Management of the High-Risk Pediatric Burn PatientBy Robert L. Sheridan and Jay J. Schnitzer

Boston, Massachusetts

Background/Purpose: Inhalation injury, flame burn exceed-ing 30%, and age under 48 months all have been cited asindependent risk factors for mortality; the combination of all3 risk factors is unusual. The authors have experienced anoverall reduction in mortality rate and chose to examine thishigh-risk group to define techniques useful in improvingoutcome in pediatric burns.

Methods: A review was done of children with all 3 risk factorsover a recent 9-year interval. All were treated with a systemof care emphasizing precise fluid repletion, early woundexcision and closure, and avoidance of injurious pulmonaryinflating pressures and concentrations of oxygen. Data areexpressed as mean 6 SD.

Results: There were 26 children admitted with all 3 riskfactors. Their average age was 2.1 6 1.1 years (range, 5weeks to 3.7 years), and burn size was 61% 6 21% (range,30% to 98%) of the body surface. All required mechanicalventilation for an average of 28 6 4.5 days (range, 7 to 74days). Two children underwent tracheostomy; all others

were treated with protracted oral intubation. Inhaled nitricoxide (NO) was used in 3 children, all of whom were consid-ered for extracorporeal membrane oxygenator (ECMO) sup-port, although none went on to ECMO. Only 7 children (27%)never had any bacteremia. Ventilator-related pneumonia oc-curred in 8 children (31%). Total lengths of stay, includingacute and rehabilitation hospitalizations, averaged 105 6 10days (1.87 6 0.2; range, 0.66 to 4.8 days per percent burn).After exclusion of 1 child with a 98% third-and fourth-degreeburn, pre-hospital cardiac arrest, and anoxic brain injury whohad support withdrawn at 6 hours, all children survived todischarge; 23 followed up in our clinic currently are alive andwell with no overt residual respiratory insufficiency.

Conclusion: A high rate of survival can be expected in youngchildren with large burns and inhalation injury.J Pediatr Surg 36:1308-1312. Copyright © 2001 by W.B.Saunders Company.

INDEX WORDS: Burn injury in children, nitric oxide, respira-tory support, inhalation thermal injury.

I NHALATION INJURY, burn size exceeding 30%,and age under 48 months have all been cited as

independent risk factors for mortality in pediatric burns.The combination of all 3 risk factors is unusual. We haveexperienced an overall reduction in mortality rate1 andchose to examine this high-risk group to define tech-niques useful in improving outcome in seriously burnedchildren. We defined this group as being at high riskbecause each of these risk factors has been cited apredictor of mortality.

Age under 4 years has been identified as a predictor ofmortality in 2 recent reviews of pediatric burn mortality.In a 1991 review, children less than 48 months of agewith burns over more than 30% of the body surface were

shown to have a higher rate of mortality than thatpredicted by burn size alone (31%v 12%;P , .05).2 Ina 1996 review, children less than 4 years of age withburns over more than 30% of the body surface also wereidentified as a high-risk group, with a mortality rate morethan double that of older children with similar injuries(46.9%v 12.5%;P , .01).3

Burn size figures prominently in all predictors of burnmortality.4 In young children, burn size over 30%, hasbeen cited as the point at which mortality rate increasessignificantly, and was therefore chosen in this review.

Inhalation injury also has been cited as an independentpredictor of mortality after burn injury and has figuredprominently in every formula that predicts burn mortal-ity.4,5 The presence of inhalation injury has been shownto double the mortality rate predicted by burn sizealone.6,7 Each of these problems—young age, large burn,and inhalation injury—brings with it a unique set ofmanagement issues.

MATERIALS AND METHODS

We chose to examine several aspects of care rendered to thesechildren including total volume of resuscitation fluid administered,vascular access, colloid administration, technique of ventilation, painmanagement, occurrence of infection, timing of operation and effi-ciency of wound closure, intraoperative temperature management,technique of nutritional support, and use of alternative skin closures.

From Shriners Burns Hospital; Division of Burns and Trauma,Department of Surgery, and Department of Pediatric Surgery, Massa-chusetts General Hospital; and Department of Surgery, Harvard Med-ical School, Boston, MA.

Presented at the 2000 Annual Meeting of the Section on Surgery ofthe American Academy of Pediatrics, Chicago, Illinois, October 28-November 1, 2000.

Supported by the Shriners Hospitals for Children.Address reprint requests to R.L. Sheridan, MD, Shriners Burns

Hospital, 51 Blossom St., Boston, MA 02114.Copyright © 2001 by W.B. Saunders Company0022-3468/01/3608-0047$35.00/0doi:10.1053/jpsu.2001.25805

1308 Journal of Pediatric Surgery, Vol 36, No 8 (August), 2001: pp 1308-1312

RESULTS

Results are summarized in Table 1. During this 9-yearinterval from July 1, 1991 to June 31, 2000 there were1,537 children admitted to the unit for care of acuteburns, 26 (1.7%) of whom had all 3 risk factors. The ageof these children was 2.16 1.1 years (range, 5 weeks to3.7 years), and burn size was 61%6 21% (range, 30% to98%) of the body surface. There were 10 boys and 16girls, 23 of whom had sustained flame burns and inha-lation injuries in structural fires. Three children whosustained documented aspirations and large burns duringimmersions in hot water were included. There were 6children who arrived more than 72 hours after injury.When they are excluded, children were admitted to theunit an average of 0.456 0.8 days (range, 0 to 3 days;median, postburn day 0) after injury. Length of stay,including rehabilitation days, was 91.56 46.2 (range, 23to 190) days. After exclusion of 1 child with a 98% third-and fourth-degree burn, prehospital cardiac arrest, andanoxic brain injury who had support withdrawn at 6hours, all children survived to discharge; 23 followed up

in our clinic currently are alive and well with no overtresidual respiratory insufficiency.

DISCUSSION

Although survival rate has improved for children withburns in recent years,1 those with all 3 risk factors formortality—young age, inhalation injury, and largeburn—are still very difficult clinical problems for theburn team. However, if they survive and their specialneeds are met in a comprehensive burn after care pro-gram, they can be expected to enjoy a generally satisfy-ing quality of life,8 justifying the efforts required to savetheir lives.

Resuscitation Fluid Requirements

These children were given approximately 6 mL/kg/%burn over the first 24 hours. It was unclear how much ofthis total resuscitation volume was administered beforearrival in the burn unit. Other reviews have documentedthe increased fluid needs of children with seriousburns.9,10 However, this volume of fluid should only be

Table 1. Characteristics of the High-Risk Group

Characteristic Results

Age 2.1 6 1.1 yrs (range, 5 wks to 3.7 yr)Burn size 61% 6 21% (range, 30 to 98)Days to admission* 0.45 6 0.8 (range, 0 to 3 d; median, postburn day 0)Length of stay† 1.87 6 0.2 (range, 0.66 to 4.8) days per percent burnTotal volume of fluid first 24 hours‡ 6.5 6 1.9 (range, 2.3 to 10.2) mL/kg/per % burnCentral venous catheters per child§ 7.9 6 5.4 (range, 1 to 25) catheters per childHours after injury that colloid infusions begun 14.0 6 12.8 (range, 2 to 60) hours after injuryLowest recorded serum albumin 1.1 6 0.5 (range, 0.5 to 2.2) mg/dLDays of ventilatory support 28.5 6 21.4 (range, 3 to 72) dHighest PaCO2; simultaneous pH 69 6 24 (range, 31 to 118) torr; 7.19 6 0.14 (range, 6.89 to 7.38)Postadmission day of first operation* 1.6 6 1.1 (range, 0 to 3) dPostadmission day that 90% definitive wound closure achieved 56.8 6 29.7 (range, 18 to 121)Fresh-frozen plasma use 5.9 6 10.5 (range, 0 to 39) units per childPacked red blood cell use 9.9 6 9.1 (range, 1 to 36) units per childMaximum operating room temperature first operation;

temperature leaving the operating room\

94.4 6 8.6 (range, 80 to 106)°F; 100.5 6 1.7°F (range, 97.8 to103.6°F)

Days of total or partial parenteral nutrition 23.7 6 19.8 (range, 0 to 67) dDischarge body weight minus admission body weight¶ 21.4 6 1.6 (range, 24.2 to 11.5) kgAllograft used 92%Integra used 12%Cultured epidermal cells (Epicell) used 27%AlloDerm used 8%Survival# 100%Average follow-up since the burn** 57.7 6 37.4 (range, 4 to 105) moReconstructive operations required 7.3 6 6.8 (range, 0 to 21)

*Six children admitted more than 72 hours after injury are excluded from this calculation.†This figure includes rehabilitation days.‡In 7 children records were not adequate to determine this endpoint.§Catheter sepsis rate was 8%.\These data were only available for 20 children.¶Three children grossly fluid overloaded at admission were excluded.#This figure does not include one child from whom support was withdrawn at six hours.**This figure includes the 23 children (92%) who were followed up in our burn clinic.

1309HIGH-RISK BURNS

administered if required to maintain an adequate urineoutput of 1 to 2 mL/kg/h. Several of the children in thisgroup required substantially less fluid than predicted, andadministration of more than that required might haveincreased morbidity. It is important to administer onlythat volume of fluid that is required to meet resuscitationendpoints.

Vascular Access

There were an average of 7.96 5.4 (range, 1 to 25)central venous catheters per child, and 16 (8%) of the205 catheters became infected. One child had a septic(Candida albicans) thrombosis of the inferior venacava that was managed successfully with prolongedanticoagulation and antifungal therapy. Vascular ac-cess is required for protracted periods of time inchildren with serious burns. Policies regarding rota-tion of central venous lines vary from unit to unit andare based on little actual data. We have found that apolicy of weekly rotation of lines, generally in theoperating room, is associated with a rate of line sepsisof about 10%.11,12 As much as possible we try tominimize line diameter to reduce the risk of deepvenous thrombosis.

Colloid Administration

Colloid is used in 3 settings: resuscitation, correctionof coagulopathy, and support of oncotic pressure. Ourpractice has been to begin colloid administration at thetime that the diffuse capillary leak seems to have“sealed” clinically. This is when the urine output beginsto rise despite the gradual reduction in crystalloid infu-sions and generally is apparent at about 18 to 24 hoursafter injury in the well-resuscitated child. For resuscita-tion colloid, our practice has been to administer 5%albumin in Ringers Lactate at a dose of 0.5 to 0.7ml/kg/% burn as a continuous infusion for approximately24 hours after the leak seals. If serum albumin fallsbelow 1.0 g/dL (or below 1.5 g/dL in the presence ofpulmonary dysfunction of enteral feeding intolerance),supplemental albumin is administered at 1 to 2 g/kg/duntil serum albumin stabilizes over 2 g/dL. This practicehas been well tolerated.13 Coagulopathy is corrected withfresh-frozen plasma at 10 mL/kg aliquots in the routinefashion.

Technique of Ventilation

All of these children required protracted mechanicalventilatory support (average, 28.56 21.4 days). All but2 were treated with protracted oral intubation, with noknown long-term airway sequalae. This strategy requiresa high degree of vigilance to avoid the potential catas-trophe of unplanned extubation and to manage it when it

occurs. Ideally, endotracheal tube security is stressedcontinuously through hospitalization. Two children un-derwent tracheostomy. There were 2 unplanned extuba-tions. One child required urgent tracheostomy when theairway could not be cannulated, and one child wasreintubated successfully. Neither child suffered anoxiaassociated with these events.

Along with many others,14,15 we believe that “gentleventilation,” accepting a respiratory acidosis, is associ-ated with a lesser degree of ventilator-induced lunginjury and better clinical outcomes.16 Children wereventilated with a sensitivity to injurious inflating pres-sures using the strategy of permissive hypercapnia. High-est PaCO2 averaged 696 24 (range, 31 to 118) torr andoccurred on postburn day 11.76 14.6 (range, 0 to 58)with a simultaneous pH of 7.196 0.14 (range, 6.89 to7.38). There were no complications associated with thisdegree of hypercarbia.

In those children with profound failure of oxygen-ation, we have found low-dose nitric oxide (NO) to be avaluable adjunct.17 All children treated with NO havebeen evaluated for extracorporeal support, but this hasnot been required in recent years. Inhaled NO was usedin 3 children, all of whom were considered for extracor-poreal membrane oxygenator (ECMO) support, althoughnone went on to ECMO. Initial doses of NO were 5 ppm.The PaO2/FIO2 ratio 1 hour after beginning NO averaged242 (250, 210, 266), a 144% improvement over thePaO2/FIO2 ratio just before beginning NO, which aver-aged 99 (60, 103, 133).

Pain Control

Adequate control of pain and anxiety are essentialto optimize psychological well being and to obtaincompliance with mechanical ventilation and other nec-essary therapies. All children were treated with infu-sions of morphine and midazolam at doses optimallytitrated to a state of light sleep. The high dosesrequired during lengthy hospitalizations were verywell tolerated.18,19

Occurrence of Infection

Infectious complications were common. Only 7 chil-dren (27%) never had any bacteremia. Ventilator-relatedpneumonia occurred in 8 children (31%), wound infec-tion in 8 (31%, although 4 of these preceded admission tothe unit), and fungemia in 5. Infectious complicationswere very common in this group and are the potentialsource of serious morbidity. The best way to deal withthem is through vigilant monitoring at the bedside andvery early treatment of suspected infectious foci. Cur-rently available data do not support the routine use ofprophylactic antibiotics.20 Early identification and re-

1310 SHERIDAN AND SCHNITZER

moval of eschar with immediate effective wound closuregreatly reduces the chance of infection.21,22

Timing of Operation and Efficiency of Wound Closure

These children were treated with early identificationand excision of deep burns and immediate biologicclosure of resulting wounds. This process generally iscompleted within 5 days of admission. It is very commonfor autograft to be exhausted early in this process, pre-senting a need for alternative methods of temporarywound closure. After excluding the children admittedmore than 72 hours after injury, the postadmission day offirst operation averaged 1.66 1.1 (range, 0 to 3) daysafter admission, and 90% definitive closure was esti-mated to have been achieved on postadmission day56.86 29.7 (range, 18 to 121).

Use of Blood Products

Great efforts were made to limit blood loss duringsurgery during this interval, and these efforts becameprogressively more successful.23 There were no docu-mented complications of transfusion when required.Most of the success at blood conservation comes throughefforts in the operating room including epinephrine cly-sis and the routine use of tourniquets on extremityexcisions.

Intraoperative Temperature Control

Great efforts were made to maintain euthermia inthe perioperative period. As a proxy for this effort,temperature management during the first operationwas examined. Temperature going into the operatingroom for the first operation averaged 100.36 1.6°F(range, 95 to 102.4°F), maximum room temperatureaveraged 94.46 8.6°F (range, 80 to 106°F) in those20 children for whom these data were available, andtemperature leaving the operating after the first oper-ation averaged 100.56 1.7°F (range, 97.8 to 103.6°F).The most efficient way to deal with this predictableproblem is through heating of the operating room. Thecomplete absence of perioperative hypothermia atteststo the efficacy of this strategy.

Technique of Nutritional Support

Enteral nutritional support, via gastric feedingtubes, was the goal in all children and generally wasstarted within 24 hours of injury. Nutritional targetswere 3 to 4 g/kg/d of protein and 1.2 to 1.5 kcal/kg/dof energy. High nitrogen, fat-free intravenous nutri-tion was used liberally to supplement children whowere not tolerating tube feedings or were held innothing-per-mouth status for surgery. Carbohydrateenergy provision by this route was limited to a max-

imum of 5 mg/kg/min.24 Days of total or partialparenteral support averaged 23.76 19.8 (range, 0 to67) days. Although data have been published suggest-ing that parenteral nutrition can adversely effect out-come, we have found this strategy of supplementalparenteral nutrition to be well tolerated.

Anabolic agents were not administered to thesechildren. After exclusion of 3 children grossly fluidoverloaded at admission, discharge body weight minusadmission body weight averaged21.4 6 1.6 (range,24.2 to 11.5) kg. The contribution of resuscitationfluid to first weight exaggerates these differences, butdespite this, only a moderate weight loss was associ-ated with the injuries. The role of anabolic agents,such as growth hormone and anabolic steroids, is animportant research question.25

Use of Alternative Skin Closures

Allograft was the principal alternative wound closurematerial used in this series of children. It was used aloneto cover excised wounds in the absence of autograft, orused to overlay widely expanded meshed autograft toprovide immediate biologic closure. Our experience withIntegra (Integra LifeSciences, Plainsboro, NJ) and Allo-Derm (LifeCell, The Woodlands, TX) is not adequate tomake convincing statements, although it seems importantto be wary of infection in the former.26 Cultured epider-mal cells (Epicell, Genzyme Tissue Repair, Cambridge,MA) was used in some children to provide a portion oftheir coverage, but was not relied on to provide the bulkof wound closure for fear that extensive graft failurewould be a life-threatening risk.27 Again, the occlusivenature of the dressings associated with this method ofclosure present a risk of infection worthy of close mon-itoring.28

Survival and Follow-Up Results

With the exception of a child with a 98% third-andfourth-degree burn, prehospital cardiac arrest, and anoxicbrain injury who had support withdrawn at 6 hours, allchildren survived to discharge. All but 2 children weredischarged to a home environment. Of the cohort, all but2 (92%) have been followed up in our clinic currently arealive and well with no overt residual respiratory insuffi-ciency. Two children have been lost to follow-up afterbeing discharged to burn care programs in other states.Average follow-up since the burn has been 57.76 37.4(range, 4 to 105) months. All of the children currentlyfollowed up in our clinic are residing at home withfamily or in foster care.

Most of the children have been followed up in ourburn clinic and have required substantial operative andnonoperative therapy to ensure optimal results and the

1311HIGH-RISK BURNS

physical ability to meet developmental milestones. Thiscomprehensive plan of care has been shown to be asso-ciated with optimal long-term outcomes.8 An average of7.36 6.8 (range, 0 to 21) reconstructive operations havebeen required by each child (excluding suture and dress-ing removal operations under anesthesia). Two childrenhave required multiple procedures (3 and 5, respectively)to drain abscesses beneath hypertrophic scars.

Conclusions

Burned children with all 3 risk factors for mortality—inhalation injury, large burn, and young age—can beexpected to survive and to have satisfying long-termoutcomes. Care of these high-risk young children prob-ably is best concentrated in centers dedicated to themanagement of such problems.29

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10. Warden GD: Burn shock resuscitation. World J Surg 16:16-23,1992

11. Sheridan RL, Weber JM, Peterson HF, et al: Central venouscatheter sepsis with weekly catheter change in paediatric burn patients:an analysis of 221 catheters. Burns 21:127-129, 1995

12. Goldstein AM, Weber JM, Sheridan RL: Femoral venous accessis safe in burned children: An analysis of 224 catheters. J Pediatrics130:442-446, 1997

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14. Kacmarek RM, Hickling KG: Permissive hypercapnia. Respira-tory Care 38:373-387, 1993

15. Hickling KG, Walsh J, Henderson S, et al: Low mortality rate inadult respiratory distress syndrome using low-volume, pressure-limitedventilation with permissive hypercapnia: A prospective study. Crit CareMed 22:1568-1578, 1994

16. Sheridan RL, Kacmarek RM, McEttrick MM, et al: Permissivehypercapnia as a ventilatory strategy in burned children: Effect onbarotrauma, pneumonia, and mortality. J Trauma 39:854-859, 1995

17. Sheridan RL, Zapol WM, Ritz RH, et al: Low-dose inhalednitric oxide in acutely burned children with profound respiratoryfailure. Surgery 126:856-862, 1999

18. Sheridan RL, Hinson M, Nackel A, et al: Development of apediatric burn pain and anxiety management program. J Burn CareRehab 18:455-459, 1997

19. Sheridan RL, McEttrick M, Bacha G, et al: Midazolam infusionin pediatric patients with burns who are undergoing mechanical venti-lation. J Burn Care Rehab 15:515-518, 1994

20. Sheridan RL, Weber JM, Pasternack MM, et al: Admissionstreptococcal screening allows elimination of burn wound prophylaxis.J Burn Care Rehabil 20:S146, 1999 (abstr)

21. Thompson P, Herndon DN, Abston S, et al: Effect of earlyexcision on patients with major thermal injury. J Trauma 27:205-207,1987

22. Tompkins RG, Burke JF, Schoenfeld DA, et al: Prompt escharexcision: A treatment system contributing to reduced burn mortality. Astatistical evaluation of burn care at the Massachusetts General Hos-pital (1974-1984). Ann Surg 204:272-281, 1986

23. Sheridan RL, Szyfelbein SK: Staged high dose epinephrineclysis in pediatric burn excisions. Burns 25:745-748, 1999

24. Sheridan RL, Yu YM, Prelack K, et al: Maximal parenteralglucose oxidation in hypermetabolic young children: A stable isotopestudy. J Parenter Enteral Nutr 22:212-216, 1998

25. Herndon DN, Hawkins HK, Nguyen TT, et al: Characterizationof growth hormone enhanced donor site healing in patients with largecutaneous burns. Ann Surg 221:649-656, 1995

26. Sheridan R, Choucair R, Donelan M, et al: Acellular allodermisin burns surgery: 1- year results of a pilot trial. J Burn Care Rehab19:528-530, 1998

27. Sheridan RL, Tompkins RG: Cultured autologous epithelium inpatients with burns of ninety percent or more of the body surface.J Trauma 38:48-50, 1995

28. Sheridan RL, Tompkins RG: Skin substitutes in burns. Burns25:97-103, 1999

29. Sheridan R, Weber J, Prelack K, et al: Early burn center transfershortens the length of hospitalization and reduces complications inchildren with serious burn injuries. J Burn Care Rehab 20:347-350,1999

1312 SHERIDAN AND SCHNITZER