Gill, P. & Falder, S. Paediatrics and Child Health | Published online: 21 April 2017
Image shows skin cells from a scald
Burns are a common form of trauma in children, resulting most frequently from scalds but also contact, flame, electrical and chemical sources. Burn patients have a wide spectrum of injury severity and diverse outcome, ranging from superficial burns with no lasting physical signs to deep, large body surface area burns which are profoundly life-changing, affecting all physiological systems. Size, site and depth are important factors affecting treatment and outcome.
There are important anatomical, physiological and psychosocial differences between adults and children. Their body proportions are different, they have thinner skin, smaller airways, reduced blood volume and high levels of distress. They are vulnerable to non-accidental injury.
Children require formal fluid resuscitation and maintenance fluids for burns more than 10% total body surface area. Complications include infection, toxic shock syndrome, adverse scarring and psychological sequelae. This paper discusses how correct assessment and management in the acute stage can reduce later morbidity and mortality.
Setting: A 16-bed burn ICU at tertiary military teaching hospital.
Patients: Adult patients more than 18 years old requiring mechanical ventilation during their initial admission to our burn ICU from January 1, 2003, to December 31, 2011.
Measurements and Main Results: A total 830 patients were included, of whom 48.2% had acute kidney injury (n = 400). These patients had a 73% increased risk of developing acute respiratory distress syndrome after controlling for age, gender, total body surface area burned, and inhalation injury (hazard ratio, 1.73; 95% CI, 1.18–2.54; p = 0.005). In a reciprocal multivariate analysis, acute respiratory distress syndrome (n = 299; 36%) demonstrated a strong trend toward developing acute kidney injury (hazard ratio, 1.39; 95% CI, 0.99–1.95; p = 0.05). There was a 24% overall in-hospital mortality (n = 198). After adjusting for the aforementioned confounders, both acute kidney injury (hazard ratio, 3.73; 95% CI, 2.39–5.82; p < 0.001) and acute respiratory distress syndrome (hazard ratio, 2.16; 95% CI, 1.58–2.94; p < 0.001) significantly contributed to mortality. Age, total body surface area burned, and inhalation injury were also significantly associated with increased mortality.
Conclusions: Acute kidney injury increases the risk of acute respiratory distress syndrome in mechanically ventilated burn patients, whereas acute respiratory distress syndrome similarly demonstrates a strong trend toward the development of acute kidney injury. Acute kidney injury and acute respiratory distress syndrome are both independent risks for subsequent death. Future research should look at this interplay for possible early interventions.
Guilabert, P. et al. (2016) British Journal of Anaesthesia. 117 (3). pp.284-296.
Since 1968, when Baxter and Shires developed the Parkland formula, little progress has been made in the field of fluid therapy for burn resuscitation, despite advances in haemodynamic monitoring, establishment of the ‘goal-directed therapy’ concept, and the development of new colloid and crystalloid solutions.
Burn patients receive a larger amount of fluids in the first hours than any other trauma patients. Initial resuscitation is based on crystalloids because of the increased capillary permeability occurring during the first 24 h. After that time, some colloids, but not all, are accepted. Since the emergence of the Pharmacovigilance Risk Assessment Committee alert from the European Medicines Agency concerning hydroxyethyl starches, solutions containing this component are not recommended for burns. But the question is: what do we really know about fluid resuscitation in burns?
To provide an answer, we carried out a non-systematic review to clarify how to quantify the amount of fluids needed, what the current evidence says about the available solutions, and which solution is the most appropriate for burn patients based on the available knowledge.
Berger, M. & Pantet O. Current Opinion in Critical Care. Post Author Corrections: June 16, 2016
Purpose of review: After major progress in the 1980s of burn resuscitation resulting, the last years’ research has focused on modulation of metabolic response and optimization of substrate utilization. The persisting variability of clinical practice is confirmed and results in difficult comparisons between burn centers.
Recent findings: Recent research explores intracellular mechanisms of the massive metabolic turmoil observed after burns: very early alterations at the mitochondrial level largely explain the hypermetabolic response, with a diminished coupling of oxygen consumption and ATP production. The metabolic alterations (elevated protein and glucose turnover) have been shown to be long lasting. Modulating this response by pharmacological tools (insulin, propranolol, and oxandrolone) results in significant clinical benefits. A moderate glucose control proves to be safe in adult burns; data in children remain uncertain as the risk of hypoglycemia seems to be higher. The enteral feeding route is confirmed as an optimal route: some difficulties are now clearly identified, such as the risk of not delivering sufficient energy by this route.
Summary: Major burn patients differ from other critically ill patients by the magnitude and duration of their inflammatory and metabolic responses, their energy and substrate requirements. Pieces of the metabolic puzzle finally seem to fit together.