Use of a helium-oxygen mixture in the treatment of postextubation stridor in pediatric patients with burns.

A mixture of helium and oxygen is less dense than room air. This property allows the gas to flow with less turbulence past airway narrowings, thereby decreasing airway resistance and increasing the volume of gas exchange. Previous studies demonstrated that airway obstruction that is manifested by stridor was present in 92% of patients requiring reintubation. Eight pediatric patients with burns in whom postextubation stridor or retractions unresponsive to racemic epinephrine developed, were treated with "heliox" (helium and oxygen) for 28 +/- 5 hours with an initial helium concentration between 50% and 70%. Of the eight patients treated with heliox, only two experienced respiratory distress and required reintubation. Both patients had stridor for a longer time before the initiation of heliox therapy compared with those patients who did not require reintubation. After initiation of heliox therapy, patients experienced a significant decrease in respiratory distress scores (6.8 +/- 0.7 vs 2.0 +/- 0.7). Heliox was able to relieve persistent stridor and thereby aid in the prevention of respiratory distress and reintubation.

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

A prospective, randomized trial was performed to determine whether maintaining serum albumin levels in burned pediatric patients had any effect on morbidity and mortality. Patients < 19 years of age with burns > 20% total body surface area were randomized to receive supplemental albumin to maintain levels 2.5 to 3.5 g/dL ("High Albumin") or were given albumin only if levels dropped < 1.5 g/dL ("Low Albumin") after completing burn shock resuscitation. The 36 patients in the Low Albumin group were well matched for age, burn size, depth of injury, and inhalation injury when compared with the High Albumin group (34 patients). As expected, serum albumin levels were significantly lower in the Low Albumin group when compared with the High Albumin group. No differences between groups were noted for resuscitation needs, maintenance fluid requirements, urine output, tube feedings received, days of antibiotic treatment, or ventilatory requirements. No differences in hematology, electrolytes, or nutritional laboratories were found. Finally, length of stay, complication rate, and mortality were not affected by albumin treatment. Albumin supplementation to maintain normal serum levels does not seem to be warranted in previously healthy children who suffer severe burns and who receive adequate nutrition.

Improved ventilatory function in burn patients using volumetric diffusive respiration.

BACKGROUND: Volumetric diffusive respiration (VDR) offers theoretical advantages over conventional mechanical ventilation (CV) by using lower airway pressures, recruiting alveoli, and mobilizing secretions. STUDY DESIGN: Forty-eight thermally injured pediatric patients with failing respiratory status were changed from CV to VDR. Data were obtained just before transition for CV and after stabilization on VDR, within six hours of transition. RESULTS: Both ventilation and oxygenation were significantly improved with PaCO2 decreasing from 47 +/- 3 to 39 +/- 11 mm Hg and PaO2 increasing from 105 +/- 8 to 171 +/- 12 mm Hg after transition to VDR. Treatment with the VDR ventilator also resulted in a significant decrease in peak inspiratory pressures (PIP) from 52 +/- 2 to 38 +/- 2 cm H2O. The PaO2 to FiO2 ratio increased from 189 +/- 16 using CV, to 329 +/- 21 using VDR, suggesting an improvement in the ventilation and perfusion matching. Ventilatory efficiency, measured by the PaO2/FiO2/PIP ratio, greatly improved after transition from CV to VDR with fraction of inspired oxygen increasing from 3.9 +/- 0.4 to 10.3 +/- 1.0. Hemodynamic function (blood pressure and pulse rate) were not adversely affected by VDR. CONCLUSIONS: The VDR ventilator is more effective than conventional ventilation for maintaining optimal gas exchange at lower airway pressures in thermally injured pediatric patients.

Management of pediatric facial burns.

The acute management of pediatric facial burns is not uniform. Many surgeons prefer to wait until primary wound separation occurs before grafting. Concerns over early excision are accentuated in small pediatric patients. The possible benefits of early excision results have led to adoption of this technique at our facility. This study presents our recent experience with early excision and grafting. Sixty-six patients with a mean age of 6.2 years underwent early excision and grafting of facial burns. Patients underwent grafting a mean 12.7 days after burn. Procedures were done in two stages. All grafts were dressed open. There were no episodes of acute airway decompensation. No patient required regrafting. Patients wore pressure masks a mean of 15.5 months after grafting. Thirteen patients had releases (10 eyelids, three lips/commissures) in the first postoperative year. These results demonstrate that early excision and grafting of facial burns can be carried out safely in pediatric patients with burns. The benefits of early wound coverage can thus be applied to facial burns in this population of patients.

Management of burns of the penis.

Burns of the penis can be physically and psychologically devastating. This is particularly true in young pediatric patients who have to content with growth as well as with the trials of adolescence and the development of self-image. Little has been written on the grafting management of these injuries. This report reviews a management technique used with great success. Ten patients who sustained full-thickness penis burns were reviewed. The grafting technique consisted of excision and grafting with sheet grafts in a one- or two-stage setting. After grafting, the penis was placed in traction with a weighted Foley catheter. Grafts were left open or stented. No complications occurred from the traction apparatus, and graft take was uniformly excellent. Short-term results have been excellent, and no urethral problems have developed over a median 3-year follow-up. This technique appears to provide excellent means of supporting the penis to accomplish superb graft take in this hard-to-manage area.

Release of the first web space with the "goalpost" procedure in pediatric burns.

First web-space contractures commonly occur in dorsal and palmar hand burns. Both abduction and extension limitations develop as a result of reduction in thumb motion. Optimal treatment of first web-space contractures should treat both abduction and extension deformities and should minimize the need for reoperation in growing children. Many techniques exist to manage web-space contractures. This article describes a long rectangular flap release ("goalpost" procedure) used to treat first web deformities in pediatric patients with burns. During the period 1987 through 1989, 31 first web-space releases were performed in 23 patients (mean age 9.2 years). The operations were performed a mean of 50 months after burn injury. No wound complications occurred and no patient required repeat operation in the follow-up period. Range of motion in abduction and extension was increased a mean of 10 degrees. The goalpost procedure is a highly acceptable alternative to standard web-space releases and offers advantages in its ability to treat both abduction and extension contractures.

A prospective study of blood loss with excisional therapy in pediatric burn patients.

Major blood loss occurs with excisional therapy of burns. To our knowledge no studies have quantitated blood loss in pediatric patients. This prospective study was performed to analyze blood loss in a pediatric burn population undergoing excision and grafting. Forty-four patients underwent 50 two-stage procedures. Blood loss was determined based on calculations of red cells administered in conjunction with estimates of total circulating red cell numbers. Results showed a mean value (+/- SEM) of 2.8% +/- 0.23% of circulating volume lost as a percentage of total body surface area (TBSA) excised, whereas 1.8% +/- 0.18% of circulating volume was lost as a percentage of TBSA grafted. Assessment of losses by age and depth of wound, patient age, and anatomic site showed no differences between these groups. Tourniquets lowered intraoperative losses but had no effect on overall losses. The value of knowing blood losses precisely is evaluated in terms of efficiency of ordering blood.

The use of Biobrane for coverage of the pediatric donor site.

Donor site dressings are highly diverse. The ultimate goal of any coverage is to minimize pain and healing time. Recently, synthetic laminates have become popular. Experience with Biobrane has mainly been with adult patients. This study examines the use of Biobrane in a pediatric population. One hundred eight consecutive applications of Biobrane in 95 patients (mean age 7.9 years) were reviewed. All applications were treated in identical fashion. Biobrane was left in place until healing occurred unless primary nonadherence occurred or fluid collections developed over a significant area, rendering the area nonadherent. Forty-three early removals of Biobrane were necessary at a mean of 3 1/2 days after application. The back and hip regions, with 43% and 80% early removal rates, respectively, were the areas where Biobrane was least successful in providing donor coverage until the site healed. The chest and thigh had successful full-term coverage in greater than 90% of cases. The principal basis for early removal was fluid accumulation, which reduced adherence. Early removal did not affect the healing time of the donor site. These results demonstrate a modest effectiveness of Biobrane as a donor site dressing on the back and hip regions in pediatric patients with burns. Selection of sites for which good success can be expected should be paramount in the decision to use this donor site material in this patient population.

Ordering of laboratory work in the management of pediatric burn patients: technical note.

A large number of laboratory tests are often ordered in the management of acutely burned patients. Administration of large volumes of fluid and frequent ventilator changes prompt many facilities to utilize ordering protocols. Forty-five consecutive acutely burned pediatric patients with burns measuring 25% or more of total body surface area (TBSA) sustained within 24 hours before admission were reviewed. Laboratory determinations were made at each shift and as indicated by changes in condition. Abnormal or critical values during the first 5 postinjury days were identified for electrolytes, renal function indices, complete blood counts (CBCs), glucose, and arterial blood gas (ABG) levels. Blood drawn for the laboratory tests was also measured. In the first 5 days postburn a total of 8303 laboratory determinations were made. Of these, 186 produced abnormal values. Four were critical values that were not expected from previous determinations. Of the four unexpected critical values obtained, two would have been picked up by our present standard noninvasive monitors. Six percent of estimated blood volume was used to perform laboratory tests. These results demonstrate that significant abnormal laboratory values are uncommon even in severely injured pediatric burn patients and that the ordering of these tests should be individualized based on patient examination and the use of noninvasive monitoring.

The relationship between platelet count, sepsis, and survival in pediatric burn patients.

Early identification of sepsis can be difficult in severe burns because of the systemic changes that routinely accompany these burns. This review examined the value of a falling platelet count in predicting the development of sepsis. Thirty-two pediatric patients who sustained lethal burn injuries were compared with 32 patients with similar burns who survived. Daily platelet count was evaluated in conjunction with clinical course. Thirty-one of the 32 non-survivors developed a platelet count less than 0.1 x 10(12)/L. Only 10 of the survivors had a similar occurrence. Platelet count decline preceded other signs of sepsis in all cases. A platelet count below 0.1 x 10(12)/L for more than 4 days was uniformly associated with death. All patients who died succumbed to multisystem organ failure, consistent with sepsis. These results emphasize platelet count as an independent predictor of sepsis and death.

Decreased pulmonary barotrauma with the use of volumetric diffusive respiration in pediatric patients with burns: the 1992 Moyer Award.

Pulmonary barotrauma is a frequent, life-threatening complication in the pediatric patient who is treated with mechanical ventilation. The volumetric diffusive respiration (VDR) ventilator, which employs a high-frequency progressive accumulation of subtidal volume breaths in a pressure-limited format with a percussive waveform, is capable of providing adequate gas exchange at lower airway pressures; this theoretically decreases the incidence of pulmonary barotrauma compared with conventional mechanical ventilation (CV). The incidence of pulmonary barotrauma since 1988 was evaluated in pediatric patients with burns who were younger than 2 years of age. Twenty-four patients who were treated with only CV were compared with 15 patients who were treated with only VDR. Pulmonary barotrauma was defined as the development of pneumothorax, pneumomediastinum, pneumopericardium, or pneumoperitoneum. There were no significant differences between CV-treated and VDR-treated groups (mean +/- SEM) in the patient characteristics of age (15.9 +/- 1.3 months vs 16.6 +/- 1.8 months), weight (11.2 +/- 0.5 kg vs 12.5 +/- 0.7 kg), percent total body surface burn (46.2% +/- 4.9% vs 55.6% +/- 6.2%), percent full-thickness burn (38.1% +/- 5.3% vs 50.0% +/- 6.6%), inhalation injury (40% vs 60%), or total number of days that mechanical ventilation was required (18.2 +/- 4.2 days vs 22.4 +/- 5.9 days); although these parameters show a slightly more severe degree of injury in the VDR-treated group. There was a reduction in the incidence of pulmonary barotrauma when VDR was used.(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective study of myocardial damage in electrical injuries.

A prospective study was undertaken to determine the incidence of possible myocardial damage following electrical injury. Sixteen patients with non-flash electrical injuries were assessed utilizing serial electrocardiograms (ECG), creatine kinase (CK) and MB creatinine kinase (MB-CK) determinations, technetium 99m stannous pyrophosphate scans, and 24-hour Holter monitors. Results showed that five patients (31%) had abnormal ECG, nine patients (56%) had elevations of the MB-CK isoenzyme, and one patient had a transiently abnormal Holter monitoring. No patient had an abnormal technetium pyrophosphate cardiac scan. Of the nine patients with elevated MB-CK levels, only two had abnormal ECG. None of the patients had clinical evidence of cardiac dysfunction. These results indicate a poor correlation of elevated MB-CK levels with ECG abnormalities, and demonstrate a relatively low incidence of myocardial damage in association with electrical injuries.

Effect of fasting on the activity and turnover of rat liver alcohol dehydrogenase.

Alcohol dehydrogenase activity in rat liver decreased with fasting to about 60% of the fed level, but the specific activities of the enzyme purified from livers of fed and 12- or 48-hr fasted animals were similar, 3.2-3.4 U/mg protein. Therefore, the decrease in enzyme activity with fasting should have resulted from a decrease in the amount of enzyme protein. Accordingly, the turnover of alcohol dehydrogenase was examined in fed and fasted rats. The fractional rate of enzyme synthesis (ks) in fed rats was determined by radioisotopic methods to be 0.13 day-1 and it increased to 0.18 day-1 after a 12- or 48-hr fast. The absolute rate of synthesis (V) and the fractional rate of degradation (kd) were calculated from these ks values and the total enzyme content in livers from animals that were fasted for 8 to 72 hr. After 48-72 hr of fasting, V decreased 16% and kd increased about 20% with respect to the fed values. Together, these changes accounted for the lowered enzyme activity in the fasted state. The rapid decrease in enzyme activity with fasting, t1/2 congruent to 16 hr, was found to be due to a rapid increase in kd from 0.14-0.16 day-1 in fed animals to 0.61 day-1 during the first 8 hr after the initiation of fast. Thereafter, kd decreased steadily to reach 0.18 day-1 after 48-72 hr of fasting.