Reducing Patient Length of Stay After Surgical Correction for Neuromuscular Scoliosis.

BACKGROUND: Surgical correction remains the most effective treatment of patients with severe neuromuscular scoliosis (NMS). However, postoperative inpatient clinical care after spinal surgery for NMS patients is highly complex and variable, depending on the provider and/or institution. Our project used a quality improvement methodology to implement a standardized clinical care pathway for NMS patients during their primary spinal surgery, with the global aim of decreasing postoperative hospitalized length of stay (LOS). METHODS: A multidisciplinary team developed a postoperative pathway for nonambulatory patients with NMS after their primary, nonstaged corrective spinal surgery. The outcome measure was mean LOS, and the process measure was percentage compliance with the newly implemented NMS pathway. The team used statistical process control charts and measures were evaluated over 3 phases to assess the impact of the interventions over time: pretesting, testing, and sustain. RESULTS: The mean LOS decreased from 8.0 to 5.3 days; a statistically significant change based on statistical process control chart rules. Percentage compliance with the NMS pathway improved during the testing and sustain phases, compared with the pretesting phase. LOS variability decreased from pretesting to the combined testing and sustain phases. CONCLUSIONS: Using quality improvement methodology, we successfully standardized major components of clinical care for patients with NMS after spinal corrective surgery. Through enhanced care consistency, the mean postoperative LOS decreased by nearly 3 days and decreased LOS variability. Robust multidisciplinary involvement with key stakeholders ensured sustainability of these improvements.

Efficacy of commercial nasal bridle use in reducing feeding tube dislodgements in pediatric patients following double stage laryngotracheoplasty.

INTRODUCTION: Maintaining placement of the nasogastric feeding tube (NGT) is imperative in the double stage laryngotracheoplasty (dsLTP) patient because of concerns for adequate nutrition and hydration in the postoperative period. Additionally, multiple reinsertions due to displacement potentiate surgical morbidities. The purpose of this study was to compare NGT dislodgment rates in children with and without a commercial nasal bridle following a dsLTP surgical procedure and to determine if the use of a commercial nasal bridle decreases accidental tube dislodgements. METHODS: Medical records of pediatric patients with NGT insertion for dsLTP between Jan 1, 2012 and June 15, 2018 were reviewed for nasal bridle use, demographics, feeding tube and bridle complications, x-rays to check NGT placement, length of stay (LOS), length of bridle use and accidental feeding tube dislodgements. RESULTS: A total of 67 patients (34 unbridled and 33 bridled) received an NGT after dsLTP. No differences in demographics were noted, except the bridled group was older (median age 6.5 [IQR: 3.7, 14.3] than the unbridled group (median age 3.2 [IQR: 2.2, 6.8], p = 0.05). There were 24 episodes of NGT dislodgement in 16 patients in the unbridled group and zero displacements in the bridled patients resulting in an incidence of 9.4 [95%CI: 6.0, 14.0] and 0.0 [95%CI: 0.0, 1.9] pullouts per 100 days for unbridled versus bridled patients, respectively. Those with displacement had significantly more x-rays to check placement (p = 0.0004) and LOS was longer (p = 0.06) with a mean (SD) of 10.9 (7.0) vs. no displacement 7.0 (3.6) days. Of those bridled, 67% were discharged with a bridle and 86% returned with the NGT and bridle in place (mean bridle placement of *** ± days) at the time of stent removal. No feeding tube or bridle complications were reported for either group. CONCLUSION: The commercial nasal bridle significantly reduced NGT displacements without complication in the examined pediatric sample s/p dsLTP. Bridle use was associated with decreased radiology exposure and LOS and was successfully used in the outpatient setting.

A Retrospective Study Identifying Breast Milk Feeding Disparities in Infants with Cleft Palate.

BACKGROUND: Breast milk represents the optimal substrate for all infants, including those with a cleft palate for whom growth may be compromised. OBJECTIVES: Frequency of breast milk feeding at the breast and per feeder (bottle, cup, enteral tube) in infants with cleft palate was determined and compared with rates reported by the Centers for Disease Control and Prevention. A secondary aim was to review growth status of the infants. DESIGN: This study represents a 5-year retrospective review using the electronic medical record. PARTICIPANTS AND SETTING: Patients were ≤12 months old at the time of the initial, presurgical encounter after a diagnosis of cleft palate had been made and were treated at one of two pediatric cleft palate and craniofacial centers in Ohio between September 30, 2010, and September 30, 2015. MAIN OUTCOME MEASURES: Outcomes measured were breast milk use, reported by mothers and documented in patients' electronic medical records, chronological body weight, as well as weight for length and weight-for-age z scores and percentiles. STATISTICAL ANALYSES PERFORMED: Descriptive statistics included median with interquartile range and frequency with percentages. World Health Organization z scores were estimated using the Centers for Disease Control and Prevention programs for weight, weight for length, and weight for age at first visit. Comparisons of infants treated at the two hospitals were done using the Wilcoxon rank-sum test or the χ2 test. RESULTS: Breast milk consumption (26 infants were breastfed and 84 received human breast milk administered with a device) was 29.5%, markedly below the 2016 Centers for Disease Control and Prevention national statistics for ever receiving breast milk (81%). Anthropometric findings included z scores of -0.95 and -0.42 for weight for age and weight for length, respectively. CONCLUSIONS: Infants with cleft palate were seldom breastfed, nor was breast milk frequently used. In addition, median weight-for-age and weight-for-length z scores suggest that growth of infants with cleft palate was below normative standards.

Prevalence of Vitamin D Deficiency in Pediatric Patients With Scoliosis Preparing for Spinal Surgery.

BACKGROUND: Establishing prevalence of vitamin D deficiency in elective scoliosis surgery may impact clinical outcomes. The objectives of this study were to document vitamin D status of patients with scoliosis preparing for surgical intervention in order to establish frequency of deficiency and determine characteristics influencing levels. METHODS: Records were queried for patients with scoliosis diagnosis who underwent posterior spinal fusion or initial growing rod placement and had serum vitamin 25 hydroxyvitamin D (D25) recorded in the preoperative period. Demographic data (gender, age, body mass index [BMI], race, scoliosis type, spine surgery procedure, and season of the year) were extracted. Chi-square analysis and multivariate modeling were used to evaluate deficiency status among various demographic categories and determine the demographic factors impacting D25. RESULTS: A total of 217 patients with a mean age of 13.6 ± 3.6 years had vitamin D levels drawn a mean of 38.7 ± 20.6 days prior to surgery. The majority of the sample presented with a diagnosis of idiopathic scoliosis (n = 126), and most patients were scheduled for spinal fusion surgery (n = 192). Nearly 75% of the study population (n = 162) demonstrated D25 values below normal. African Americans presented with greater risk of deficiency (p < .0002) compared to Caucasians, as did patients preparing for spinal fusion versus growing rod placement (p < .03). Severe hypovitaminosis D was more common in winter than any other season (p < .005). Patients with neuromuscular scoliosis demonstrated significantly higher D25 levels over the idiopathic diagnosis type (p < .0002). Gender, BMI, and age did not impact D25. CONCLUSION: Low D25 levels are reported in pediatric patients with scoliosis preparing for corrective spinal surgery. Population subsets most at risk for deficiency in this limited study include African American children, those presenting for spinal fusion surgery, and patients admitted in winter season.

Clinical Trial of Vitamin D2 vs D3 Supplementation in Critically Ill Pediatric Burn Patients.

BACKGROUND: Hypovitaminosis D exists postburn. However, evidence-based guidelines for vitamin D repletion are unknown. This investigation examined differences between D2 and D3 supplementation on outcome in children with burn injuries. METHODS: Fifty patients with total body surface area burn of 55.7% ± 2.6% and full-thickness injury of 40.8% ± 3.8% were enrolled, ranging in age from 0.7-18.4 years. All participants received multivitamin supplementation per standardized clinical protocol. In addition, 100 IU/kg D2, D3, or placebo was administered daily during hospitalization using a randomized, double-blinded study design. Assay of total 25-hydroxyvitamin D (D25), 1,25-dihydroxyvitamin D (D1,25), 25-hydroxyvitamin D2 (25-OH-D2), 25-hydroxyvitamin D3 (25-OH-D3), and parathyroid hormone (PTH) was performed at 4 preplanned time intervals (baseline, midpoint, discharge, and 1 year postburn). Differences in vitamin D status were compared over time and at each specific study interval. RESULTS: There were no significant differences in serum vitamin D levels between groups, but >10% of patients had low D25 at discharge, and percent deficiency worsened by the 1-year follow up for the placebo (75%), D2 (56%), and D3 (25%) groups. There were no statistical differences in PTH or clinical outcomes between treatment groups, although vitamin D supplementation demonstrated nonsignificant but clinically relevant decreases in exogenous insulin requirements, sepsis, and scar formation. CONCLUSIONS: The high incidence of low serum D25 levels 1 year following serious thermal injury indicates prolonged compromise. Continued treatment with vitamin D3 beyond the acute phase postburn is recommended to counteract the trajectory of abnormal serum levels and associated morbidity.

Investigation of Bone Health Subsequent to Vitamin D Supplementation in Children Following Burn Injury.

BACKGROUND: The effect of supplemental vitamin D on fracture occurrence following burn injuries is unclear. The objective of this study was to evaluate postintervention incidence of fractures in children during the rehabilitative phase postburn (PB) following participation in a randomized clinical trial of vitamin D supplementation. MATERIALS AND METHODS: Follow-up for fracture evaluation was obtained in 39 of 50 patients randomized to daily enteral vitamin D2, D3, or placebo throughout the acute burn course. Serum 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, D2, D3, calcitonin, and bone alkaline phosphatase (BAP) measurements were obtained PB day 7, midpoint, discharge, and 1-year PB. Urinary calcium was obtained PB day 7 and midpoint. Dual-energy x-ray absorptiometry (DXA) was performed at discharge and 1-year PB. RESULTS: Fractures were reported in 6 of 39 respondents. Four fractures occurred in the placebo group, 2 in the D2 group, and none in the D3 group. Serum vitamin D, calcitonin, BAP, and urinary calcium were similar between fracture groups. The group with fracture morbidity had larger burn size (83.8% ± 4.9% vs 53.0% ± 2.9%, P < .0001), greater full-thickness burn (69.7% ± 9.4% vs 39.4% ± 4.1%, P = .02), and increased incidence of inhalation injury (33% vs 6%, P = .04). Decreased bone mineral density z score was noted at discharge in the placebo fracture compared with no-fracture group (P < .05). CONCLUSION: This preliminary report suggests there may be benefit of vitamin D3 in reducing postdischarge fracture risk. Results reaffirm the importance of monitoring bone health in pediatric patients postburn.

Clinical safety and efficacy of probiotic administration following burn injury.

Provision of probiotics has been limited postburn by questionable potential for bacterial translocation and risk of infection in an immune-compromised population. The purpose of this study was to evaluate the safety of probiotic administration in acutely burned, pediatric patients. Subjects were randomized to receive probiotic (n = 10) vs placebo (n = 10) twice daily. The investigational product was initiated within 10 days of burn, and daily supplementation continued until wound closure. Nursing staff was provided education regarding optimal procedures to minimize potential for study product cross contamination. Clinical outcomes (infection, antibiotic, antifungal, and operative days, tolerance, and mortality) were recorded. Length of stay was modified for burn size. Student's t-test, χ test, and nonparametric Wilcoxon's rank-sum test were used for comparative analysis. No differences were noted (probiotic; placebo) for age (7.1 ± 2.2; 6.9 ± 1.7), burn size (38.0 ± 5.9; 45.5 ± 4.45), full thickness (24.6 ± 5.6; 32.1 ± 5.4), postburn day admit (0.8 ± 0.4; 1.1 ± 0.4), or inhalation injury (10%; 20%). Infection days, antibiotic use, constipation, and emesis were similar between groups. Trends toward increased antifungal and laxative use as well as diarrhea incidence were evident in the controls (P < .30). Flatulence was statistically higher with probiotics. The control group trended toward higher requirement for excision/graft procedure. Medical length of stay was not significantly different between groups; however, time required to complete wound healing was shortened with probiotics. This study documents safety and provides preliminary efficacy data relative to probiotic supplementation postburn.

Relationship between zolpidem concentrations and sleep parameters in pediatric burn patients.

Zolpidem is a short-acting non-benzodiazepine hypnotic that is used to improve sleep architecture in patients with burn injuries. This study evaluated the relationship between zolpidem administration and sleep parameters in a cohort of children with severe burn injuries. Standard age-based zolpidem dosing practices were employed. Polysomnography data were recorded at 30-second intervals throughout the night. Serum concentrations of zolpidem were measured at 0, 1, 2, 4, 5, 6, and 8 hours after administration of the first dose. The relationship between zolpidem concentrations and sleep parameters was evaluated using Markov mixed-effects pharmacodynamic models. Ten children received two doses of zolpidem at 22:00 and 02:00 hours. The median total amount of sleep was 361.0 (interquartile range [IQR]: 299.0-418.5) minutes; approximately 65% of the normal reference value for an 8-hour period. Slow-wave and rapid eye movement (REM) sleep were also dramatically reduced (18-37% of normal). With two doses of zolpidem, stage 2 sleep was 99% of normal levels. Higher peak zolpidem concentrations were associated with increased stage 2 sleep (r = .54; P = .04). Despite this, a median of 120.0 (IQR: 99.5-143.5) transitions between nocturnal sleep stages were recorded, with a median of 55.5 (IQR: 36-75) night-time awakenings per patient. In pediatric burn patients, higher zolpidem serum concentrations were associated with restoration of stage 2 sleep to normal levels. Nonetheless, slow-wave and REM sleep were profoundly depressed with frequent transitions between sleep stages, suggesting that alternative hypnotic agents may be required to restore normal sleep architecture in severely burned children.

Quantity and quality of nocturnal sleep affect morning glucose measurement in acutely burned children.

Hyperglycemia after severe burn injury has long been recognized, whereas sleep deprivation after burns is a more recent finding. The postburn metabolic effects of poor sleep are not clear despite reports in other populations demonstrating the association between sleep insufficiency and deleterious endocrine consequences. The aim of this study was to determine whether a relationship between sleep and glucose dynamics exists in acutely burned children. Two overnight polysomnography runs (2200 to 0600) per subject were conducted in 40 patients with a mean (± SEM) age of 9.4 ± 0.7 years, 50.1 ± 2.9% TBSA burn, and 43.2 ± 3.6% full-thickness injury. Serum glucose was drawn in the morning (0600) immediately after the sleep test. Insulin requirements during the 24-hour period preceding the 0600 glucose measurement were recorded. Generalized linear models were used by the authors to evaluate percent time in each stage of sleep, percent wake time, total sleep time, sleep efficiency, and morning serum glucose, accounting for insulin use. Increased time awake (P = .04, linear; P = .02, quadratic) and reduced time spent in stage 1 sleep (P = .03, linear) were associated with higher glucose levels. Sleep efficiency (P = .01, linear; P = .02, quadratic) and total sleep time (P = .01 linear; P = .02, quadratic) were inversely associated with glucose level. Morning glucose levels appear to be affected by the quality and quantity of overnight sleep in children who have sustained extensive burn injuries. Future research is needed to elucidate the metabolic and neuroendocrine consequences of sleep deprivation on metabolism after burns.

Comparison of sleep parameters obtained from actigraphy and polysomnography during the rehabilitative phase after burn.

The evaluation of sleep is an important aspect of holistic care. Polysomnographic assessment is not always possible or justified. Actigraphy has gained popularity as an alternative sleep/wake monitor. The purpose of this study was to determine whether actigraphy has reasonable validity within the special population of rehabilitating burn patients. Total sleep time, sleep efficiency, number of arousals, wake time after sleep onset, and latency of sleep onset as assessed by actigraphy (proportional integration mode [PIM] and zero crossing mode [ZCM]) were compared with polysomnography in 36 children an average of 10.5 years after burn injury during an overnight hospital stay. The subjects' mean age at the time of study was 14.4 years; original burn injuries involved 63% TBSA, 41% of that full thickness. Polysomnographic data demonstrated the mean total sleep time to be only 5.25 hours of sleep per night. This study reaffirms previous findings of significantly increased wake time and N1 sleep with a reduction in rapid eye movement compared to normal. Although both the ZCM and PIM did not accurately derive total sleep time using polysomnography results as the benchmark, PIM was more precise in the estimation of the number of sleep arousals and ZCM more accurately characterized sleep latency. In conclusion, actigraphy provides a fairly good indication of sleep for the rehabilitating burn patient as long as clinicians and researchers remain mindful of its limitations. Additional field testing is warranted to determine its application in adult and critically ill populations after injury and the usefulness of actigraphy in the home setting.

A pilot review of the long-term impact of burn injury on sleep architecture in children.

Distorted sleep patterns exist in the acutely burned pediatric population. No prior study has used polysomnography to assess sleep proficiency in children years after discharge. The objective of this retrospective, pilot investigation was to examine sleep in children multiple years after burn injury to characterize the long-term impact of burns on sleep. Twenty-two subjects (mean age, 13.0 ± 0.9 years; 9.3 ± 0.7 years after burn; burn, 56.4 ± 6.1% TBSA; full-thickness burn, 52.0 ± 8.9%) whose parents reported disturbed sleep at home or in whom problematic sleep was exhibited during an inpatient stay, underwent overnight polysomnography. The amount of time children spent in various sleep stages, as well as sleep efficiency, were compared with norms. Sleep latency and number of arousals also were reviewed. Patients in the late burn recovery phase experienced significantly increased time in wake (P < .0001) and N1 stages (P < .0001) and nearly reached statistical significance in stage N2 (P = .07) in comparison with age-matched and sex-matched norms. Subjects exhibited decreased time in N3 (P = .07) and significantly less time in rapid eye movement sleep than normal controls (P < .0001). Sleep efficiency also was significantly decreased from the norm in the burn group (P < .0001). Marked reduction in the restorative phases of sleep persists for years after burn. Sleep efficiency also was significantly diminished in pediatric burn patients multiple years from injury. Evaluation of sleep adequacy should be a routine component of outpatient assessment in pediatric burns with consideration of referral to a sleep specialist as indicated.

The effect of ketamine administration on nocturnal sleep architecture.

Substantial evidence exists in the acute, rehabilitative and outpatient settings demonstrating the presence of significant sleep pattern disturbances after burn injury. Although the etiology is multifactorial and includes environmental, injury, and treatment mediators, previous clinical studies have not analyzed the critically important relationship of various medications to sleep architecture. The purpose of this investigation was to describe the after-effect of ketamine on sleep patterns in seriously ill burn patients. Forty pediatric patients with a mean TBSA burn of 50.1 ± 2.9% (range, 22-89%) and full-thickness injury of 43.2 ± 3.6% (range, 24-89%) were enrolled in this sleep study. Twenty-three of the 40 patients received ketamine on the day of polysomnography testing. Standard polysomnographic sleep variables were measured from 10:00 pm until 7:00 am. Chi-square test and t-test were used for comparison of descriptive variables between the ketamine and nonketamine groups. A logarithmic transformation was used for analysis when necessary. Ketamine administration was associated with reduced rapid eye movement (REM) sleep when compared with patients who did not receive ketamine on the day of the sleep study (P < 0.04). Both ketamine and nonketamine groups were clearly REM deficient when compared with nonburn norms. There was no relationship between ketamine use and effect on nocturnal total sleep time, number of awakenings, or percent of time awake or in stage 1, 2, or 3 + 4 sleep. In conclusion, ketamine was associated with altered sleep architecture as evidenced by a reduction in REM sleep. This finding does not seem to be clinically significant when considering the magnitude of overall REM sleep pattern disturbance observed in both the ketamine and nonketamine groups compared with nonburn norms. Further research is required to identify potential mechanisms of disturbed sleep so that appropriate interventions can be developed.

Sleep apnea: a risk factor for obese burned children during the rehabilitative phase of injury.

Obesity is associated with sleep disturbances that negatively impact general health. Recent reports indicate a high prevalence of obesity in burned children during the rehabilitative phase of injury. This retrospective review examined the relationship between sleep apnea and obesity in children recovering from burn injury. Nineteen subjects (mean age 14.0 ± 0.9 years, 8.0 ± 0.9 years postburn, TBSA burn 55.6 ± 7.0%, full-thickness burn 52.7 ± 8.7%) were examined for polysomnographic and respiratory outcomes. The groups were differentiated by body mass index (BMI). The obese group was defined as having a BMI ≥90th percentile according to age and gender specifications as defined by the Centers for Disease Control and Prevention. The BMI of the nonobese group was below the 90th percentile. Using t-test or χ, sleep and respiratory recordings were compared between the obese and the nonobese groups. The mean age, percent burn, percent full-thickness burn, years following acute injury, and the percentage of patients with burns to the neck region were similar in both groups; however, by design, BMI was significantly different. Total sleep time; sleep efficiency; sleep latency and time spent in stages 1, 2, 3; and rapid eye movement were similar between groups. Nonetheless, the number of apneic episodes, respiratory disturbance index, and oxygen desaturation measures were significantly higher in the obese group. In view of the significant respiratory disturbances apparent in pediatric burn survivors, routine appraisal of respiratory symptoms during sleep is recommended. In comparison to their normal weight counterparts, obese burned children appear to be at substantially greater risk of sleep-related respiratory compromise multiple years after an acute burn injury.

Overweight and obesity: overrepresentation in the pediatric reconstructive burn population.

Pediatric burn patients are predisposed to excessive weight gain in the reconstructive period, but the cause is unclear. An overweight (OW) or obese (OB) condition is associated with numerous health risks, decreased physical function, and increased morbidity. The purpose of this study was to compare the frequency of OW status in reconstructive, pediatric burn patients with the prevalence in the US population. The authors reviewed the records of 1533 pediatric patients, >1 year from acute burn, admitted for an elective reconstructive procedure. Body mass index between 85th and 95th percentile, according to the National Center for Health Statistics for 2000 growth charts, was classified as OW, and body mass index >95th percentile was classified as OB. Frequency of OW and OB and racial disparity was calculated as a percentage of total patients and compared with pediatric data from National Health and Nutrition Examination Survey for 1999 to 2006, a nationally representative sample. The rate of OW and OB was 16.3 and 24.1%, respectively, in the authors' pediatric burn population. White patients had OW and OB rates of 15.9 and 23.6%, respectively, compared with 18.2 and 30.2%, respectively, in black patients. All OW and OB rates were outside the 95% confidence interval of the nationally representative National Health and Nutrition Examination Survey population. The rates of OW and OB in pediatric reconstructive burn patients exceed the US population standard across age and race stratifications. The prevention and treatment of excessive weight gain should be a component of rehabilitation in pediatric burns.

Enhancing patient safety: the effect of process improvement on bedside fluoroscopy time related to nasoduodenal feeding tube placement in pediatric burn patients.

Nutrition support is essential in the care of burn patients. Early in the course of treatment, postpyloric feeding tube placement permits initiation of enteral nutrition, minimizes risk of aspiration, and may also attenuate hypermetabolism. Fluoroscopy aids in postpyloric feeding tube placement, yet concerns remain about safety. The purpose of this study was to measure fluoroscopy-associated radiation exposure during bedside feeding tube placement in pediatric burn patients and to take appropriate action to improve hospital protocols that minimize radiation exposure. During a 19-year period, radiation doses were measured before and after performance improvement of radiation safety initiatives. This plan included mandatory training for surgical house officers, measurement of maximum midline dosage for each procedure, limitation of radiation exposure to 5 minutes, and development of standardized policies and protocols for feeding tube placement. Phase 1 of the study retrospectively determined fluoroscopy time required for enteral tube placement. Phase 2 used thermoluminescent chips to measure the amount of radiation during fluoroscopy to establish an acceptable midline radiation dose. Phase 3 evaluated fluoroscopy times following implementation of improved safety processes. There were 357 procedures in phase 1 and mean fluoroscopy time was 4.1 minutes. Of the 10 procedures in phase 2, mean fluoroscopy time decreased to 2.7 minutes. There were 1804 procedures in phase 3, and mean fluoroscopy time was 2.3 minutes. Mean radiation exposure was significantly reduced following implementation of standardized policies and the development of a clinical protocol for bedside fluoroscopy (P<.0001). With proper processes, fluoroscopy procedures result in minimal radiation exposure for patients and staff.

Energy requirements of pediatric patients with Stevens-Johnson syndrome and toxic epidermal necrolysis.

INTRODUCTION: The primary purpose of this study was to compare the measured resting energy requirements (MREE) of children with Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN) with that of children with burns of similar size. A secondary goal was to develop a predictive equation useful in estimating the energy of children with SJS/TEN. METHODS: This retrospective study included 30 patients admitted to our pediatric burn unit between 12/91 and 03/06. All patients were admitted within 10 days of injury and had at least 1 metabolic cart measurement. Fifteen patients with SJS/TEN comprised group 1. Group 2 consisted of 15 burn patients matched for total wound size, age, preinjury weight, and gender. Caloric intake and discharge weight (percent of preburn weight) were recorded. RESULTS: The energy needs of the SJS/TEN group were 22% less than the burn group. Correlation between MRE x 1.3 and caloric intake was 0.89 for the SJS/TEN group and 0.92 for the burn group (P < .0001). Both the SJS/TEN and burn groups were managed by nutrition goals based on the MREE x 1.3, and patients were 95.1% +/- 6.3% and 98.9% +/- 6% of preinjury weight at discharge, respectively, in each group. An equation for the estimation of energy requirements in pediatric SJS/TEN patients was statistically generated: (24.6 x weight in kg) + (% wound x 4.1) + 940. CONCLUSION: The energy requirement in pediatric SJS/TEN patients is less than that following burn injury. The application of a 30% factor to MREE is supported in SJS/TEN and thermal injury.

An evaluation of the safety and efficacy of an anti-inflammatory, pulmonary enteral formula in the treatment of pediatric burn patients with respiratory failure.

Respiratory failure is associated with a high mortality rate in burned children. Recently, a specialized pulmonary enteral formula (SPEF) was commercially introduced as an adjunct intervention in acute lung injury management. SPEF contains condition-specific nutrients to modulate the inflammatory response. The study examined SPEF impact in critically ill, pediatric burn patients with respiratory failure. Medical records of acute burn patients admitted December 1997 to October 2006 were reviewed for SPEF treatment. Respiratory and renal indices were compared on the first and final days of SPEF use. Nineteen patients with respiratory failure received SPEF for a mean of 10.8 +/- 0.9 days during their acute burn course. Mean age was 5.3 +/- 1.5 years. Mean total body surface area burn was 44.3 +/- 5.4% with 32.5 +/- 6.4% full thickness. Patients were admitted 2.3 +/- 0.9 days postburn. Significant improvements in peak pressure, PEEP, FiO2, P:F ratio, Pco2, Po2, and ETco2 were noted. Seventeen of the 19 patients survived despite the fact that 9 of the 19 patients developed severe barotrauma requiring multiple tube thoracotomies, and all 19 had extremely poor prognoses at SPEF initiation. Adult SPEF formula for critically ill, pediatric burn patients with respiratory failure is safe and well tolerated. SPEF seems to facilitate recovery from acute lung injury as evidenced by improvements in oxygenation and pulmonary compliance.

A microbiologic study of enteral feeding hang time in a burn hospital: can feeding costs be reduced without compromising patient safety?

BACKGROUND: Procedural changes for hospitalized patients must always balance safety with fiscal constraints. Microbiologic contamination of enteral feeding solutions has been previously associated with nosocomial infections. Formula manipulation and hang time contribute to microbial load, and there is considerable variation in hang time recommendations in the medical literature. With cost containment in mind, the purpose of this performance improvement study was to determine if an increase in hang time of a modular tube feeding product would increase microbial load or affect the nosocomial infection rate in pediatric burn patients. METHODS: This biphasic trial initially evaluated the microbial load of the feeding after delivery of two 4-hour aliquots into a container using the same delivery set (total hang time of 8 hours; number of tests = 20). Second, once this feeding procedure was deemed microbiologically safe, tube feedings were administered to patients, and both microbial load and nosocomial infection rate were monitored for 1 year. RESULTS: Contamination levels at the end of the 8-hour period using the same feeding set with 2 consecutive 4-hour feeding aliquots (number of tests = 38) were lower than standard recommendations. The hospital's nosocomial infection rate was not altered by this procedural change, and feeding-set expenses were reduced. CONCLUSIONS: The hang time of our enteral feeding administration set can be increased safely from 4 hours to 8 hours, with the tube feeding preparation added as two 4-hour aliquots without a significant change in microbial load or nosocomial infection rate, thus promoting simultaneous fiscal responsibility and patient safety.

Hypovitaminosis D in acutely injured pediatric burn patients.

PROBLEM: The prevalence of vitamin D insufficiency, its etiology, and associated sequelae among acutely injured burn patients is unknown. OBJECTIVE: This study assessed vitamin D and endocrine status, as well as the effect of anabolic agents, in pediatric patients who had sustained burns in excess of 25% total body surface area (TBSA). SUBJECTS: Sixty-nine patients with a mean TBSA burn of 50.6+/-2.2% (range 27% to 94%) and full thickness injury of 41.3+/-3.0% (range 0% to 94%) were studied. Subjects ranged in age from 0.6 to 18 years (mean, 5.8+/-0.6 years). Main outcome measures Blood samples were obtained for serum 25-hydroxyvitamin D (D25), 1,25-dihydroxyvitamin D (D1,25), albumin, cortisol, triiodothyronine (T3), tetraiodothyronine (T(4)), thyroid stimulating hormone (TSH), and parathormone (PTH). RESULTS: Two hundred eighty morning blood samples of D25 and D1,25 demonstrated that 45% and 26.2% were low and 8.9% and 11% were very low, respectively. At least one low D25 or D1,25 level occurred in 62.3% of all subjects. Very low levels were noted in 23.2% of all patients. There was an increased incidence of hyperparathyroidism in patients with very low serum D25. Vitamin D25 and D1,25 levels were lower in subjects with larger burns or inhalation injury, as well as those treated with thyroxine or oxandrolone. Serum albumin, cortisol, T(4), and TSH were not correlated with concentration of vitamin D. CONCLUSIONS: Demonstration of a high incidence of low serum vitamin D indicates vitamin D status may be significantly compromised in burned children. It is unclear why vitamin D deficiency exists in this population. The most effective way to improve vitamin D status remains elusive at this time.

Four-year review of burns as an etiologic factor in the development of long bone fractures in pediatric patients.

Reduced bone density has been documented in children after burns. This loss of bone may place children at heightened risk for fractures. The medical records of all acutely injured patients with burns in excess of 40% TBSA burn admitted to our institution between January 1, 1997, through December 31, 2000, were reviewed for fracture incidence. Patients with fractures sustained during the course of initial trauma were not included in the review. One hundred four records were reviewed. These patients had a mean age of 6.7 +/- 0.51 years, (range, 0.2 to 18.0) and a mean %TBSA burn of 59.9 +/- 1.60 (range, 40 to 98) with a mean full-thickness %burn of 51.7 +/- 2.16 (range, 0 to 95). Fifteen long bone fractures were documented in six patients during the review time frame. All fractures were initially suspected by physical therapy personnel upon regularly scheduled therapy sessions and subsequently verified by x-ray. All fractures identified by this review occurred in children less than 3 years of age. Most fractures were noted during the rehabilitation phase of injury (range, 73 to 283 days after burn) once wounds were more than 95% healed, except for one child, who sustained multiple fractures during the acute recovery phase at a referring hospital. A 5.8% incidence of fractures was noted in patients with burns in excess of 40% (6 of 104 admissions). The etiology of the fractures is unknown, although the hormonal milieu postburn, depressed vitamin D status, inadequate protein intake, and decreased weight-bearing activity are potential contributory factors. In addition, infants and toddlers tend to provide more resistance to therapy because of an inherent lack of cognition. This may account for the increased breaks in this population.