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Mortality determinants in massive pediatric burns. An analysis of 103 children with > or = 80% TBSA burns (> or = 70%
S E Wolf1, J K Rose, M H Desai
1Department of Surgery, University of Texas Medical Branch, Galveston, USA.
Insights
Mortality in massively burned children has decreased significantly, with most patients now considered candidates for survival. Key predictors of increased mortality include sepsis and multiorgan failure during hospitalization.
Area of Science:
- Pediatric critical care medicine
- Burn trauma management
- Surgical outcomes research
Background:
- Historically, extensive burns (>80% body surface area) in children were often fatal.
- Advances in specialized burn care have improved survival rates over the past 15 years.
- This study aimed to update predictors of mortality in pediatric massive burn cases.
Purpose of the Study:
- To assess survival rates in pediatric patients with massive burns.
- To identify current predictors of mortality in this patient population.
- To guide future burn care strategies.
Main Methods:
- Analysis of 103 pediatric patients (6 months-17 years) with burns ≥80% body surface area (≥70% full-thickness).
- Treatment involved early excision and grafting.
- Statistical analysis included univariate and multivariate logistic regression to identify mortality predictors.
Main Results:
- The overall mortality rate was 33%.
- Significant predictors of increased mortality included younger age, larger burn size, inhalation injury, delayed IV access, lower hematocrit, lower base deficit, higher serum osmolarity, sepsis, inotropic support, low platelet count, and ventilator dependency.
- Despite these factors, survival is now achievable for most patients.
Conclusions:
- Mortality in massively burned children has declined, making survival a possibility for nearly all patients.
- Sepsis and multiorgan failure during hospitalization are critical indicators of poor prognosis.
- While initial presentation factors are less predictive than before, very young age, limited donor sites, inhalation injury, resuscitation delays, sepsis, and multiorgan failure remain associated with higher mortality risk.
Objective:
Survivors and nonsurvivors among 103 consecutive pediatric patients with massive burns were compared in an effort to define the predictors of mortality in massively burned children.
Summary Background Data:
Predictors of mortality in burns that are used commonly are age, burn size, and inhalation injury. In the past, burns over 80% of the body surface area that are mostly full-thickness often were considered fatal, especially in children and in the elderly. In the past 15 years, advances in burn treatment have increased rates of survival in those patients treated at specialized burn centers. The purpose of this study was to document the extent of improvement and to define the current predictors of mortality to further focus burn care.
Methods:
Beginning in 1982, 103 children ages 6 months to 17 years with burns covering at least 80% of the body surface (70% full-thickness), were treated in the authors' institution by early excision and grafting and have been observed to determine outcome. The authors divided collected independent variables from the time of injury into temporally related groups and analyzed the data sequentially and cumulatively through univariate statistics and through pooled, cross-sectional multivariate logistic regression to determine which variables predict the probability of mortality.
Results:
The mortality rate for this series of massively burned children was 33%. Lower age, larger burn size, presence of inhalation injury, delayed intravenous access, lower admission hematocrit, lower base deficit on admission, higher serum osmolarity at arrival to the authors' hospital, sepsis, inotropic support requirement, platelet count < 20,000, and ventilator dependency during the hospital course significantly predict increased mortality.
Conclusions:
The authors conclude that mortality has decreased in massively burned children to the extent that nearly all patients should be considered as candidates for survival, regardless of age, burn size, presence of inhalation injury, delay in resuscitation, or laboratory values on initial presentation. During the course of hospitalization, the development of sepsis and multiorgan failure is a harbinger of poor outcome, but the authors have encountered futile cases only rarely. The authors found that those patients who are most apt to die are the very young, those with limited donor sites, those who have inhalation injury, those with delays in resuscitation, and those with burn-associated sepsis or multiorgan failure.