LEFT-VENTRICULAR FAILURE COMPLICATING SEVERE PEDIATRIC BURN INJURIES

Purpose: Despite improvements in the overall survival rates for critic ally burned children, failed resuscitation may account for 54% of deat hs following burn injuries. Clinical and experimental studies have imp licated failure of the right side of the heart in adults, biventricula r failure in elderly patients, and inadequate resuscitation as causes of refractory burn shock, This retrospective study of resuscitation at a tertiary pediatric burn center showed that myocardial depression is a complicating factor in the treatment of the pediatric burn victim. Methods: From 1989 to 1992, 28 critically burned children (greater tha n or equal to 60% total burn surface area) were resuscitated primarily at our center (admission within 24 hours of injury). Twenty-seven chi ldren had central lines, nine of whom underwent pulmonary artery cathe terization for intensive hemodynamic monitoring because standard resus citative therapy had failed. The average amount of fluid received at 8 and 24 hours after injury was within 10% of the calculated volume bas ed on the Parkland formula. Results: Indexes of a failing rescue attem pt included respiratory distress (PaO2 FIO2 less than or equal to 200) , central venous pressure of greater than 10 mm Hg, and urine output o f less than 1 mL/kg/h. Filling pressures were found to be normal or el evated in all children, indicating adequate volume replacement. Evalua tion of cardiac function was performed using a thermodilution techniqu e and showed that 100% of the study group had depressed left ventricul ar function, with an average left ventricular stroke work index (LVSWI ) of 19.9 g.m/m(2) (normal, 44 to 68 g.m/m(2)), whereas only 38% had c oncomitant right ventricular failure. This left-sided dysfunction pers isted throughout the acute resuscitation period but was improved after appropriate modification of fluid resuscitation and initiation of vas opressors (average final LVSWI, 38.0 g.m/m(2)). There were no complica tions from placement of the Swan-Ganz catheters in this group. Conclus ion: Cardiogenic failure is a major determinant of a failing pediatric burn resuscitation, and, contrary to the adult burn patient, the myoc ardial depression is predominantly left-sided. Information from pulmon ary artery catheters can help direct therapy by providing indications for vasopressors and modifying fluid resuscitation. Copyright (C) 1995 by W.B. Saunders Company