Cost-efficacy of cultured epidermal autografts in massive pediatric burns.

OBJECTIVE: To assess the efficacy of cultured epidermal autografts (CEA) for closure of burn wounds in pediatric burn patients with full-thickness burns of more than 90% total body surface area. SUMMARY BACKGROUND DATA: Paucity of donor sites in massive burns makes the use of expanded skin of paramount importance. CEA techniques have been used in burned patients with differing and controversial results. The true impact and the efficacy of such techniques in massive burns remain uncertain. METHODS: Patients with full-thickness burns of more than 90% body surface area treated between May 1988 and May 1998 were studied. Patients grafted with CEA were compared with patients grafted with conventional meshed autografts. Rates of death and complications, length of hospital stay (LOS), hospital cost, acute readmissions for reconstruction, and quality of scars were studied as outcome measures. RESULTS: Patients treated with CEA had a better quality of burn scars but incurred a longer LOS and higher hospital costs. Both groups had comparable readmissions for open wounds, but patients treated with CEA required more reconstructive procedures during the first 2 years after the injury. The incidence of sepsis and pneumonia in both groups was comparable. CONCLUSIONS: Conventional meshed autografts are superior to CEA for containing hospital cost, diminishing LOS, and decreasing the number of readmissions for reconstruction of contractures. However, the use of CEA provides better scar quality such that perhaps future research should focus on bioengineered dermal templates to promote take and diminish long-term fragility.

Osteomyelitis in burn patients requiring skeletal fixation.

Deep and severe burns often present with the exposure of musculoskeletal structures and severe deformities. Skeletal fixation, suspension and/or traction are part of their comprehensive treatment. Several factors put burn patients at risk for osteomyelitis, osteosynthesis material being one of them. In order to determine the safety of skeletal fixation, we reviewed all pediatric patients treated with pin insertion during the past 10 years. Forty-one severely burned children (61+/-3% TBSA full thickness burns), had a total of 357 skeletal fixation procedures. Pins were maintained an average of 25.3+/-1.7 days. Thirteen pins (3. 6%) were loose before the expected time of removal, two patients (4. 8%) presented with cellulitis of the pin site and two patients (4. 8%) presented with osteomyelitis. Loose pins, pin site cellulitis, burn wound infection and sepsis were not associated with osteomyelitis. Skeletal fixation in severely burned patients presents with a low incidence of infectious complications. Its use should be considered in patients affected by severe burns that present with exposed deep structures and for positioning purposes. The exact timing for pin removal in burned patients is still to be defined.

The isolated burned palm in children: epidemiology and long-term sequelae.

The isolated burn of the palm is a typical injury in young children. Positioning and splinting in small hands is difficult, and long-term sequelae of these injuries are not uncommon. The objective of the present study was to assess the outcome of palm burns and to identify the risk factors for long-term sequelae. All patients admitted to our hospital affected with isolated palm injuries between January of 1988 and January of 1998 were reviewed. In total, 120 pediatric patients were admitted with isolated palm burns; 110 patients (91.7 percent) had partial-thickness burns, and 10 patients (8.3 percent) had full-thickness burns. Only four patients (3.3 percent) required excision and skin autografting, but all patients whose palms were operated on in the acute phase developed burn contractures. Sixteen patients (13.3 percent) developed palmar contractures, and more than half of them (56 percent) required reconstructive procedures. All palm burns that healed in more than 3 weeks developed scarring and sequelae (p<0.05 compared with no sequelae). Pediatric palmar burns are benign injuries with a low incidence of late sequelae. However, flame and contact burns are more prone to develop scarring. Excision and autografting should be performed on wounds that take over 3 weeks to heal, but it does not prevent late sequelae.

Effects of tracheostomies on infection and airway complications in pediatric burn patients.

Considerable controversy exists as to whether tracheostomy is ever indicated in burn patients. New advents in the treatment of inhalation injury have improved survival, making the use of tracheostomy more usual. The purpose of this study was to analyze the outcome of tracheostomies, and the effect of time on complications. Patients requiring ventilatory support and tracheostomies were studied. Demographic data, hospital course, ventilatory parameters and complications were analyzed. Two hundred ninety patients required ventilation and 36 tracheostomy. Mean percentage of TBSA burned was 59%+/-4. Ninety percent of these patients presented with inhalation injury. Mortality in tracheostomy patients was 25 and 16% in all ventilated patients. Thirty-five percent of the patients developed late complications. Patients who had their airway converted to tracheostomy before day 10 postinjury had a significantly lower incidence of subglottic stenosis. and patients who required airway pressures over 50 cm H2O for more than 10 days had a significantly higher incidence of tracheomalacia. Pneumonia occurred at similar incidence in ventilated and tracheostomy patients. The mortality and late complications of pediatric burn patients with tracheostomy has decreased over the last decade. They do not present with higher incidence of pneumonia. Maintenance of airway pressures below 50 cm H2O and conversion of the artificial airway to tracheostomy before day 10 postinjury may be advisable in patients requiring long term ventilation to prevent late complications.

Biobrane versus 1% silver sulfadiazine in second-degree pediatric burns.

Partial-thickness burns in children have been treated for many years by daily, painful tubbing, washing, and cleansing of the burn wound, followed by topical application of antimicrobial creams. Pain and impaired wound healing are the main problems. We hypothesized that the treatment of second-degree burns with Biobrane is superior to topical treatment. Twenty pediatric patients were prospectively randomized in two groups to compare the efficacy of Biobrane versus 1% silver sulfadiazine. The rest of the routine clinical protocols were followed in both groups. Demographic data, wound healing time, length of hospital stay, pain assessments and pain medication requirements, and infection were analyzed and compared. Main outcome measures included pain, pain medication requirements, wound healing time, length of hospital stay, and infection. The application of Biobrane to partial-thickness burns proved to be superior to the topical treatment. Patients included in the biosynthetic temporary cover group presented with less pain and required less pain medication. Length of hospital stay and wound healing time were also significantly shorter in the Biobrane group. None of the patients in either group presented with wound infection or needed skin autografting. In conclusion, the treatment of partial-thickness burns with Biobrane is superior to topical therapy with 1% silver sulfadiazine. Pain, pain medication requirements, wound healing time, and length of hospital stay are significantly reduced.

Massive transfusion of reconstituted whole blood is well tolerated in pediatric burn surgery.

BACKGROUND: Massive transfusions can produce cardiovascular instability, metabolic abnormalities, dilutional coagulopathy, and pulmonary dysfunction. They also have been related to a higher incidence of infections. The purpose of this study was to assess the safety of massive transfusion of reconstituted whole blood. METHODS: Twenty consecutive severely burned pediatric patients underwent near-total burn excision on admission and blood transfusion with reconstituted whole blood. Patients were studied for coagulopathies and postoperative complications related to massive transfusion. RESULTS: Only one patient presented with postoperative bleeding related to acute renal failure. No other complications occurred. There were no septic episodes or pulmonary dysfunction. The amount of massive blood transfusion did not correlate with any laboratory or clinical disturbance. CONCLUSION: Massive transfusion of reconstituted whole blood in severely burned pediatric patients is safe; it does not compromise hemostasis nor is it associated with an increased rate of septic episodes or pulmonary complications. A prospective randomized clinical trial comparing its effectiveness versus packed red cells is necessary.

Effect of topical and subcutaneous epinephrine in combination with topical thrombin in blood loss during immediate near-total burn wound excision in pediatric burned patients.

Bleeding is a major concern during burn wound excision. To evaluate the efficacy of epinephrine to control blood loss, a prospective cohort of 42 pediatric patients were examined. Half of the patients received topical epinephrine to excised wounds and donor sites and subcutaneous epinephrine to scalp donor sites during total burn excision, while the other half did not. Both groups of patients received bovine topical thrombin sprayed at a concentration of 1000 U/ml. Mean blood loss in the epinephrine group was 1090 ml (range 20-4000), with a blood loss of 0.48+/-0.12 ml/cm2 excised, while the control group was 1271 ml (range 40-3750) and 0.51+/-0.15 ml/cm2. Differences in preoperative and postoperative hematocrits were respectively -3.4+/-7.8 and -4.6+/-7.5. The groups were not statistically different in this analysis. Subgroup analysis by age, burn size and time of burn to excision showed no differences. No complications or side effects of the use of the vasopressor solution occurred. In conclusion, no differences in blood loss were found between the groups. The routine use of local epinephrine during total wound excision in combination with topical thrombin in pediatric patients operated within 24 h after the admission may not be necessary. The effect of topical thrombin on blood loss should be analyzed separately.

Topical nystatin powder in severe burns: a new treatment for angioinvasive fungal infections refractory to other topical and systemic agents.

Angioinvasive fungal infections have a significant morbidity and mortality in the immunocompromised host. Massive burns produce a profound derangement in cellular immunity along with a loss of cutaneous barrier function. Treatment of fungal burn wound infections poses a difficult therapeutic challenge. We present a new method of treatment for angioinvasive fungal infections with nystatin powder at a concentration of 6,000,000 units/g. It proved to be efficacious in four consecutive severely burned patients affected by massive angioinvasive fungal infection. Both superficial and deep tissue infections were eradicated without any other therapeutic interventions or adverse effects on wound healing.

Dural reconstruction of a class IV calvarial burn with decellularized human dermis.

Calvarial burns involving the brain (Class IV) are reported to be rare. They represent a treatment challenge. Wound coverage can be accomplished with serial debridement of bone and grafting over granulating tissue, local flaps and free tissue transfer. The former techniques are often not feasible in the young infant. We present a successful case of a six-week-old female patient affected of full thickness burns involving the skull and brain. The bone, dura mater and superficial brain were debrided and the defect covered with AlloDerm and split thickness grafts. The area engrafted completely and no complications or CSF leak occurred. An acellular human allogeneic dermis (AlloDerm) can be successfully used to replace dura mater in burn patients.

Outcome of scalp donor sites in 450 consecutive pediatric burn patients.

The scalp is a useful and reliable donor site in pediatric burn patients that can be multiply harvested with minimal morbidity. Healing complications, however, may include alopecia and chronic folliculitis. To investigate scalp donor-site morbidity, a consecutive series of 2478 pediatric burn patients treated over a 10-year period were reviewed. A total of 450 of these patients had scalp donor sites for wound closure. Percent of total body surface area burned was 46+/-23 percent (mean+/-standard deviation), and the mean number of sequential scalp donor-site harvests was 2.2+/-2 (range, 1 to 10) with mean intervals between harvesting of 6+/-0.6 days. Ten patients (2.2 percent) had related complications. Eight patients developed scalp folliculitis, with Staphylococcus sp as the predominant organism (80 percent). Two patients were managed successfully with wound care alone; the other six patients required surgical debridement and split-thickness skin grafting to achieve wound healing. These eight patients developed varying degrees of alopecia. Two patients developed alopecia without previous folliculitis. Six patients required reconstructive surgery, which consisted of primary closure (3), staged excision (1), and tissue expansion (2). A number of variables were examined to determine any differences in the group that had complications compared with the group of patients that did not. No differences in age, sex, race, burn type, burn size, septic episodes, time to wound closure, or number of times the scalp was harvested were detected. Healed second-degree burns to the scalp that were subsequently taken as donor sites seemed to be a risk factor (p < 0.05) for folliculitis and alopecia. Our study confirms that scalp donor sites are reliable with low morbidity. Complications include alopecia and chronic folliculitis that can be avoided by meticulous technique and avoidance of previously burned areas.

Lung function following thermal injury in children--an 8-year follow up.

INTRODUCTION: despite the frequency of pulmonary complications and the reports of abnormal lung function as a sequela of severe thermal injury, most of the lung function studies following thermal injury have been directed at the immediate post-burn period. This investigation is designed to evaluate late residual respiratory impairment in patients with severe thermal injury. METHODS: spirometry and lung volumes were completed on 17 children with severe thermal injury 8 years post-injury. None of the patients had pre-existing lung disease prior to injury. RESULTS: the patient demographic data was as follows: nine male, eight female patients; mean TBSB=67+/-29%; mean third degree=62+/-32%; 13 patients had inhalation injury diagnosed by bronchoscopy. Spirometry and lung volumes at examination as a percentage of predicted values were: [see table in text]. Spirometry and lung volumes show: two patients had an obstructive disease process; nine patients had an obstructive and restrictive disease process; five patients had a purely restrictive process; and one patient had a diffusion defect. CONCLUSION: the data indicate that children who survive severe thermal injury may not regain normal lung function.

Reduction in mortality in pediatric patients with inhalation injury with aerosolized heparin/N-acetylcystine [correction of acetylcystine] therapy.

Smoke-inhalation injury causes a destruction of the ciliated epithelium that lines the tracheobronchial tree. Casts produced from these cells, polymorphonuclear leukocytes and mucus, can cause upper-airway obstruction, contributing to pulmonary failure. We have reported that a combination of aerosolized heparin and a mucolytic agent, N-acetylcystine [corrected], can ameliorate cast formation and reduce pulmonary failure secondary to smoke inhalation. In this study, 90 consecutive pediatric patients between 1985 and 1995 who had bronchoscopically diagnosed inhalation injury requiring ventilatory support were studied. Forty-three children admitted between 1985 and 1989 acted as controls. Forty-seven children admitted between 1990 and 1994 received 5000 units of heparin and 3 ml of a 20% solution of N-acetylcystine [corrected] aerosolized every 4 hours the first 7 days after the injury. All patients were extubated when they were able to maintain spontaneously a PaO2/FIO2 ratio of more than 400. The number of patients requiring reintubation for successive pulmonary failure was recorded, as was mortality. The results indicate a significant decrease in reintubation rates, in incidence of atelectasis, and in mortality for patients treated with the regimen of heparin and N-acetylcystine [corrected] when compared with controls. Heparin/N-acetylcystine [corrected] nebulization in children with massive burn injury and smoke-inhalation injury results in a significant decrease in incidence of reintubation for progressive pulmonary failure and a reduction in mortality.

Emergency management of pediatric burn victims.

Pediatric burn injuries present a major challenge to the health care team, but an orderly, systematic approach can simplify the initial stabilization and management. A clear understanding of the pathology of burn injuries is essential in providing quality burn care in the prehospital setting and at the referring hospital. After the patient has been rescued from the offending agent, assessment of the burn victim begins with the primary survey and life-threatening injuries initially addressed first. This is followed by a secondary survey to document and treat other injuries or problems. Intravenous access may be established in concert with the local/regional medical control and appropriate fluid resuscitation begun. Burn wounds should be covered with clean, dry sheets, and the patient kept warm with blankets to prevent hypothermia. The patient should be transported to the local hospital ED in the most appropriate mode available. At the local hospital, it should be determined if the burn patient needs burn center care, using the ABA Guidelines. In preparing for and organizing the transfer of the burn victim, consideration must be given to the continued monitoring and management of the patient during transport. In transferring burn patients the same priorities developed for the prehospital management are still operative. During the initial assessment and treatment and throughout the transport, an adequate airway, breathing, circulation, fluid resuscitation, urine output, and pain control must be assured. Ideally, transport of burn victims will occur through and organized, protocol driven plan that includes specialized transport mechanisms and personnel. Successful transport of burn victims, whether in the pre-hospital phase or during inter-hospital transfer, requires careful attention to treatment priorities, protocols, and attention to detail.

Enteral feeding intolerance: an indicator of sepsis-associated mortality in burned children.

OBJECTIVE: To determine if enteral feeding intolerance (EFI) is associated with sepsis and increased mortality in children with severe burns. DESIGN: A survey. SETTING: A pediatric burn unit. PATIENTS: Ninety-one children surviving longer than 5 days with greater than 80% total body surface area burns. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Enteral feeding intolerance indicated by high gastric residuals (> 150 mL/h) or uncontrollable diarrhea (> 2500 mL/d); thrombocytopenia (platelet count < 100 x 10(9)/L); hyperglycemia (glucose level > 11.1 mmol/L [> 200 mg/dL]); sepsis (pathogenic bacteremia or fungemia noted on blood culture results); and mortality. RESULTS: Neither EFI nor sepsis developed in 71 patients, EFI alone developed in 2 patients, sepsis alone developed in 5 patients, and EFI and sepsis developed in 13 patients. Enteral feeding intolerance and sepsis were associated by contingency table analysis (P<.001). Mortality was 8% (6 patients) in those with neither EFI nor sepsis, 50% (1 patient) in those with EFI alone, 60% (3 patients) in those with sepsis alone, and 77% (10 patients) in those with EFI-associated sepsis. The 2 latter groups were different from the group with neither EFI nor sepsis (P<.05). Enteral feeding intolerance was identified in 70% of patients before sepsis; thrombocytopenia, 64%; and hyperglycemia, 66%. When compared with thrombocytopenia and hyperthermia, no variables were found to be superior to others for predicting sepsis. CONCLUSIONS: Enteral feeding intolerance was associated with the development of sepsis and increased mortality in children with greater than 80% total body surface area burns. This sign was identified in 70% of the cases before pathogens were found in the blood; no difference could be shown between the identification of EFI, thrombocytopenia, and hyperglycemia before sepsis. These data indicate that the development of EFI should be used as an indicator of infection and should prompt a search for an inciting focus.

Mortality determinants in massive pediatric burns. An analysis of 103 children with > or = 80% TBSA burns (> or = 70% full-thickness).

OBJECTIVE: Survivors and nonsurvivors among 103 consecutive pediatric patients with massive burns were compared in an effort to define the predictors of mortality in massively burned children. SUMMARY BACKGROUND DATA: Predictors of mortality in burns that are used commonly are age, burn size, and inhalation injury. In the past, burns over 80% of the body surface area that are mostly full-thickness often were considered fatal, especially in children and in the elderly. In the past 15 years, advances in burn treatment have increased rates of survival in those patients treated at specialized burn centers. The purpose of this study was to document the extent of improvement and to define the current predictors of mortality to further focus burn care. METHODS: Beginning in 1982, 103 children ages 6 months to 17 years with burns covering at least 80% of the body surface (70% full-thickness), were treated in the authors' institution by early excision and grafting and have been observed to determine outcome. The authors divided collected independent variables from the time of injury into temporally related groups and analyzed the data sequentially and cumulatively through univariate statistics and through pooled, cross-sectional multivariate logistic regression to determine which variables predict the probability of mortality. RESULTS: The mortality rate for this series of massively burned children was 33%. Lower age, larger burn size, presence of inhalation injury, delayed intravenous access, lower admission hematocrit, lower base deficit on admission, higher serum osmolarity at arrival to the authors' hospital, sepsis, inotropic support requirement, platelet count < 20,000, and ventilator dependency during the hospital course significantly predict increased mortality. CONCLUSIONS: The authors conclude that mortality has decreased in massively burned children to the extent that nearly all patients should be considered as candidates for survival, regardless of age, burn size, presence of inhalation injury, delay in resuscitation, or laboratory values on initial presentation. During the course of hospitalization, the development of sepsis and multiorgan failure is a harbinger of poor outcome, but the authors have encountered futile cases only rarely. The authors found that those patients who are most apt to die are the very young, those with limited donor sites, those who have inhalation injury, those with delays in resuscitation, and those with burn-associated sepsis or multiorgan failure.

Cellulitis associated with burn scars: a retrospective review.

This retrospective study evaluated 55 patients with burn scar cellulitis who required hospital readmission from January 1977 to July 1994. The overall incidence of burn scar cellulitis was 1.6%, and it was highest among patients who had undergone fascial excision (17.1%) as compared to those who had undergone tangential excisions (1.5%), or those who received nonoperative therapies (0.7%). Also, the use of meshed graft 4:1 for wound coverage exhibited a higher incidence of scar cellulitis (17.1%) as compared to the use of 2:1 meshed graft (1.1%). Methicillin-sensitive Staphylococcus aureus was the most common offending organism (69%), so it was concluded that all patients should be treated initially with antibiotics having methicillin-sensitive staphylococcal coverage. The lower extremity was involved 80% of the time, and the most commonly affected age group was 11 to 15 years. All patients were healthy and displayed no vascular, immunologic, or neurologic compromise at the time of readmission.

Seizure disorders in burned children: a retrospective review.

This review shows that hyponatremia is the most common cause of burn seizures in children, followed by a history of epilepsy, hypoxia, sepsis with high fever, unknown aetiology and drug toxicity or sudden drug withdrawal. This study also shows that burn seizure is most common in younger children and is related to size and degree of burn. We recommend close monitoring of metabolism, haemodynamics, arterial blood gases, wound and blood cultures, and levels of abnormalities in serum, electrolytes, glucose, Ca, P and Mg. Prompt corrections of any problems in these areas can be vital. Invasive procedures for the diagnosis of seizures, including lumbar puncture and EEG, should be reserved for infrequent non-responding cases.

The 1995 Clinical Research Award. Younger pediatric patients with burns are at risk for continuing postdischarge weight loss.

Pediatric patients with severe burns exhibit growth delays. This study investigates weight history after discharge. Twenty-seven children with burns covering more than 40% of their total body surface area were studied from admission until 2 to 4 years after injury. Younger children decreased their weights for height; older patients mainly increased theirs. Alterations during the first year of follow-up correlated with alterations until 2 and 3 years (r = 0.91 and r = 0.76, respectively). Once initiated, net weight gain continued, whereas net weight losses diminished with time. Preburn equivalent weights, however, could not be reached within 3 years. Special attention must be paid to children who are close to or less than their ideal body weights at the time of injury, especially if they are young, because further weight loss may be critical. Outpatient nutritional therapy should be focused to control these developments.