Continuous noninvasive cardiac output in children: is this the next generation of operating room monitors? Initial experience in 402 pediatric patients.

BACKGROUND: Electrical Cardiometry(™) (EC) estimates cardiac parameters by measuring changes in thoracic electrical bioimpedance during the cardiac cycle. The ICON(®), using four electrocardiogram electrodes (EKG), estimates the maximum rate of change of impedance to peak aortic blood acceleration (based on the premise that red blood cells change from random orientation during diastole (high impedance) to an aligned state during systole (low impedance)). OBJECTIVE: To determine whether continuous cardiac output (CO) data provide additional information to current anesthesia monitors that is useful to practitioners. METHODS: After IRB approval and verbal consent, 402 children were enrolled. Data were uploaded to our anesthesia record at one-minute intervals. Ten-second measurements (averaged over the previous 20 heart beats) were downloaded to separate files for later comparison with routine OR monitors. RESULTS: Data from 374 were in the final cohort (loss of signal or improper lead placement); 292,012 measurements during 58,049 min of anesthesia were made in these children (1 day to 19 years and 1 to 107 kg). Four events had a ≥25% reduction in cardiac index at least 1 min before a clinically important change in other monitored parameters; 18 events in 14 children confirmed manifestations of other hemodynamic measures; eight events may have represented artifacts because the observed measurements did not seem to fit the clinical parameters of the other monitors; three other events documented decreased stroke index with extreme tachycardia. CONCLUSIONS: Electrical cardiometry provides real-time cardiovascular information regarding developing hemodynamic events and successfully tracked the rapid response to interventions in children of all sizes. Intervention decisions must be based on the combined data from all monitors and the clinical situation. Our experience suggests that this type of monitor may be an important addition to real-time hemodynamic monitoring.

Assessing the mental health and psychosocial wellbeing of Ukrainian pediatric trauma and burn patients and their caregivers amidst the war: insights from a surgical medical mission in Poland.

On a recent surgical medical mission caring for Ukrainian pediatric burn and trauma patients in Poland, an assessment of the mental health and well-being of children and their caregivers was completed. Children living in war zones frequently experience significant distress and mental health problems, but little is known about the impact of co-existing related or unrelated burn injuries or physical disabilities. 19 Ukrainian children and their caregivers were interviewed utilizing validated questionnaires Child Behavioral Checklist (CBCL) and Youth Self-Report (YSR) to assess their risk for developing or for the presence of clinically-significant mental health problems. We found a high percentage of children at risk for developing mental health disorders and an unexpectedly high number of children meeting criteria for mental health disorders. As a result of interviewing the caregivers, agreement was seen between the self-assessment in children and the perception of parents about their children's wellbeing. Further study is needed to better understand the complex interactions between pre-existing burn and traumatic injuries and their impact on the psychosocial wellbeing of children living in war-torn environments.

Immediate and early tissue expander placement for acute closure of scalp wounds.

BACKGROUND: Scalp tissue expansion is a reliable technique for reconstruction of scalp alopecia and other deformities. However, the conventional practice involves establishing temporary wound coverage before expander placement, expansion, and definitive reconstruction. We propose that immediate (at the time of injury and initial wound debridement, leaving an open wound during expansion) tissue expander placement may be a reasonable approach to the management of full-thickness scalp wounds not amenable to primary closure. METHODS: We performed a retrospective chart review identifying all patients who underwent immediate placement of scalp tissue expanders at the Lviv Burn Center (Lviv Medical University Burn Center, Ukraine). RESULTS: A total of 15 patients were identified who received a total of 21 tissue expanders at the time of acute burn treatment. The indications included electrical burn (46.7%), trauma (20%), tumor resection (13.3%), flame burn (13.3%), and chemical burn (6.7%). Of the 21 expanders placed, 4 (19%) complications were reported. There was 1 (4.7%) implant exposure and 3 (14%) implant infections. All of the patients in this series had complete reconstructions after removal of their expanders because all complications occurred toward the end of expansion. CONCLUSIONS: Immediate placement of tissue expanders is a reasonable approach that greatly expedites scalp reconstruction. In this series, the complication rate was consistent with or slightly higher than published rates of complications in conventional techniques. Immediate expansion may be especially useful when other reconstructive options (such as free tissue transfer) are unavailable or not feasible.

Global Burn Prevention: Ukraine.

Burn injury accounts for a large proportion of surgically treatable disease. It is estimated that over 180 000 flame burn deaths occur annually across the globe, with roughly 95% occurring in low- or middle-income countries (LMIC). Within these countries, children account for a disproportionately high number of burn injuries. As such, the WHO has identified burn prevention as a topic of interest, with an increased need in LMIC. Here, we describe the creation and implementation of a burn prevention program in Ukraine. We instituted a 5-step burn prevention initiative consisting of; data gathering, program design, implementation, outcome evaluation, program maintenance, and expansion. The burn prevention initiative has been adopted nationally leading to policy change. Active education and an information campaign were used to target pediatric scald injuries and improve first-aid care. The authors have successfully implemented a targeted multifaceted, national, burn prevention program within Ukraine. The described approach may be used as a guide and adapted to create similar prevention programs within other countries or regions. At this time, the Russo-Ukrainian War has caused an abrupt hold on our role in the prevention program and left the healthcare system in havoc. Moving forward, our team is prepared to re-evaluate the impact of the war on social life and the medical system and aid in redesigning the prevention program when appropriate.

Airway management of recovered pediatric patients with severe head and neck burns: a review.

There are approximately 10,000 pediatric burn survivors in the United States each year, many of whom will present for reconstructive surgery after severe burns in the head and neck (1). These recovered burn victims, who are beyond the acute phase of injury, often have significant scarring and contractures in the face, mouth, nares, neck, and chest, which can make airway management challenging and potentially lead to a 'cannot intubate, cannot ventilate' scenario (2). Although numerous cases have been presented in the literature on this topic (3-17), there are no comprehensive review articles on the unique challenges of airway management in the recovered pediatric burn patient with distorted airway anatomy. This article aims to provide a comprehensive review of airway management in such patients, focusing on challenges encountered during mask ventilation and tracheal intubation, as well as the role of surgical release of neck contractures to facilitate tracheal intubation. Lessons learned from all reported cases identified in a thorough literature search are incorporated into this review.

Evaluation of liposomal bupivacaine infiltration at reconstructive skin graft donor sites in adolescent and young adult burn patients: A retrospective analysis.

BACKGROUND: Postoperative pain at skin graft donor sites is frequently undertreated in burn patients, which can impair reconstructive outcomes and result in harmful psychological consequences. We find a critical need to explore and promote non-opioid, multimodal analgesics. Donor site infiltration of the local anesthetic liposomal bupivacaine in adolescent and young adult burn patients has not been previously investigated. Therefore, the goal of this study was to evaluate intraoperative liposomal bupivacaine infiltration for postoperative donor site pain control in adolescent and young adult burn patients undergoing reconstructive skin graft procedures. METHODS: This retrospective analysis included patients aged 14-25 years, who underwent at least two reconstructive skin graft procedures, one that received donor site infiltration of the standard treatment (bupivacaine hydrochloride) and one that received donor site infiltration of liposomal bupivacaine. The final sample included 30 patients with a total of 44 liposomal bupivacaine cases and 53 standard treatment cases analyzed. RESULTS: In the authors' five-year experience, the use of liposomal bupivacaine compared to standard treatment was associated with statistically significant decreases in 0-4 h postoperative pain scores (mean 1.4/10 versus 2.3/10, p = 0.04) and 0-24 h postoperative pain scores (mean 1.7/10 versus 2.4/10, p = 0.02). Neither analgesic was associated with adverse events. Differences in length of stay and inpatient postoperative opioid usage were not regarded as significant. CONCLUSION: In this retrospective analysis, the authors report the first results that suggest intraoperative liposomal bupivacaine donor site infiltration may be associated with statistically improved patient outcomes in adolescent and young adult burn patients. However, the reported differences are most likely not clinically significant, establishing the necessity for further evaluation of using liposomal bupivacaine in this unique patient population.

Resumption of Short-term Burn Reconstruction Missions to Ukraine in Light of COVID-19: A Paradigm Shift.

The COVID-19 pandemic has disrupted the lives of billions of people globally. Some medical systems continue to be overburdened due to the viral illness leading to incredible public health challenges domestically as well as abroad. However, with vaccination distribution increasing globally, many are pushing for a return to some form of normalcy. In the medical community, some are weighing the risks of returning to global health missions and considering protective strategies to minimize risk of viral spread. Here, we describe our experience in returning to an annual burn reconstruction mission in a low- and middle-income country. We have successfully carried out a return surgical mission trip. Our team of 10 individuals was able to perform over 75 procedures on 25 pediatric patients in 4 operative days. We applied a variety of protective strategies and altered mission protocol to limit exposure and transmission risk while focusing heavily on education and training. Additionally, we increased the use of telemedicine and eliminated typical in-person clinic visits. We increased operative complexity to increase impact while limiting patient exposure. Rigorous perioperative safety and follow-up protocols were implemented. The increased use of telemedicine, reduction of in-person visits, emphasis on education, and implementation of safety and follow-up protocols have led to an improvement in efficiency, safety, and accountability. Our adaptations have provided guidance on responsibly resuming surgical outreach missions, with changes that are likely to endure beyond the COVID-19 pandemic.

Acute pulmonary edema due to occult air embolism detected on an automated anesthesia record: illustrative case.

BACKGROUND: The authors report a case of venous air embolism (VAE) during a pediatric posterior fossa craniotomy with resulting pulmonary edema requiring postoperative ventilation. Pulmonary edema is a known but rare complication of VAE, and diagnosis and treatment are discussed. OBSERVATIONS: The embolism was undetected during the surgical procedure, and the first clinical sign of respiratory decompensation appeared an hour after the initial insult, with imaging suggesting acute pulmonary edema. A transient but significant end-tidal carbon dioxide decrease was detected on postoperative review of the anesthesiology record. LESSONS: This report highlights an uncommon sequela of VAE and the importance of post hoc automated record review for intraoperative event analysis.

Experience of outreach in a resource-constrained environment: 10 years of outcomes in burn care.

OBJECTIVE: The objective of this work was to describe an efficient and sustainable outreach model in a resource-constrained environment, with a multifaceted approach focusing on national policy change, telemedicine, injury prevention, education and treatment of burns. SUMMARY BACKGROUND DATA: Burn injury constitutes a significant portion of morbidity and mortality worldwide, particularly in children, and in low- and middle-income countries. METHODS: We reviewed the impact of ten-years of a burn outreach program. Our focus was on clinical data on burn care within one region of Ukraine. We assessed knowledge of burn prevention/first aid utilizing a large survey, analyzed clinical data from our outreach clinic and telemedicine program, and analyzed data within a newly created burn repository within Ukraine. RESULTS: A national burn prevention policy has been implemented through our efforts along with a burn prevention program. Educational efforts have led to improvements of major complication rates (wound infection [7% vs. 16%], pneumonia [2.4% vs. 0.3%], sepsis [1.6% vs. 0.6%], UTI [2% vs. 0.6%], and cellulitis [11% vs. 3.4%]), respiratory support of acutely ill patients [1.3% vs. 0.4%], and blood transfusion triggers. CONCLUSIONS: Broadly, our model could be an example of building sustainable outreach programs in resource-constrained environments. Through collaboration with local healthcare providers, we have developed and implemented an outreach program in a resource-constrained environment.

Anesthetic considerations for major burn injury in pediatric patients.

Major burn injury remains a significant cause of morbidity and mortality in pediatric patients. With advances in burn care and with the development of experienced multi-disciplinary teams at regionalized burn centers, many children are surviving severe burn injury. As members of the multi-disciplinary care team, anesthesia providers are called upon to care for these critically ill children. These children provide several anesthetic challenges, such as difficult airways, difficult vascular access, fluid and electrolyte imbalances, altered temperature regulation, sepsis, cardiovascular instability, and increased requirements of muscle relaxants and opioids. The anesthesia provider must understand the physiologic derangements that occur with severe burn injury as well as the subsequent anesthetic implications.

Inhalation burn injury in children.

With advances in burn care, many children are surviving severe burn injuries. Inhalation injury remains a predictor of morbidity and mortality in burn injury. Inhalation of smoke and toxic gases leads to pulmonary complications, including airway obstruction from bronchial casts, pulmonary edema, decreased pulmonary compliance, and ventilation-perfusion mismatch, as well as systemic toxicity from carbon monoxide poisoning and cyanide toxicity. The diagnosis of inhalation injury is suggested by the history and physical exam and can be confirmed by bronchoscopy. Management consists of supportive measures, pulmonary toilet, treatment of pulmonary infection and ventilatory support as needed. This review details the pathophysiology, diagnosis, and management options for inhalation injury.

[Analgesic and sedative effects of multimodal analgesia in stage of emergence after general anesthesia for cleft lip and/or palate prosthesis].

OBJECTIVE: To investigate the effects of multimodal analgesia on analgesia and sedation during emergence of general anesthesia for cleft lip and/or palate surgery pediatric patients. METHODS: Fifty-four pediatric patients with ASA I and II cleft lip and/or palate, aged 2-7, undergoing prosthesis were randomly allocated into 2 groups: control group (Group C, n=28) inhaling nitrous oxide/oxygen (50%:50%) and sevoflurane(5%) for general anesthesia, and multimodal group (Group M, n=26), injected intravenously with fentanyl and atracurium in addition to inhalation of nitrous oxide/oxygen (50%:50%) and sevoflurane (5%). Ventilation was controlled with PCV modal to maintain end-tidal CO2 to 35-45 mmHg. Local anesthesia at the surgical site was facilitated by the surgeon before the beginning of surgery. After intubation, rectal paracetamol was used for Group M (120 mg for 2-4 year-olds and 325 mg for 5-7 year-olds) and fentanyl 0.5 microg/kg was injected for postoperative analgesia 10 min before the end of surgery. An observer who was blinded to the protocol recorded the time from the discontinuation of sevoflurane and nitrous oxide to tracheal extubation, accessed the sedation and pain scale, recorded the time ready for discharge from post-anesthesia care unit (PACU) and the incidence of adverse effects. RESULTS: The time ready for discharge from PACU of Group M was (25+/-4) min, significantly shorter than that of Group C [(32+/-3) min, t=7.426, P<0.01]. The analgesia satisfaction rate of Group M was 69.2% (18/26), significantly higher than that of Group C [25.0%, 7/28, P<0.05]. The severe pain rate of Group M was 7.7%, significantly lower than that of Group C (35.7%, F=5.333, P=0.021). The agitation rate of Group M was 11.5%, significantly lower than that of Group C (39.3%, F=4.571, P=0.033). CONCLUSION: Multimodal analgesic regimen of infiltration of local anesthetic at surgical site and rectal paracetamol and intravenous fentanyl provides sufficient analgesia, minimizes the incidence of agitation after general anesthesia in cleft lip and/or palate surgery for children, increases the speed of referring patients in PACU, and ensures the safety of the postanaesthetic patients.

Pain Management in Pediatric Burn Patients: Review of Recent Literature and Future Directions.

Childhood burns are a profoundly traumatic and painful experience. Despite recognition of the prevalence of burn injuries in children and the severity of the associated pain, burn pain remains undertreated. At the same time, more evidence is emerging to suggest that undertreated pain has serious long-term medical and psychiatric consequences, many of which can be ameliorated with improved pain control. Pain in burn patients is, however, notoriously difficult to treat, perhaps because there is a chronic pain aspect underlying the acute pain that accompanies wound care and procedures. This difficulty is compounded by the fact that there are little data to guide decision making in these patients. This article aims to identify the best strategies to guide clinical practice through a review of the past 10 years' development in pediatric burn pain management. However, because clinical investigations remain limited in burned children, we also aim to draw attention to those areas where the data do not identify an optimal approach and further work is needed. Overall, in addition to just the traditional pharmacological approaches to pain, such as acetaminophen, benzodiazepines, and opioids, there is growing evidence to support more widespread use of regional anesthesia and novel technologies such as virtual reality. Starting with an improved understanding of the current state of the literature, we can identify areas of research and important questions whose answers will ultimately improve care and reduce suffering for this unfortunate population of children.