Fluid resuscitation of infants and children with massive thermal injury

Role of resuscitation ratio in monitoring burn patients

INTRODUCTION

Efforts with the utilization of an Input/Output ratio (I/O ratio) are done with success for analyzing and moving forward the treatment in the resuscitation phase of the burn patient. The need for conducting this research is to apply the I/O ratio in our cohort as a helpful index for classifying the resuscitation response of the burn patients. Our prespecified hypothesis is if it matters the analysis of the I/O ratio at 8 h of fluid resuscitation period.

MATERIAL AND METHOD

This prospective observational study was performed in 50 patients (22 adults and 28 children) admitted in the Intensive Care of the Service of Burns in Tirana, Albania in the period January to December 2016. We calculated the I/O ratio at 8 h and the end of the 1st 24 h based on the stratification of patients according to the ratio in respective groups. In the adult population we did an analysis whereby the ratio I/O at 8 h has a relationship with the 24 h results as well as with ICU-free days.

RESULTS

The 24 h fluid resuscitation was done with the majority clustered in the range 2-4 ml/kg/% TBSA with fluid-weight score (ml/kg) correlated with % TBSA. After calculation of the I/O ratio at 8 h, 29 patients were assigned in over-responders (<0.166), 16 patients in the expected group(0.166-0.334), and 5 patients were assigned in under-responders (>0.334). There is a strong correlation between the I/O ratio at 8 h and the I/O ratio at 24 h and I/O ratio predict better the longer ICU-free days.

CONCLUSIONS

The I/O ratio is a very useful parameter not only at 12 h and 24 h but also at 8 h after burns. By classifying the patients into outcome groups that reflect not only the volume given but moreover the physiologic reactions to the resuscitation volume gotten, we were more attentive to patients in under-responders at 8 h. This parameter fulfills the criteria for better classifying patients and a better understanding of the physiology of burns.

Management of severe thermal burns in the acute phase in adults and children

OBJECTIVES

To provide recommendations to facilitate the management of severe thermal burns during the acute phase in adults and children.

DESIGN

A committee of 20 experts was asked to produce recommendations in six fields of burn management, namely, (1) assessment, admission to specialised burns centres, and telemedicine; (2) haemodynamic management; (3) airway management and smoke inhalation; (4) anaesthesia and analgesia; (5) burn wound treatments; and (6) other treatments. At the start of the recommendation-formulation process, a formal conflict-of-interest policy was developed and enforced throughout the process. The entire process was conducted independently of any industry funding. The experts drew up a list of questions that were formulated according to the PICO model (Population, Intervention, Comparison, and Outcomes). Two bibliography experts per field analysed the literature published from January 2000 onwards using predefined keywords according to PRISMA recommendations. The quality of data from the selected literature was assessed using GRADE® methodology. Due to the current paucity of sufficiently powered studies regarding hard outcomes (i.e. mortality), the recommendations are based on expert opinion.

RESULTS

The SFAR guidelines panel generated 24 statements regarding the management of acute burn injuries in adults and children. After two scoring rounds and one amendment, strong agreement was reached for all recommendations.

CONCLUSION

Substantial agreement was reached among a large cohort of experts regarding numerous strong recommendations to optimise the management of acute burn injuries in adults and children.

The renaissance man of burn surgery: Basil A. Pruitt, Jr

Dr. Basil A. Pruitt Jr., a consummate clinical and translational surgeon-scientist, has spent over half a century at the forefront of an advancing standard of burn care. Commanding the US Army Institute for Surgical Research in San Antonio, he trained generations of leading burn clinicians and allied scientists. At his direction, there were forged discoveries in resuscitation from shock, treatment of inhalation injury, control of burn-related infections, prevention of iatrogenic complications, and understanding the sympathetic, endocrine, and immune responses to burn injury. Most consequentially, this team was among the first to recognize and define alterations in the basal metabolic rate and thermoregulation consequent to burn injury. These investigations prompted groundbreaking insights into the coordinated nervous, autonomic, endocrine, immune, and metabolic outflows that a severely burned patient uses to remain alive and restore homeostasis. Marking his scientific consequence, many of his reports continue to bear fruit when viewed through a contemporary lens. This article summarizes some of the major findings of his career thus far and is intended to complement a Festschrift recently held in his honor.

Pediatric burn resuscitation: past, present, and future

Burn injury is a leading cause of unintentional death and injury in children, with the majority being minor (less than 10%). However, a significant number of children sustain burns greater than 15% total body surface area (TBSA), leading to the initiation of the systemic inflammatory response syndrome. These patients require IV fluid resuscitation to prevent burn shock and death. Prompt resuscitation is critical in pediatric patients due to their small circulating blood volumes. Delays in resuscitation can result in increased complications and increased mortality. The basic principles of resuscitation are the same in adults and children, with several key differences. The unique physiologic needs of children must be adequately addressed during resuscitation to optimize outcomes. In this review, we will discuss the history of fluid resuscitation, current resuscitation practices, and future directions of resuscitation for the pediatric burn population.

Wound healing trajectories in burn patients and their impact on mortality

The rate of wound healing and its effect on mortality has not been well described. The objective of this article is to report wound healing trajectories in burn patients and analyze their effects on in-hospital mortality. The authors used software (WoundFlow) to depict burn wounds, surgical results, and healing progression at multiple time points throughout admission. Data for all patients admitted to the intensive care unit with ≥ 20% TBSA burned were collected retrospectively. The open wound size (OWS), which includes both unhealed burns and unhealed donor sites, was measured. We calculated the rate of wound closure (healing rate), which we defined as the change in OWS/time. We also determined the time delay (DAYS) from day of burn until day on which there was a reduction in OWS < 10%. Data are medians [interquartile range]. There were 38 patients with complete data; 25 had documentation of successful healing (H), and 13 did not (NH). H differed from NH on age (38 years [32-57] vs 63 [51-74]), body mass index (27 [21-28] vs 32 [19-52]), 24-hour fluid resuscitation (12 L [10-16] vs 18 [15-20]), pressors during first 48 hours (72% vs 100%), use of renal replacement therapy (32% vs 92%), and mortality (4% vs 100%). Repeated measures analysis of covariance showed a significant difference between survivors and nonsurvivors on OWS as a function of time (P<.001). Patients with a positive healing rate (+2%/day) after postburn day 20 had 100% survival whereas those with a negative healing rate (-2%/day) had 100% mortality. For H patients, median DAYS was 41 (28-54); median DAYS/TBSA was 1.3 (1.0-1.9). Survivors had a 0.62% drop in OWS/day, or 4.3%/week. In this cohort of patients with ≥ 20% TBSA, there was a difference in mortality after postburn day 20, between patients with a positive healing rate (+2%/day, 100% survival) and those with a negative healing rate (-2%/day, 100% mortality, P < .05).

Management of Burns and Anesthetic Implications

Burn injuries are highly complex and affect almost every major organ system in the body. The treatment of burn patients requires the presence of a well-organized team of caregivers who understand the multifaceted consequences of burn injuries and who are adept at coordinating care. An understanding of the multitude of abnormalities that must be addressed helps to guide therapy in these patients. Careful anesthetic and perioperative management of these patients carries special importance in this fragile patient population as a part of their often lengthy recovery and rehabilitation.

Graphic aids for calculation of fluid resuscitation requirements in pediatric burns

The Parkland formula is currently the most widely used protocol to guide fluid resuscitation of acute burns and has been adapted for pediatric use. We describe 3 novel graphic devices (a nomogram, slide rule, and disc calculator) based on this formula, which have significant advantages over existing graphic and electronic devices. The robust low-cost graphic devices would be particularly suited to developing countries and difficult locations, but could be used as the primary means of calculation in any environment. If a computer or calculator is used as the primary means of calculation, the graphic devices provide a simple and rapid means of checking and preventing errors that may arise because of inadvertent mis-keying of data or incorrect application of the pediatric Parkland formula.

Review of a fluid resuscitation protocol: "fluid creep" is not due to nursing error

Recent reviews of burn resuscitation have included the suggestion that "fluid creep" may be influenced by practitioner error. Our center uses a nursing-driven resuscitation protocol that permits titration of fluid based on hourly urine output, including the addition of colloid when patients fail to respond appropriately. The purpose of this study was to examine protocol compliance. We reviewed 140 patients (26 children) with burns of ≥20% TBSA who received protocol-directed resuscitation from 2005 to 2010. We compared each patient's actual hourly fluid infusion with that predicted by the protocol. Sixty-seven patients (48%) completed resuscitation using crystalloid alone, whereas 73 patients required colloid supplementation. Groups did not differ in age, gender, weight, or time from injury to admission. Patients requiring colloid had larger median total burns (33.0 vs 23.5% TBSA) and full-thickness burns (15.5 vs 4.5% TBSA) and more inhalation injuries (60.3 vs 28.4%; P < .001) than those who resuscitated with crystalloid alone. Because we included basic maintenance fluids in their regimen, patients had median predicted requirements of 5.4 ml/kg/%TBSA. Crystalloid-only patients required fluid volumes close to Parkland predictions (4.7 ml/kg/%TBSA), whereas patients who received colloid required more fluid than the predicted volume (7.5 ml/kg/%TBSA). However, the hourly difference between the predicted and received fluids was a median of only 1.0% (interquartile range: -6.1 to 11.1%) and did not differ between groups. Pediatric patients had greater calculated differences than adults. Crystalloid patients exhibited higher urine outputs than colloid patients until colloid was started, suggesting that early over-resuscitation did not contribute to fluid creep. Adherence to our protocol for burn shock resuscitation was excellent overall. Fluid creep exhibited by more seriously injured patients was not due to nurses' failure to follow the protocol. This review has illuminated some opportunities for practice improvement, possibly using a computerized decision support system.

Special considerations in paediatric burn patients

Burn injuries are a major cause of morbidity and mortality in children. In India, the figure constitutes about one-fourth of the total burn accidents. The management of paediatric burns can be a major challenge for the treating unit. One has to keep in mind that “children are not merely small adults”; there are certain features in this age group that warrant special attention. The peculiarities in the physiology of fluid and electrolyte handling, the uniqueness of the energy requirement and the differences in the various body proportions in children dictate that the paediatric burn management should be taken with a different perspective than for adults. This review article would deal with the special situations that need to be addressed while treating this special class of thermal injuries. We must ensure that not only the children survive the initial injury, but also the morbidity and complications are minimized. If special care is taken during the initial management of paediatric burn injuries, these children can be effectively integrated into the society as very useful and productive members.

Colloid normalizes resuscitation ratio in pediatric burns

Fluid resuscitation of burned children is challenging because of their small size and intolerance to over- or underresuscitation. Our American Burn Association-verified regional burn center has used colloid "rescue" as part of our pediatric resuscitation protocol. With Institutional Review Board approval, the authors reviewed children with ≥15% TBSA burns admitted from January 1, 2004, to May 1, 2009. Resuscitation was based on the Parkland formula, which was adjusted to maintain urine output. Patients requiring progressive increases in crystalloid were placed on a colloid protocol. Results were expressed as an hourly resuscitation ratio (I/O ratio) of fluid infusion (ml/kg/%TBSA/hr) to urine output (ml/kg/hr). We reviewed 53 patients; 29 completed resuscitation using crystalloid alone (lactated Ringer's solution [LR]), and 24 received colloid supplementation albumin (ALB). Groups were comparable in age, gender, weight, and time from injury to admission. ALB patients had more inhalation injuries and larger total and full-thickness burns. LR patients maintained a median I/O of 0.17 (range, 0.08-0.31), whereas ALB patients demonstrated escalating ratios until the institution of albumin produced a precipitous return of I/O comparable with that of the LR group. Hospital stay was lower for LR patients than ALB patients (0.59 vs 1.06 days/%TBSA, P = .033). Twelve patients required extremity or torso escharotomy, but this did not differ between groups. There were no decompressive laparotomies. The median resuscitation volume for ALB group was greater than LR group (9.7 vs 6.2 ml/kg/%TBSA, P = .004). Measuring hourly I/O is a helpful means of evaluating fluid demands during burn shock resuscitation. The addition of colloid restores normal I/O in pediatric patients.

Enteral resuscitation and early enteral feeding in children with major burns--effect on McFarlane response to stress

AIM

Early enteral feeding has become standard practice for burned patients. The aim of this study was to determine whether early enteral feeding could be used as an avenue for resuscitation and feeding and the effect it would have on the induction/amelioration of the hormonal stress response.

METHOD

Eighteen children with <20% TBSA were randomly assigned to either early enteral feeding and resuscitation, or intravenous resuscitation with the induction of enteral feeding delayed. The enteral fluid volume was incrementally increased every 3h with a simultaneous equal reduction in the intravenous volume until all the calculated intravenous fluid requirements for resuscitation and maintenance could be administered enterally. In the second group, intravenous resuscitation continued for 48 h when enteral feeding was introduced. Parameters measured were the clinical responses and outcome as well as the concentrations of insulin, insulin-like growth factor 1, glucagon, cortisone and growth hormone. The estimated and calculated energy expenditure was measured calorimetrically and bowel permeability was assessed using a dual sugar absorption test.

RESULTS

Three children were excluded from the study because of early death from organ failure or carbon monoxide poisoning. Early enteral resuscitation and feeding (ER/EEF) was initiated within a median of 10.7h post-burn in nine children and late enteral feeding introduced on an average 54 h post-burn. The ER/EEF group showed an anabolic response with significantly higher insulin concentrations (p=0.008) and insulin: glucagon ratios (p=0.043). Although blood glucose concentrations were initially slightly elevated (EEF: 10.3g/l, LEF: 8.1g/l), they rapidly returned to within the normal range. The cortisol and IGF1 concentrations did not differ significantly between the two treatment groups. Growth hormone concentrations were significantly higher in the late enteral feeding (LEF) group (p=0.03). The estimated energy expenditure was not different amongst the groups. Small bowel permeability [lactulose:rhamnose (L:R) ratios] decreased significantly over time (p=0.02) in both study groups. No pulmonary aspiration was found. Diarrhoea in the ER/EEF settled quickly (2-4 days), whereas in the LEF group it persisted for longer than a week. The LEF group lost a median of 7.75% (acceptable range=<or=5%) of admission body weight, whereas the ER/EEF group lost a median of 3.01%. Patients in the LEF group required antibiotic treatment for a longer period (p=0.08) and their hospital stay was longer, though not significant.

CONCLUSIONS

Enteral resuscitation and early enteral feeding is a safe and effective method and particularly suited for children in developing countries. It resulted in the amelioration of the hormonal stress response and improved outcome. Enteral resuscitation should not be introduced in a patient in shock or with existing gastrointestinal disease. Complications were minimal.

Fire and smoke injuries

The successful management of burns and related injuries requires a comprehensive team approach at a designated burn center. This team should consist of burn surgeons, burn nurses, respiratory therapists, physical therapists, occupational therapists, clinical nutritionists, social workers, chaplains, and other clinical consultants. This article focuses specifically on the management of thermal burns and inhalational injuries, with an emphasis on assessment, resuscitation, and critical care management. It also discusses special considerations related to burned trauma patients.

Standard variables fail to identify patients who will not respond to fluid resuscitation following thermal injury: brief report

Approximately 13% of thermally injured patients fail resuscitation, in that they die during the first 48 h postburn despite full resuscitative efforts. The purpose of this study was to characterize these patients, and to develop a predictor of resuscitation failure.

METHODS

Records of 3807 thermally injured patients admitted to this burn centre during 1980-1997 were reviewed. Patients were classified as surviving to hospital discharge ("NONFAIL/LIVE"), as surviving resuscitation but dying later ("NONFAIL/DIE"), or as failing resuscitation ("FAIL"). Ordinal logistic regression was used to develop a predictor of membership in each of these three groups.

RESULTS

With respect to total burn size, full-thickness burn size, and inhalation injury, the three groups represented a gradation in injury severity from least severe (NONFAIL/LIVE) to most severe (FAIL). The predictive model had an overall accuracy of 91.6%; however, it correctly classified NONFAIL/LIVE patients more often (97.7% accuracy) than it did NONFAIL/DIE patients (57.5%) or FAIL patients (16.1%).

CONCLUSION

Patients who failed resuscitation were more severely injured than those who survived resuscitation, but was not possible accurately to predict who will fail resuscitation using data available on admission.

Initial Management of Burns

Burns is a preventable tragedy, which is unfortunately still common in India. The possibility of disfigurement, death and emotional trauma as a result of burns is a shattering experience to the victim as well as his/her family. Proper initial management can salvage many such unfortunate victims. Burns patients require close monitoring, barrier nursing and sympathetic attitude of medical and paramedical staff in a burns ICU to have a reasonable chance of survival.

Burns

During the past 20 yrs, as burn care has evolved as a specialty of surgery, survival and outcome quality have soared. Public expectations for survival and long-term outcomes are at previously unprecedented levels. These changes are the result of a number of advances in aspects of burn care that have occurred in parallel and have fostered increasing regionalization of this resource-intensive activity into fewer specialized centers. These are complex hospitalizations and can be divided into four phases: initial evaluation and resuscitation, initial wound excision and biological closure, definitive wound closure, and rehabilitation and reconstruction.

High frequency percussive ventilation and conventional ventilation after smoke inhalation: a randomised study

Inhalation injury and bacterial pneumonia represent some of the most important causes of mortality in burn patients. Thirty-five severely burned patients were randomised on admission for conventional ventilation (CV; control group) versus high frequency percussive ventilation (HFPV; study group). HFPV is a ventilatory mode, introduced 10 years ago which combines the advantages of CV with some of those of high frequency ventilation. Arterial blood gases, ventilatory and hemodynamic variables were recorded for 5 days at 2h intervals. Incident complications were classically managed. A statistical analysis (Student's t-test and Wilcoxon signed rank test) demonstrated a significant higher PaO(2)/FiO(2) from days 0 to 3 in the HFPV group. No significant differences were observed for the other parameters. Our findings suggest that HFPV can improve blood oxygenation during the acute phase following inhalation injury allowing reduction of FiO(2). No significant differences were observed between groups for mortality nor incidence of infectious complications in this study.

Management of the high-risk pediatric burn patient

BACKGROUND/PURPOSE

Inhalation injury, flame burn exceeding 30%, and age under 48 months all have been cited as independent risk factors for mortality; the combination of all 3 risk factors is unusual. The authors have experienced an overall reduction in mortality rate and chose to examine this high-risk group to define techniques useful in improving outcome in pediatric burns.

METHODS

A review was done of children with all 3 risk factors over a recent 9-year interval. All were treated with a system of care emphasizing precise fluid repletion, early wound excision and closure, and avoidance of injurious pulmonary inflating pressures and concentrations of oxygen. Data are expressed as mean +/- SD.

RESULTS

There were 26 children admitted with all 3 risk factors. Their average age was 2.1 +/- 1.1 years (range, 5 weeks to 3.7 years), and burn size was 61% +/- 21% (range, 30% to 98%) of the body surface. All required mechanical ventilation for an average of 28 +/- 4.5 days (range, 7 to 74 days). Two children underwent tracheostomy; all others were treated with protracted oral intubation. Inhaled nitric oxide (NO) was used in 3 children, all of whom were considered for extracorporeal membrane oxygenator (ECMO) support, although none went on to ECMO. Only 7 children (27%) never had any bacteremia. Ventilator-related pneumonia occurred in 8 children (31%). Total lengths of stay, including acute and rehabilitation hospitalizations, averaged 105 +/- 10 days (1.87 +/- 0.2; range, 0.66 to 4.8 days per percent burn). After exclusion of 1 child with a 98% third-and fourth-degree burn, pre-hospital cardiac arrest, and anoxic brain injury who had support withdrawn at 6 hours, all children survived to discharge; 23 followed up in our clinic currently are alive and well with no overt residual respiratory insufficiency.

CONCLUSION

A high rate of survival can be expected in young children with large burns and inhalation injury.

Early fluid resuscitation improves outcomes in severely burned children

BACKGROUND

Recent evidence suggests that timely fluid resuscitation can significantly reduce multiorgan failure and mortality in thermally injured children. In this study, children who received fluid resuscitation within 2 h of a thermal injury were compared with children in which fluid resuscitation was delayed by 2-12 h. We hypothesized that fluid resuscitation given within 2 h of a thermal injury attenuates renal failure, cardiac arrest, cardiac arrest deaths, incidence of sepsis, and overall mortality.

METHODS

A retrospective chart review was made on 133 children admitted to our institute from 1982 to 1999 with scald or flame burns covering more than 50% of their body surface area. Comparisons between early (< 2 h of injury) or delayed (> or = 2 h of injury) fluid resuscitation were made in children experiencing renal failure, sepsis, non-survivors with cardiac arrest requiring pulmonary and advanced life support, and overall mortality. Comparisons were made using the chi2-test with Yates' continuity correction and joint binomial confidence intervals using the Bonferroni correction.

RESULTS

The incidence of sepsis, renal failure, non-survivors with cardiac arrest, and overall mortality was significantly higher in burned children receiving fluid resuscitation that was delayed by 2 h or more compared with those receiving fluid resuscitation within 2 h of thermal injury (P < 0.001).

CONCLUSIONS

Data suggest that fluid resuscitation, given within 2 h of a thermal injury, may be one of the most important steps in the prevention of multi-organ failure and mortality.

Long-term outcomes of burned children after in-hospital cardiac arrest

OBJECTIVE

Cardiopulmonary resuscitation (CPR) in severely burned patients experiencing cardiac arrest (CA) has been considered by some as futile. The objective of this article is to report predisposing factors and the outcomes of burned children experiencing in-hospital CA at our institution.

DESIGN

The records of 595 children admitted from 1985 to 1998 with burns covering >35% of their total body surface area were reviewed. Thirty-four children receiving CPR after in-hospital CA were studied for predisposing factors and long-term outcomes.

SETTING AND PATIENTS

Shriners Burns Hospital. Burned children of both genders, 0.5-19 yrs of age, who experienced in-hospital CA and received CPR.

INTERVENTION

Standard burn care and CPR.

MEASUREMENTS AND MAIN RESULTS

Predisposing factors of CA, mortality, and long-term outcomes were measured. The incidence of CA in burned children with burns on >35% total body surface area was 5.7%. No significant difference in age or burn size could be shown between long-term CA survivors (n = 17) and nonsurvivors (n = 17). CPR was successful (defined as survival for at least 1 day after CA) in 22 of 34 children (65%), with 17 of the 22 survivors (77%) experiencing long-term survival, currently from 2-14 yrs. Significant predisposing factors of CA were sepsis, identified in 53% of the nonsurvivors vs. 12% of the survivors (p<.05), and delayed fluid resuscitation (>2 hrs after burn injury), identified in 82% of the nonsurvivors vs. 6% of the survivors (p<.001). There was only one morbid long-term survivor. This survivor was diagnosed as having anoxic brain injury with persistent neurologic deficiencies.

CONCLUSION

In this study, 50% of the burned children experiencing CA are long-term survivors. We suggest that all burned children with CA should be afforded cardiopulmonary resuscitation.

The usefulness of combined high-frequency percussive ventilation during acute respiratory failure after smoke inhalation

Inhalation injury and bacterial pneumonia represent some of the most important causes of mortality in burn patients. We describe 11 severely burned patients with acute respiratory failure due to inhalation injury who did not respond adequately to conventional respiratory support. High-frequency percussive ventilation (HFPV) is a recent ventilatory mode, which combines the advantages of conventional ventilation with some of those of high-frequency ventilation. Seven patients developed pulmonary infection during the acute phase; one patient died of multiple organ failure on day 25. All the other patients survived; two developed bronchiolitis obliterans symptoms before discharge. No side-effects were noted and haemodynamic tolerance of HFPV was excellent. Our findings suggest that HFPV can improve pulmonary function and gas exchange in these catastrophic pulmonary failures following inhalation injury.

The cornerstones and directions of pediatric burn care

Active basic-science investigations and directed clinical research have resulted in effective therapies for improving the outcomes of burned children. Major areas of inquiry have been in resuscitation, hypermetabolism, wound coverage, and inhalation injury, all of which have yielded fruitful results. Probably the most important advance has been the widespread use of early excision and grafting, which has changed the pathophysiology of burn injury. Further advances in the fields of metabolism, wound healing, and respiratory medicine may improve results even further, particularily in functional and cosmetic outcomes.

Inhaled nitric oxide in burn patients with respiratory failure

BACKGROUND

Inhaled nitric oxide (NO) has the potential to improve ventilation/perfusion matching and decrease pulmonary artery pressure in patients with profound respiratory failure.

METHODS

Eight patients, average age of 35 years (range, 2.5-77 years) and burn size 49% (range, 19-80%), with inhalation injury and respiratory failure failing conventional management (average Pao2/FiO2 ratio (PFR) 85) were given inhaled NO at 20 ppm.

RESULTS

An immediate mean increase in PFR of 10% and a decrease in pulmonary artery mean pressure of 7.8% was noted. At 24 hours, the average improvement in PFR was 28% and that in pulmonary artery mean pressure was 7.7%. Although not reaching statistical significance, these changes were more pronounced in those patients who went on to survive. There was no hypotension attributed to NO administration, and maximum methemoglobin levels averaged 0.9%.

CONCLUSIONS

Inhaled NO can be safely administered to selected burn patients with severe respiratory failure who are perceived to be failing conventional support. Although current data are not adequate to support its general use, an immediate and sustained improvement in PFR and pulmonary artery mean pressure may correlate with eventual recovery of pulmonary function. Continued evaluation in controlled settings seems warranted and is in progress.

The complexities of managing severe burns with associated trauma

A high incidence of severe inhalation injuries can be expected in the combined injury patient. The initial management remains attention to the ATLS priorities of airway, breathing, and circulation, with prompt and safe transfer to a regional center of excellence. The treatment of either the burn or the associated injuries may be compromised by their combined presence, and a team approach is essential to their optimal management. Circulatory management goals based on oxygen consumption and delivery allow greater understanding and control of the physiologic demands placed on the patient by the disease process. The management of inhalation injury and ARDS is at an exciting turning point in history, and we now have in hand and use many techniques that allow salvage of these mortal conditions. Pain management is essential to humane care and requires frequent assessment and patient control to be effective. Rehabilitation of the burn and trauma patient starts on the day of injury and requires team dedication to the areas of greatest morbidity early in the planning of surgical priorities and physical therapy.

Permissive hypercapnia as a ventilatory strategy in burned children: effect on barotrauma, pneumonia, and mortality

OBJECTIVE

To document the incidence of barotrauma, pneumonia, and respiratory death associated with a mechanical ventilation protocol based on permissive hypercapnia in pediatric burn patients.

DESIGN

Retrospective review.

MATERIALS AND METHODS

Patients were managed using a mechanical ventilation protocol based on permissive hypercapnia, tolerating moderate (pH > 7.20) respiratory acidosis to keep inflating pressures below 40 cm H2O.

MAIN RESULTS

Over a 2.5-year interval, 54 burned children (11% of 495 acute admissions) with an average age of 6.5 years (range 5 weeks to 17 years), average burn size of 44% (range 0 to 98%), and median burn size of 46% required mechanical ventilatory support for an average of 12.5 days (range 1 to 56 days). Inhalation injury was diagnosed in 34 (63%) of the children and 72% percent were admitted within 24 hours of injury. Overt barotrauma occurred in 5.6% of the patients, pneumonia in 32%, and respiratory death in 0%.

CONCLUSIONS

A conventional ventilation protocol based on permissive hypercapnia is associated with acceptable rates of barotrauma and pneumonia. The low incidence of respiratory death associated with this strategy suggests that it also minimizes ventilator-induced lung injury.

The Burn Wheel: a practical guide to fluid resuscitation

During preparation for mass casualties of burn victims in the Gulf War (1990-91), a 'Battlefield Burns Table' was devised to allow rapid calculation of fluid replacement. By standardizing weights and using only Hartmann's Solution BP, a regimen could be prescribed by the non-specialist without resort to mathematical calculations. By means of a revolving disc, this has now been refined for use in a civilian setting where expert burn advice may not be immediately available.

Diagnosis and treatment of smoke inhalation

Inhalation remains the most frequent and serious comorbid event that occurs in thermally injured patients. A thorough understanding of the pathophysiology enables individualization of therapy and appropriate triage of patients. We summarize our current knowledge of the pathophysiology, diagnosis, and treatment of inhalation injury, with a focus on newer treatment strategies that are evolving secondary to laboratory research.

Transport and stabilization of the pediatric trauma patient

The incidence of pediatric trauma continues to increase, presenting at almost every emergency department. Life-threatening injuries need to be cared for immediately, in whatever institution the patient presents. For severely injured children, optimal care is ultimately provided at specialized trauma centers. Physicians caring for trauma patients in less specialized institutions must be aware of who to transfer to a trauma center. Effective stabilization and timely, safe transport are vital to reduce further injury.

Burn shock resuscitation

The goal of fluid resuscitation in the burn patient is maintenance of vital organ function at the least immediate or delayed physiological cost. To optimize fluid resuscitation in severely burned patients, the amount of fluid should be just enough to maintain vital organ function without producing iatrogenic pathological changes. The composition of the resuscitation fluid in the first 24 hours postburn probably makes very little difference; however, it should be individualized to the particular patient. The utilization of the advantages of hypertonic, crystalloid, and colloid solutions at various times postburn will minimize the amount of edema formation. The rate of administration of resuscitation fluids should be that necessary to maintain satisfactory organ function, with maintenance of hourly urine outputs of 30 cc to 50 cc in adults and 1-2 cc/kg/% burn in children. When a child reaches 30 kg to 50 kg in weight, the urine output should be maintained at the adult level. With our current knowledge of the massive fluid shifts and vascular changes that occur, mortality related to burn-induced hypovolemia has decreased considerably. The failure rate for adequate initial volume restoration is less than 5% even for patients with burns of more than 85% of the total body surface area. These improved statistics, however, are derived from experience in burn centers, where there is substantial knowledge of the pathophysiology of burn injury. Inadequate volume replacement in major burns is, unfortunately, common when clinicians lack sufficient knowledge in this area.