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 |
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Table
I - Galveston resuscitation formula |
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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 |
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Table II -
Demographics of the patients. |
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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 |
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Table
III - Characteristics of survivors |
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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
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.
- 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.
- 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.
- 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.
- Burke J.F.: Contribution of frozen skin bank to
treatment of massive burns. Acta Medica Polona., 19: 283-8, 1978.
- Munster A.M.: Cultured skin for massive burns. A
prospective, controlled trial. Ann. Surg., 224: 372-5, 1996.
- 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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