|Year : 2015 | Volume
| Issue : 1 | Page : 12-18
Management of acute complications of pediatric burns - our experience of 7 years
Mathangi K Ramakrishnan1, Karnam G Ravikumar2, Krupanandan Ravikumar2, Thangarajan Mathivanan1, Venkataraman Jayaraman3, Mary Babu1
1 Department of Burns and Plastic Surgery, CHILDS Trust Medical Research Foundation, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, Tamil Nadu, India
2 Department of Pediatric Intensive Care Unit, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, Tamil Nadu, India
3 Department of Burns and Plastic Surgery, Chennai Medical College Hospital and Research Center, Tiruchirappalli, Tamil Nadu, India
|Date of Web Publication||11-Dec-2015|
Dr. Mathangi K Ramakrishnan
Department of Burns and Plastic Surgery, CHILDS Trust Medical Research Foundation, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Material and Methods: This is a retrospective review of children with burns admitted to the Kanchi Kamakoti Childs Trust Hospital, a 220-bed tertiary-care children's hospital in Chennai, India. Results: Four hundred and twenty-nine children with burns were admitted and treated between 2007 and 2014. Among these, 40 patients with over 20% deep and deep partial thickness burns were transferred to the Pediatric Intensive Care Unit (PICU) for various acute complications. In the presence of invasive sepsis or complication at the time of admission or later, the children are transferred to the PICU. Of the 40 cases transferred, 13 died and 27 survived. Details of the management of these complications and the causes of death were analyzed. It was realized that the survival of 27 burnt children was possible due to the combined team approach of treatment by the burn and plastic surgeons and the intensivists of the PICU. Conclusion: Continued approach is necessary for better survival in pediatric burns.
Keywords: Pediatric burns, sepsis, burns outcome, burns critical care, burns global burden
|How to cite this article:|
Ramakrishnan MK, Ravikumar KG, Ravikumar K, Mathivanan T, Jayaraman V, Babu M. Management of acute complications of pediatric burns - our experience of 7 years. Indian J Burns 2015;23:12-8
|How to cite this URL:|
Ramakrishnan MK, Ravikumar KG, Ravikumar K, Mathivanan T, Jayaraman V, Babu M. Management of acute complications of pediatric burns - our experience of 7 years. Indian J Burns [serial online] 2015 [cited 2019 Dec 7];23:12-8. Available from: http://www.ijburns.com/text.asp?2015/23/1/12/171629
| Introduction|| |
In advanced countries, there is a category of physicians called acute care practitioners who take care of the early management of burns. However, in India, it is the burn and plastic surgeons who look after early burns, along with the intensivists when needed.
WHO has raised the pediatric age to 18 years and due to this wide range, the presentations of burns, etiology, and management differs considerably. The adolescent, who is almost an adult, is physiologically very different from a small infant, and all the age groups can be the victims of burns. ,, In this respect, pediatric burns are a special category and the acute complications have to be managed by the burn surgeons, pediatricians, and pediatric intensivists together. Such a combined approach alone can give a better outcome. In the Indian scenario, the management of this approach is comfortable, because early major surgical excisions and primary surgical procedures can be undertaken when the child is in the ICU.
This hospital has 220 beds, including a 10 bed burns ward, a 10 bed PICU, and a 7 bed High Dependency Unit. With such a full-fledged PICU, care of burn children with acute complications are possible. Four hundred and twenty-nine children were admitted and treated between 2007 and 2014. Of these, 40 were transferred to the PICU and 27 cases survived and 13 cases died. There is no such data from other developing countries to compare and hence, the result in our hospital is satisfactory (Survival 67% and mortality of 33%).
| Materials and Methods|| |
A methodology was developed between the pediatric intensivists and burn surgeons to identify acute complications which necessitate the treatment in the PICU.
Criteria for transfer to the Pediatric Intensive Care Unit for acute complications are:
- Serious cases of burns over 30-40% are immediately shifted to the PICU.
- The total body surface area (TBSA) involved must be not <20% deep and deep partial thickness burn regardless of the causative agent.
- To categorize a case as serious after noting the vital signs, the presence of shock is necessary, whether hypovolemic due to delay in transfer to the hospital from the peripheral rural areas, or with sepsis and septic shock.
- Status of the burn wound - Infected with sepsis and septic shock.
- Presence of facial edema, with a history of hot liquid ingestion or exposure to fumes or fire, hot water or chemicals, with respiratory distress.
- Pulmonary injuries such as atelectasis, vocal cord palsy, pneumonia, collapse of the lung, or acute respiratory distress syndrome (ARDS).
- Acute kidney injury due to both hypovolemia and shock with anoxia resulting in oliguria and anuria.
- Hematologic complications - anemia, thrombocytopenia, and disseminated intravascular coagulation (DIC).
- Gastrointestinal complications including bleeding, hypokalemia, ileus, DIC, and rarely ischemic gangrene of the bowel.
- Myocardial dysfunction.
- Metabolic complications.
- Multi organ dysfunction syndrome.
Management of acute complications and results
This occurs in children who came from distant areas and were not resuscitated adequately with fluids. Insensible water loss also occurs from the open wounds. These types of patients arrive in a serious state. In the emergency room, they are immediately resuscitated to maintain a cuff pressure of 6-8 cm of water, to help recovery. 
During the management of these cases of shock, we target capillary refill time of <2 s, normal blood pressure and heart rate for the age, urine output of 1 ml/kg/h, and normal mental status.
Burn wound infection with invasive sepsis and septic shock
The burn wound infection with invasive sepsis is a serious condition in the child. ,,, As soon as the child arrives, the wound swab and blood are cultured for bacteria and sensitivity of the organism is evaluated. As soon as the Gram-staining of the swab depicts infection, of a very virulent strain, top of the line antibiotics are given. After the culture and sensitivity of the organisms appropriate antibiotics are administered as per the hospital antibiotic policy, described below.  The policy also is revised regularly.
When the septic shock presents with persistence of hypotension despite a fluid bolus of 40 ml/kg, the need to starting vasopressors arises. At this point, treatment is with isotonic crystalloids of up to 40 ml/kg given intravenously. If there is persistent hypotension, further colloids or albumin up to 20 ml/kg is started, always noting the urinary output. In the case of refractory shock, dopamine is given through a central line up to 20 mg/kg/m. If hypotension persists adrenaline is often used, followed by nor adrenaline.
Atelectasis, ARDS, pulmonary edema, and pneumothorax are commonly seen during management of children with burns and sepsis.  If the child requires intubation and ventilation for severe shock or pulmonary complications, we employ lung protective ventilation strategies to prevent acute lung injury and maintain O 2 . This primarily consists of providing a tidal volume of 6 ml/kg.
Acute kidney injury
We target a urine output of 1 ml/kg/h during treatment of shock. Blood investigations such as urea, creatinine, and electrolytes are done regularly to watch for signs of acute kidney injury. Those with acute kidney injury are managed by hemodialysis or ultra-filtration as peritoneal dialysis is technically difficult due to burn wounds in the abdomen.
Although systemic arterial hypertension has been recognized as a common complication of thermal injury in children the clinical characteristics have not been defined. The reason for hypertension in these children is due to multiple factors. The main etiology is due to elevate renin-angiotensin production and increased amount of blood catecholamine. The groups of children in our study were between the ages of 7 and 10 years, and sex distribution was equal. Out of the 39 children with burns treated in the PICU, seven children had persistent hypertension from day one of burn.
Patients were classified as hypertensive on the basis of a systolic blood pressure over 115 mmHg and/or diastolic blood pressure over 75 mmHg sustained for more than 24 h, or requiring antihypertensive treatment (BM…). Hypertension was seen between the groups of children whose burn size varied from 20% to 40% TBSA. Children with persistent hypertension were treated with drugs. Antihypertensive drugs were given for the minimum possible duration. Hypertension settles as the wounds were covered with collagen membrane or excisions of the dead tissue was done. Calcium channel blockers (nifedipine), beta-blocker (atenolol), alpha-adrenergic agonist (prazosin), angiotensin-converting enzyme inhibitors (Envas), etc., are the commonly used drugs.
Children with burns have reduced Glasgow Coma Scale (GCS) which is monitored regularly and any deterioration is investigated. A poor GCS may also be a sign of serious CNS conditions such as intracranial hemorrhage, infarcts, meningitis, and posterior reversible encephalopathy syndrome. After computed tomography/magnetic resonance imaging scan, management depends on the cause of encephalopathy.
Anemia, thrombocytopenia, and DIC are the common hematological complications seen in children with severe burns. Fresh frozen plasma and platelet transfusion is given when required.
Sepsis often causes feed intolerance and paralytic ileus. Hypokalemia is another common cause for abdominal distension. These children may require intravenous fluids and intermittent nasogastric aspiration to prevent abdominal distension. Elevated liver enzymes and low albumin are frequently seen in severe sepsis but rarely progresses to acute liver failure.
Burns and severe sepsis can result in myocardial dysfunction which can make correction of hypotension more difficult. Echocardiography is a common noninvasive procedure carried out in PICU to monitor myocardial contractility and ejection fraction. Vasoactive drugs such as dobutamine, adrenaline, and rarely milrinone are used in the management of cardiogenic shock.
They include hypoglycemia, hyperglycemia, hyponatremia, hypernatremia, hypokalemia, hyperkalemia, hypocalcemia, and hypomagnesemia. We monitor bedside glucose every 6 hourly and electrolytes every 12 th hourly. Severe hypoalbuminemia (albumin <2 g/dl) with edema requires transfusion of 20% human albumin. 
When more than two organ systems are affected, it is called multi-organ dysfunction syndrome. Depending on the organ or systems involved, management is targeted to provide support and prevent further deterioration.
| Results|| |
Overall, 40 children with burns were treated in the PICU during the study period 2007-2014 for various complications. [Table 1] gives the age, sex, % TBSA, and type of Burns in the 40 cases transferred to PICU. Thirty-two (80%) patients were under 9 years of age, indicating the increased incidence of burns in toddlers. Scald burns (57.5%) were more common followed by flame burns (27.5%) in our study.
[Table 2] summarizes the details of indoor stay in PICU of the 40 Burns cases. [Table 2] gives the number of survivors and nonsurvivors for the period of 10, 20, 30, and above 30 days. Of the 13 nonsurvivors, 7 (54%) patients died within 10 days. Of 15 cases stayed in PICU for 10 days, only 8 cases survived and the rest of the 7 cases died. There were 12 patients who remained in PICU for more than 30 days and 10 of them recovered and only 2 died.
|Table 2: Details of indoor stay in PICU of the 40 burns cases (2007-2014)|
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The types of acute complications encountered in children with burns in our study are listed in [Table 3]. There were about 16 complications and most of the patients had more than one complication. The statistical significance of the complication with respect to mortality is analyzed by P value. If the value P < 0.05 the complication is found to be significant. Out of 13 children who died three of them had face and airway involvement. Six out of thirteen children had an uncorrected shock at the time of admission indicating poor fluid resuscitation efforts in the transferring facility. A total of 9 children required further fluid boluses in excess of 60 ml/kg.
|Table 3: Management of acute complications in pediatric burns more than 20% BSA admitted to PICU with survivors and nonsurvivors|
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All 13 children had sepsis and septic shock according to the definitions. Of these, 10 children had pulmonary complications such as collapse and consolidation. Nine children had acute kidney injury requiring renal replacement therapy. We encountered hypertension in 2 children and encephalopathy in 2 children. Hematological involvement was very common in this cohort with all 13 children having DIC and thrombocytopenia.
Feed intolerance and other gastro-intestinal manifestations were seen in 8 children. One child was found to have myocardial dysfunction on echocardiography causing cardiogenic shock. Multi-organ dysfunction was present in 10 children. Metabolic complications were also seen common in children who died of severe sepsis. Five children had hyponatremia and 10 had hypernatremia. Eleven had hypoalbuminemia associated with generalized edema. Three children were found to have hyperglycemia and two had hypoglycemia. Eleven children had hypokalemia and 2 had hyperkalemia.
| Discussion|| |
A total of 40 burn children who suffered burn over 20% deep and deep partial thickness were the subjects in this study. Of these 27 patients survived and thirteen patients succumbed. First point noted was that while looking at the progress of the burn, all the patients went through a phase of sepsis. Hence, sepsis was the common factor in the survivors and nonsurvivors.
When we compared the number of days stay in the PICU, which denotes larger time required for full recovery, most of the deaths occurred in patients who stayed for lesser number of days in the PICU, obviously due to the failure of treatment or sepsis. Only two patients who stayed in the PICU for 37 days and 21 days died even after a longer stay period. One had associated renal failure which necessitated dialysis and the second in the terminal stages went into DIC with acinetobacter infection, and the other had continued pulmonary infection with acinetobacter and candida. Systemic candidiasis was detected in the 18 th day of stay at PICU, but the child did not survive despite antifungal therapy and supportive care.
The duration of stay should not deter continued treatment, which may become successful.
Since there are no similarly reported studies so far in the Indian subcontinent, we looked at the epidemiological data published from some low-income countries. Labib and Shalaby reports from Department of Pediatrics, Faculty of Medicine, Cairo University, Egypt that children burns were getting admitted to ICU, mainly for renal impairment, respiratory stress, and sepsis.  Here also sepsis plays a role in pediatric burns. Epidemiological analysis and cost of hospitalization associated with pediatric burn in Kermanshah, Iran showed the main cause of mortality in their study was hot liquids and flame.  In our study too, children with burns due to hot liquids - like hot oil and milk had poorer outcomes.
In many epidemiological studies, references are there for pediatric burn injuries in the low-income group of countries. ,
Peck et al., published data in Bulletin of the WHO in 2009:87 (802-803), wherein he mentions that 95% of fire-related burn deaths occur in Low and Middle-Income Countries. Not only are the burn injuries and deaths common in people of lower economic status, but the survivors find that their preinjury poverty levels worsen after recovery. When children get burnt in the house with the parents, the children get the least priority far as treatment is considered. He writes "Recovery is not skin deep." True to this statement when we look at burnt children brought late to the hospitals, what strikes the burn surgeon is the agonizing open wounds, invasive sepsis, septic shock and if they do survive, the unsightly scars, and contractures which maim these children. Children also are the victims of posttraumatic stress disorders, though the incidence is not as high as in western countries. 
The combined team approach of the PICU personnel and the burns surgeons can improve the mortality in this developing country.
| Conclusion|| |
In our exclusive children's hospital during 2007-2014 about 429 burn injuries have been admitted and among them 40 burn patients with over 20% deep and deep partial thickness were transferred to the PICU for various acute complications. We documented the number of days of stay in the PICU of the 40 cases and prolonged stay of 30 days or more increased the survival rate of the burn patients. Out of 16 patients in whom acute complications we observed, the common complication suffered by every child who died was septic shock. A combined approach of the burn surgeons and PICU personnel is much desirable to reduce the mortality associated with burns in a developing country like India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]