, Martini Hospital, Groningen, The Netherlands
| | - Benedikt Preckel
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam Universitair Medische Centra, Amsterdam, The Netherlands; Department of Anesthesiology, Amsterdam Universitair Medische Centra, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam Universitair Medische Centra, Amsterdam, The Netherlands; Department of Intensive Care, Amsterdam Universitair Medische Centra, Amsterdam, The Netherlands
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Nayyar A, Charles AG, Hultman CS. Management of Pulmonary Failure after Burn Injury: From VDR to ECMO. Clin Plast Surg 2018; 44:513-520. [PMID: 28576240 DOI: 10.1016/j.cps.2017.02.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This article highlights the challenges in managing pulmonary failure after burn injury. The authors review several different ventilator techniques, provide weaning parameters, and discuss complications.
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Affiliation(s)
- Apoorve Nayyar
- Department of Surgery, University of North Carolina School of Medicine, Suite 7038, Burnett Womack, CB#7195, Chapel Hill, NC 27599, USA
| | - Anthony G Charles
- Department of Surgery, University of North Carolina School of Medicine, Suite 7038, Burnett Womack, CB#7195, Chapel Hill, NC 27599, USA
| | - Charles Scott Hultman
- Department of Surgery, University of North Carolina School of Medicine, Suite 7038, Burnett Womack, CB#7195, Chapel Hill, NC 27599, USA.
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Newsome AS, Sultan S, Murray B, Jones SW, Pappas A, Schmidt KT, Filteau G, Laux JP, Wolfe A, Williams F, Cairns BA. Effect of inhaled iloprost on gas exchange in inhalation injury. BURNS OPEN 2017. [DOI: 10.1016/j.burnso.2017.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Goh CT, Jacobe S. Ventilation strategies in paediatric inhalation injury. Paediatr Respir Rev 2016; 20:3-9. [PMID: 26628193 DOI: 10.1016/j.prrv.2015.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 10/19/2015] [Indexed: 10/22/2022]
Abstract
Inhalation injury increases morbidity and mortality in burns victims. While the diagnosis remains largely clinical, bronchoscopy is also helpful to diagnose and grade the severity of any injury. Inhalation injury results from direct thermal injury or chemical irritation of the respiratory tract, systemic toxicity from inhaled substances, or a combination of these factors. While endotracheal intubation is essential in cases where upper airway obstruction may occur, it has its own risks and should not be performed prophylactically in all cases of inhalation injury. The evidence-base informing the selection of optimal ventilation strategy in inhalation injury is sparse, and most recommendations are based on extrapolation from (largely adult) studies in acute respiratory distress syndrome (ARDS). Conventional ventilation using a lung-protective approach (i.e. low tidal volume, limited plateau pressure, and permissive hypercarbia) is recommended as the initial approach if invasive ventilation is required; various rescue strategies may become necessary if there is a poor response. The efficacy of many widely used pharmacologic adjuncts in inhalation injury remains uncertain. Further research is urgently required to address these gaps in our knowledge.
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Affiliation(s)
- Chong Tien Goh
- Advanced Trainee in Intensive Care Medicine, Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Sydney.
| | - Stephen Jacobe
- Senior Staff Specialist, Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Sydney, and Clinical Associate Professor, Sydney Medical School, University of Sydney, NSW, Australia
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Abstract
Children have unique physiologic, physical, psychological, and social needs compared with adults. Although adhering to the basic tenets of burn resuscitation, resuscitation of the burned child should be modified based on the child's age, physiology, and response to injury. This article outlines the unique characteristics of burned children and describes the fundamental principles of pediatric burn resuscitation in terms of airway, circulatory, neurologic, and cutaneous injury management.
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Prone positioning improves oxygenation in adult burn patients with severe acute respiratory distress syndrome. J Trauma Acute Care Surg 2012; 72:1634-9. [PMID: 22695433 DOI: 10.1097/ta.0b013e318247cd4f] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Prone positioning (PP) improves oxygenation and may provide a benefit in patients with acute respiratory distress syndrome (ARDS). This approach adds significant challenges to patients in intensive care by limiting access to the endotracheal or tracheostomy tube and vascular access. PP also significantly complicates burn care by making skin protection and wound care more difficult. We hypothesize that PP improves oxygenation and can be performed safely in burn patients with ARDS. METHODS PP was implemented in a burn intensive care unit for 18 patients with severe refractory ARDS. The characteristics of these patients were retrospectively reviewed to evaluate the impact of PP on Pao2:FiO2 ratio (PFR) during the first 48 hours of therapy. Each patient was considered his or her own control before initiation of PP, and trends in PFR were evaluated with one-way analysis of variance. Secondary measures of complications and mortality were also evaluated. RESULTS Mean PFR before PP was 87 (± 38) with a mean sequential organ failure assessment score of 11 (± 4). PFR improved during 48 hours in 12 of 14 survivors (p < 0.05). Mean PFR was 133 (± 77) immediately after PP, 165 (± 118) at 6 hours, 170 (± 115) at 12 hours, 214 (± 126) at 24 hours, 236 (± 137) at 36 hours, and 210 (± 97) at 48 hours. At each measured time interval except the last, PFR significantly improved. There were no unintended extubations. Facial pressure ulcers developed in four patients (22%). Overall, 14 survived 48 hours (78%), 12 survived 28 days (67%), and six survived to hospital discharge (33%). CONCLUSIONS PP improves oxygenation in burn patients with severe ARDS and was safely implemented in a burn intensive care unit. Mortality in this population remains high, warranting investigation into additional complementary rescue therapies. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Improved Survival Following Thermal Injury in Adult Patients Treated at a Regional Burn Center. J Burn Care Res 2008. [DOI: 10.1097/bcr.0b013e31815f6efd] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
A lesão inalatória é hoje a principal causa de morte nos pacientes queimados, motivo pelo qual se justifica o grande número de estudos publicados sobre o assunto. Os mecanismos envolvidos na gênese da lesão inalatória envolvem tanto os fatores de ação local quanto os de ação sistêmica, o que acaba por aumentar muito as repercussões da lesão. Atualmente, buscam-se ferramentas que permitam o diagnóstico cada vez mais precoce da lesão inalatória e ainda estratégias de tratamento que minimizem as conseqüências da lesão já instalada. Esta revisão aborda os mecanismos fisiopatológicos, os métodos diagnósticos e as estratégias de tratamento dos pacientes vítimas de lesão inalatória. Ressalta ainda as perspectivas terapêuticas em desenvolvimento.
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Abstract
Acute respiratory distress syndrome is a common condition among the critically ill and is associated with high morbidity and mortality [table: see text] rates. Improved understanding of the underlying inflammatory pathogenetics has encouraged the search for strategies that, by modifying this immune response, can improve outcome for this group of patients. Some agents are obviously anti-inflammatory. Others have been used primarily for other purposes; their immune effects are incidental, but no less important. Although immunomodulatory strategies have been discussed for many years, they now are beginning to show positive results, as in the study using activated protein C. Most patients with ARDS die with ARDS, rather than from ARDS. The approach to treatment must not be lung-limited but must take into account the systemic effects of the inflammatory response. The complex nature of the syndrome makes it likely that no single agent will provide the long-desired cure. Rather, it is probable that an individual patient will require a combination of several agents or different agents at different times during the disease process (Table 1). Mortality rates from ARDS already are beginning to fall with improved nutritional and ventilatory support. Positive results from trials using immunomodulatory agents are being reported, and soon such agents will form part of the routine management of patients with ARDS, further improving the outlook for these patients.
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Free University of Brussels, Brussels, Belgium.
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Millili JJ. Use of nitric oxide as an adjuvant therapy in respiratory failure after burn injuries. THE JOURNAL OF BURN CARE & REHABILITATION 2001; 22:308-10. [PMID: 11482692 DOI: 10.1097/00004630-200107000-00014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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