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Left ventricular failure complicating severe pediatric burn injuries
E M Reynolds1, D P Ryan, R L Sheridan
1Pediatric Surgical Services, Massachusetts General Hospital, Boston 02114, USA.
Insights
Pediatric burn resuscitation failure is often due to myocardial depression, predominantly left-sided. Pulmonary artery catheter data guides therapy with vasopressors and fluid adjustments for improved outcomes.
Area of Science:
- Pediatric Critical Care Medicine
- Burn Injury Management
- Cardiovascular Physiology
Background:
- Failed resuscitation contributes significantly to mortality in critically burned children.
- Myocardial depression is implicated in burn shock, with varying patterns in adults and the elderly.
- Understanding cardiac dysfunction is crucial for optimizing pediatric burn resuscitation.
Purpose of the Study:
- To investigate the role of myocardial depression in failed resuscitation among critically burned children.
- To identify the specific patterns of cardiac dysfunction (left vs. right ventricular) in this population.
- To evaluate the utility of hemodynamic monitoring in guiding resuscitation strategies.
Main Methods:
- Retrospective analysis of 28 critically burned children (>60% TBSA) resuscitated between 1989-1992.
- Invasive hemodynamic monitoring, including pulmonary artery catheterization in 9 patients with failed standard therapy.
- Fluid resuscitation guided by the Parkland formula, with assessment of cardiac function via thermodilution.
Main Results:
- All patients exhibited depressed left ventricular function (average LVSWI 19.9 g.m/m2, normal 44-68).
- 38% of patients also showed concomitant right ventricular failure.
- Left ventricular dysfunction persisted but improved with vasopressors and modified fluid resuscitation.
Conclusions:
- Cardiogenic failure, predominantly left-sided myocardial depression, is a key factor in failed pediatric burn resuscitation.
- Pulmonary artery catheter data is valuable for directing vasopressor use and modifying fluid resuscitation.
- Therapeutic adjustments based on hemodynamic monitoring can improve cardiac function in pediatric burn victims.
Purpose:
Despite improvements in the overall survival rates for critically burned children, failed resuscitation may account for 54% of deaths following burn injuries. Clinical and experimental studies have implicated failure of the right side of the heart in adults, biventricular 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 (> or = 60% total burn surface area) were resuscitated primarily at our center (admission within 24 hours of injury). Twenty-seven children had central lines, nine of whom underwent pulmonary artery catheterization for intensive hemodynamic monitoring because standard resuscitative therapy had failed. The average amount of fluid received at 8 and 24 hours after injury was within 10% of the calculated volume based on the Parkland formula.
Results:
Indexes of a failing rescue attempt included respiratory distress (PaO2/FlO2 < or = 200), central venous pressure of greater than 10 mm Hg, and urine output of less than 1 mL/kg/h. Filling pressures were found to be normal or elevated in all children, indicating adequate volume replacement. Evaluation of cardiac function was performed using a thermodilution technique and showed that 100% of the study group had depressed left ventricular function, with an average left ventricular stroke work index (LVSWI) of 19.9 g.m/m2 (normal, 44 to 68 g.m/m2), whereas only 38% had concomitant right ventricular failure. This left-sided dysfunction persisted throughout the acute resuscitation period but was improved after appropriate modification of fluid resuscitation and initiation of vasopressors (average final LVSWI, 38.0 g.m/m2). There were no complications from placement of the Swan-Ganz catheters in this group.
Conclusion:
Cardiogenic failure is a major determinant of a failing pediatric burn resuscitation, and, contrary to the adult burn patient, the myocardial depression is predominantly left-sided. Information from pulmonary artery catheters can help direct therapy by providing indications for vasopressors and modifying fluid resuscitation.