Annals of Burns and Fire Disasters - vol. XII - n° 3 - September 1999

SURVIVAL IN PAEDIATRIC BURNS INVOLVING 100% TOTAL BODY SURFACE AREA

Barret J.P., Desai M.H., Herndon D.N.

Shriners Burns Hospital and the University of Texas Medical Branch, Galveston, Texas, USA


SUMMARY. Background: Survival following severe thermal injury has improved during the last two decades. The question of when futility of treatment is reached has however not yet been resolved. We hypothesized that even patients with the largest burn size (i.e. 100%) are candidates for survival. Methods: To test our hypothesis, we reviewed all paediatric burn patients admitted to our centre in the last 10 years suffering from full-thickness burns in over 98% TBSA. Survival and favourable outcome were the primary endpoints, Findings: Six patients were admitted in the last 10 years with full-thickness burns in over 98% TBSA. Three patients survived and were successfully discharged home after a mean hospital stay of 126 ± 50 days. One patient was covered with cultured epidenual autografts, while the rest of survivors received widely expanded meshed skin autografts. The patients required 13.3 ± 3.7 operations to achieve wound closure.
Interpretation: Survival following massive burn injuries of 100% body area with a 99% full-thickness component is feasible. All paediatric burns, regardless of burn size, are candidates for treatment and survival.

Introduction

Survival after massive burn injury has improved dramatically over the last decade. 1,2 Currently, the probability of mortality after burns is low and can be predicted soon after injury on the basis of simple, objective clinical criteria.' One of the three major risk factors for death is a burned body surface area greater than 40%. The point when futility of treatment has been reached, however, is still to be determined. We retrospectively analysed paediatric burn victims with full-thickness burn percentages equal to or over 98% T13SA in order to assess survival. We hypothesize that all paediatric burns, regardless of TBSA burned, are candidates for survival.

Material and methods

Patients with burns in 98% TBSA or more were examined retrospectively in order to determine if survival after this major traumatic insult is feasible in children. The patients received fluid resuscitation according to the Galveston formula (Table I) and enteral nutrition was initiated on admission. Immediate total excision of all fullthickness burns was performed in the first 24 h after the injury, and all wounds were covered with homologous human skin (homografts). The homografts were replaced at weekly intervals and the wounds were covered either with widely expanded meshed autologous skin or with cultured epidermal amografts.

First 24 h (Ringer's lactate) Second 24 h
5000 ml/m² burned
2000 ml/m² BSA (D5W in children < 2 yr)
½ first 8 h, ½ next 16 h
3750 ml/m² burned
1500 ml/m² BSA

Table I - Galveston resuscitation formula

Results

In the past ten years, six patients with full-thickness burns in 98% or over TBSA have been treated at the Shriners Burns Hospital, Galveston, Texas. All the patients received total burn wound excision in the first 24 h after the injury. The patients demographics are presented in Table II.

Age (yr) 8.6 ± 4.1
Sex (m/f) 2 : 4
TBSA burned (%) 99.3 ± 1.0
TBSA full-thickness burns (%) 98.5 ± 0.5

TBSA: Total body surface area
Data depicted as menu ± standard deviation

Table II - Demographics of the patients.

The survivors characteristics are shown in Table III.

Patient # Age (Yr) TBSA burned (%) TBSA full-thickness burns (%)
1 8 100 99.9
2 12 98 98
3 14 100 99

TBSA: Total body surface area

Table III - Characteristics of survivors

Three patients survived their injuries, and three patients died, representing a 50% survival rate in this small series of patients. One patient died of burn shock early on day one post-burn, while the other two survived respectively 14 and 23 days, succumbing to systemic sepsis and respiratory distress syndrome.
The three patients who survived remained in hospital for 126 ± 50 days (mean ± SD), and required 13.3 ± 3.7 operations to achieve wound closure. One patient was covered with cultured epidermal autografts and the other two with widely expanded meshed autografts. All three patients returned home and resumed their previous activities.

Discussion

Survival after burn injury has been steadily increasing during the last two decades. Risk factors identified for death following thermal injury are: age greater than 60 yr, inhalation injury, and a burned body surface area exceeding 40%.` A method for determining the probability of death would be extremely useful for the counselling of patients and relatives and taking medical decisions. This is true not only for burn centre practitioners but also for all physicians involved to some extent in the treatment of severe burns. The point when futility of treatment has been reached somehow vanishes in the critical care setting. It would be an over-simple clinical judgement to assume that patients with 100% burns have no chance of survival. In our present series this patient population achieved a survival rate of 50%. Recent advances in critical care and burn treatment have made this experience possible. The change in the approach to burn wound treatment from conservative treatment to early excision and grafting made one of the biggest impacts on survival. Years ago, burn wounds were allowed to separate by means of human and bacterial collagenases. Patients who survived sepsis, pain, and misery were subsequently subjected to autografting over granulating tissue. Today, early tangential or fascial excision makes it possible to remove all dead tissue, with the result that burn wound sepsis is now extremely rare.' Currently, as shown in the present series of patients, up to 100% BSA can be excised in the first 24 h post-burn in one operative setting. Coverage of the burn wound with homologous human skin stored in skin banks has also proved effective to prevent infection, improve survival, and modulate the hypermetabolic response. More recently, the techniques of cultured epidermal autografts have made it possible to cover extensive areas with cultured epidermis. Ideally, with the new achievements of tissue engineering, nearly any burn can be excised and covered with new skin, processed and expanded from a single stem cell. Homografts, cultured epidermal autografts, and widely expanded meshed autografts were used to cover the extensive loss of skin that the patients presented in the present series. Although the management of these wounds was extremely challenging, the techniques effectively provide a quick mechanical and biological barrier between the internal media and the environment.
The patients who survived were successfully discharged home after a mean hospital stay of three months. A question arises when we consider the outcome and the psychosocial implications of this major insult in the paediatric populations. It would be facile to assume that survival after such a severe burn means that patients are condemned to a less than acceptable life. Blakeney et al.' showed recently that children who survive massive burn injuries can achieve a positive psychosocial adaptation. By all objective scales, the group of survivors and their parents were within normal limits. This study involved patients with burns in over 80% T13SA. Whether the same psychosocial adaptation occurs in burns of over 99% TBSA needs to be studied.
In conclusion, paediatric burns in over 99% T13SA present acceptable survival. The role of the new bioengineered skin substitutes, anabolic agents, and psychosocial adaptation to these selected massive burns needs to be studied.
Currently, all paediatric patients are candidates for survival following thermal injury.

RESUME. Notices générales: La survie après une lésion thermique grave s'est améliorée dans les derniers vingt ans. Mais la question du moment où les soins deviennent inutiles n'a pas encore été résolue. Les Auteurs ont formulé l'hypothèse que même les patients atteints des brûlures les plus étendues (c'est-à-dire 100%) peuvent être sauvés. Méthodes: Pour mettre leur hypothèse à l'épreuve, les Auteurs ont considéré tous les patients pédiatriques hospitalisés dans leur centre pendant les derniers dix ans atteints de brûlures à toute épaisseure dans plus de 98% de la surface corporelle totale. La survie et le résultat favorable étaient les considérations les plus importantes. Résultats: Six patients ont été hospitalisés dans la période atteints de brûlures à toute épaisseur dans 98% de la surface corporelle totale. Trois patients ont survécu et ont été renvoyés de l'hôpital en bonnes conditions après une période moyenne de 126 ± 50 jours. Un patient a reçu des autogreffes épidermiques cultivées et les autres des autogreffes cutanées grandement augmentées avec la technique du meshing. Les patients ont nécessité 13,3 ± 3,7 opérations pour obtenir la fermeture des lésions. Interprétation: La survie après les brûlures graves dans 100% de la surface corporelle, dont 99% à toute épaisseur, est réalisable. Tous les enfants brûlés, sans distinction de l'étendue des brûlures, doivent être traités dans l'attente de la survie.


BIBLIOGRAPHY

  1. Ryan C.M., Schoenfeld D.A., Thorpe W.P., Sheridan R.L., Cassem E.H., Tompkins R.G.: Objective estimates of the probability of death from burn injuries. New Engl. J. Med., 338: 362-6, 1998.
  2. Wolf S.E., Rose J.K., Desai M.H., Mileski J.P., Barrow R.E., Hemdon D.N.: Mortality determinants in massive paediatric burns. Ann. Surg., 225: 554-559, 1997.
  3. Saffle J.R., Davis B., Williams P.: Recent outcomes in the treatment of burn injury in the United States: A report from the American Burn Association Patient Registry. J. Burn Care Rehabil., 16: 219-32, 1995.
  4. Hemdon D.N., Barrow R.E., Rutan R.L., Rutan T.C., Desai M.H., Abston S.: A comparison of conservative versus early excision therapies in severely burned patients. Ann. Surg., 209: 547-52, 1989.
  5. Burke J.F.: Contribution of frozen skin bank to treatment of massive burns. Acta Medica Polona., 19: 283-8, 1978.
  6. Munster A.M.: Cultured skin for massive burns. A prospective, controlled trial. Ann. Surg., 224: 372-5, 1996.
  7. Blakeney P., Meyer W. 111, Robert R., Desai M., Wolf S., Herndon D.: Long-term psychosocial adaptation of children who survive burns involving 80% or greater total body surface area. J. Trauma, 44: 62532, 1998.
This paper was received on 10 May 1999.
Address correspondence to: Juan P. Barret, MD
Department of Plastic Surgery, Academisch Ziekenhuis Groningen
Hanzeplein 1, Postbus 30.001, 9700 RB Groningen
The Netherlands (tel.: 31-50-3611630; fax: 31-50-3613043)

 

G. WHITAKER INTERNATIONAL BURNS PRIZE
PALERMO, ITALY
Under the patronage of the Authorities of the Sicilian Region for 2000

By law n. 57 of June 14th 1983 the Sicilian Regional Assembly authorized the President of the Region to grant the Giuseppe Whitaker Foundation, a non-profit-making organization under the patronage of the Accademia dei Lincei with seat in Palermo, an annual contribution for the establishment of the G. Whitaker International Burns Prize aimed at recognizing the activity of the most qualified experts from all countries in the field of burns pathology and treatment.
The amount of the prize is fixed at twenty million Italian Lire. The prize will be awarded every year by the month of June in Palermo at the seat of the G. Whitaker Foundation.
The Adjudicating Committee is composed of the President of the Foundation, the President of the Sicilian Region, the Representative of the Accademia dei Lincei within the G. Whitaker Foundation, the Dean of the Faculty of Medicine and Surgery of Palermo University, the President of the Italian Society of Plastic Surgery, three experts in the field of prevention, pathology, therapy and functional recovery of burns, the winner of the prize awarded in the previous year, and a legal expert nominated in agreeement with the President of the Region as a guarantee of the respect for the scientific purpose which the legislators intended to achieve when establishing the prize.
Anyone who considers himself/herself to be qualified to compete for the award may send by January 31st 2000 a detailed curriculum vitae to: Michele Masellis M.D., Secretary-Member of the Scientific Committee G. Whitaker Foundation, Via Dante 167, 90141 Palermo, Italy.




 

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