Management of the high-risk pediatric burn patient

Background/Purpose: Inhalation injury, flame burn exceeding 30%, and age un der 48 months all have been cited as independent risk factors for mortality ; the combination of all 3 risk factors is unusual. The authors have experi enced an overall reduction in mortality rate and chose to examine this high -risk group to define techniques useful in improving outcome in pediatric b urns. Methods:A review was done of children with all 3 risk factors over a recent 9-year interval. All were treated with a system of care emphasizing precis e fluid repletion, early wound excision and closure, and avoidance of injur ious pulmonary inflating pressures and concentrations of oxygen. Data are e xpressed as mean +/- SD. Results: There were 26 children admitted with all 3 risk factors. Their ave rage age was 2.1 +/- 1.1 years (range, 5 weeks to 3.7 years), and burn size was 61% +/- 21% (range, 30% to 98%) of the body surface. All required mech anical ventilation for an average of 28 +/- 4.5 days (range, 7 to 74 days). Two children underwent tracheostomy; all others were treated with protract ed oral intubation. Inhaled nitric oxide (NO) was used in 3 children, all o f whom were considered for extracorporeal membrane oxygenator (ECMO) suppor t, although none went on to ECMO. Only 7 children (27%) never had any bacte remia. Ventilator-related pneumonia occurred in 8 children (31%). Total len gths of stay, including acute and rehabilitation hospitalizations, averaged 105 +/- 10 days (1.87 +/- 0.2; range, 0.66 to 4.8 days per percent burn). After exclusion of 1 child with a 98% third-and fourth-degree burn, pre-hos pital cardiac arrest, and anoxic brain injury who had support withdrawn at 6 hours, all children survived to discharge; 23 followed up in our clinic c urrently are alive and well with no overt residual respiratory insufficienc y. Conclusion: A high rate of survival can be expected in young children with large burns and inhalation injury. J Pediatr Surg 36:1308-1312. Copyright ( C) 2001 by W.B. Saunders Company.