Safety and Tolerance of Intraoperative Enteral Nutrition Support in Pediatric Burn Patients.

BACKGROUND: Multiple surgical procedures required by patients with extensive thermal injuries impedes delivery of adequate nutrition support, leading to caloric deficits, weight loss, delayed wound healing, and increased length of stay. The standard practice at our institution for >20 years has been to continuously infuse postpyloric enteral nutrition (EN) during surgery. The purpose of this review was to examine the safety and efficacy of intraoperative EN support. METHODS: A retrospective chart review of pediatric patients with burn injuries >30% total body surface area provided a 20-year (1995-2014) safety assessment associated with intraoperative feeding along with an evaluation of gastrointestinal tolerance and efficacy. Continuous variables were summarized by mean and SD, whereas categorical variables were summarized by counts and percentages. RESULTS: The 20-year review confirmed the safety of intraoperative feeding, as the assessment of 434 patients revealed no incidence of aspiration. Patients were successfully fed during an average of 8.4 ± 6.5 surgical procedures and received EN support for a mean of 49.9 ± 31.7 days. Uninterrupted nutrition delivery was well tolerated with minimal gastrointestinal intolerance. Patients achieved an average nitrogen balance of 3.1 ± 2.8 and 70% maintained ±10% of their body weight at time of discharge. CONCLUSION: EN has been safely provided with marginal intolerance during surgical procedures over the past 20 years. Continuous nutrition support with negligible interruption is integral to meet nutrient needs for wound healing, preservation of weight and nutrition parameters, and optimize length of stay in pediatric patients with extensive thermal injuries.

Pediatric perioperative measures of sleep, pain, anxiety and anesthesia emergence: A healing touch proof of concept randomized clinical trial.

BACKGROUND AND PURPOSE: The purpose of this study was to determine the impact of healing touch (HT) on sleep, anxiety, anesthesia emergence and pain. METHODS: HT, sham HT, control with an aide (CP) and control groups without the presence of an aide (CNP), underwent polysomnography (PSG) preoperatively. The Yale Preoperative Anxiety Scale (YPAS) score was obtained preoperatively before medications were given and in the preoperative surgery area. Sedation score, anesthesia emergence score and vital signs were recorded. Pain scores were determined by the Observation Pain Assessment Scale (OPAS) postoperatively and at time of discharge. Preoperative laboratory blood was drawn for C-reactive protein (CRP), glucose, cortisol and vitamin D25 levels as indicators of stress and anxiety, and a HT satisfaction survey was given. RESULTS: Thirty-nine patients consented to participate and were randomly assigned to HT (9), HT sham (12), CP (7) and CNP (11) groups. Mean patient age was 13.0 years, and no significant group differences were found for age, sex, race or patient procedure, categorized as laser, burn reconstruction and plastic surgery reconstruction. Additionally, no significant group differences were detected for any of the PSG parameters, YPAS scores, OPAS scores, medications, anesthesia emergence score, bloodwork or satisfaction survey score. CRP, glucose and cortisol levels were higher in the CNP group, suggesting that pediatric patients undergoing elective surgeries may benefit from more pre-operative support, possibly by HT. CONCLUSIONS: Although no tracked parameters showed statistically significant findings, anecdotal HT benefits included enhanced relaxation and sounder sleep.

A Retrospective Study Identifying Breast Milk Feeding Disparities in Infants with Cleft Palate.

BACKGROUND: Breast milk represents the optimal substrate for all infants, including those with a cleft palate for whom growth may be compromised. OBJECTIVES: Frequency of breast milk feeding at the breast and per feeder (bottle, cup, enteral tube) in infants with cleft palate was determined and compared with rates reported by the Centers for Disease Control and Prevention. A secondary aim was to review growth status of the infants. DESIGN: This study represents a 5-year retrospective review using the electronic medical record. PARTICIPANTS AND SETTING: Patients were ≤12 months old at the time of the initial, presurgical encounter after a diagnosis of cleft palate had been made and were treated at one of two pediatric cleft palate and craniofacial centers in Ohio between September 30, 2010, and September 30, 2015. MAIN OUTCOME MEASURES: Outcomes measured were breast milk use, reported by mothers and documented in patients' electronic medical records, chronological body weight, as well as weight for length and weight-for-age z scores and percentiles. STATISTICAL ANALYSES PERFORMED: Descriptive statistics included median with interquartile range and frequency with percentages. World Health Organization z scores were estimated using the Centers for Disease Control and Prevention programs for weight, weight for length, and weight for age at first visit. Comparisons of infants treated at the two hospitals were done using the Wilcoxon rank-sum test or the χ2 test. RESULTS: Breast milk consumption (26 infants were breastfed and 84 received human breast milk administered with a device) was 29.5%, markedly below the 2016 Centers for Disease Control and Prevention national statistics for ever receiving breast milk (81%). Anthropometric findings included z scores of -0.95 and -0.42 for weight for age and weight for length, respectively. CONCLUSIONS: Infants with cleft palate were seldom breastfed, nor was breast milk frequently used. In addition, median weight-for-age and weight-for-length z scores suggest that growth of infants with cleft palate was below normative standards.

Clinical Trial of Vitamin D2 vs D3 Supplementation in Critically Ill Pediatric Burn Patients.

BACKGROUND: Hypovitaminosis D exists postburn. However, evidence-based guidelines for vitamin D repletion are unknown. This investigation examined differences between D2 and D3 supplementation on outcome in children with burn injuries. METHODS: Fifty patients with total body surface area burn of 55.7% ± 2.6% and full-thickness injury of 40.8% ± 3.8% were enrolled, ranging in age from 0.7-18.4 years. All participants received multivitamin supplementation per standardized clinical protocol. In addition, 100 IU/kg D2, D3, or placebo was administered daily during hospitalization using a randomized, double-blinded study design. Assay of total 25-hydroxyvitamin D (D25), 1,25-dihydroxyvitamin D (D1,25), 25-hydroxyvitamin D2 (25-OH-D2), 25-hydroxyvitamin D3 (25-OH-D3), and parathyroid hormone (PTH) was performed at 4 preplanned time intervals (baseline, midpoint, discharge, and 1 year postburn). Differences in vitamin D status were compared over time and at each specific study interval. RESULTS: There were no significant differences in serum vitamin D levels between groups, but >10% of patients had low D25 at discharge, and percent deficiency worsened by the 1-year follow up for the placebo (75%), D2 (56%), and D3 (25%) groups. There were no statistical differences in PTH or clinical outcomes between treatment groups, although vitamin D supplementation demonstrated nonsignificant but clinically relevant decreases in exogenous insulin requirements, sepsis, and scar formation. CONCLUSIONS: The high incidence of low serum D25 levels 1 year following serious thermal injury indicates prolonged compromise. Continued treatment with vitamin D3 beyond the acute phase postburn is recommended to counteract the trajectory of abnormal serum levels and associated morbidity.

Zolpidem and Sleep in Pediatric Burn Patients with Attention Deficit/Hyperactivity Disorder.

Existing research shows that hospitalized patients, especially pediatric burn patients, are often sleep deprived. A pre-existing diagnosis of attention deficit/hyperactivity disorder (ADHD) further compounds a burn patient's inability to sleep. This retrospective study compared the effectiveness of zolpidem on patients with acute burns with ADHD (n = 23) and patients with acute burns without ADHD (n = 23). Effectiveness was defined based on the need for a change in the sleep medication or an increase in the zolpidem dose during the first 12 days of treatment. This study found that sleep dysfunction was similar in pediatric burn patients with and without a concurrent diagnosis of ADHD. Sixteen (69.6%) patients with and 13 (56.5%) patients without ADHD required a sleep medication change (p = 0.541). Further, while patients with ADHD required a sleep medication change (median = 5 days) sooner than those without ADHD (median = 9 days), it appears that zolpidem is not an effective drug for managing sleep in pediatric burn patients with or without ADHD.

Investigation of Bone Health Subsequent to Vitamin D Supplementation in Children Following Burn Injury.

BACKGROUND: The effect of supplemental vitamin D on fracture occurrence following burn injuries is unclear. The objective of this study was to evaluate postintervention incidence of fractures in children during the rehabilitative phase postburn (PB) following participation in a randomized clinical trial of vitamin D supplementation. MATERIALS AND METHODS: Follow-up for fracture evaluation was obtained in 39 of 50 patients randomized to daily enteral vitamin D2, D3, or placebo throughout the acute burn course. Serum 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, D2, D3, calcitonin, and bone alkaline phosphatase (BAP) measurements were obtained PB day 7, midpoint, discharge, and 1-year PB. Urinary calcium was obtained PB day 7 and midpoint. Dual-energy x-ray absorptiometry (DXA) was performed at discharge and 1-year PB. RESULTS: Fractures were reported in 6 of 39 respondents. Four fractures occurred in the placebo group, 2 in the D2 group, and none in the D3 group. Serum vitamin D, calcitonin, BAP, and urinary calcium were similar between fracture groups. The group with fracture morbidity had larger burn size (83.8% ± 4.9% vs 53.0% ± 2.9%, P < .0001), greater full-thickness burn (69.7% ± 9.4% vs 39.4% ± 4.1%, P = .02), and increased incidence of inhalation injury (33% vs 6%, P = .04). Decreased bone mineral density z score was noted at discharge in the placebo fracture compared with no-fracture group (P < .05). CONCLUSION: This preliminary report suggests there may be benefit of vitamin D3 in reducing postdischarge fracture risk. Results reaffirm the importance of monitoring bone health in pediatric patients postburn.

Application of a method used to deconstruct a single dose pharmacokinetic profile from multiple dose data.

With traditional non-compartmental methods, it is challenging to deconstruct plasma concentration versus time curves to assess the influence of individual doses. This study describes the application of a mathematical approach used to deconstruct a single dose curve using data derived from the second, third, fourth or nth dosing interval. Using data from a prospective clinical trial it is demonstrated that this approach reliably estimates pharmacokinetic parameters measured following two doses of zolpidem tartrate. Additionally, the study demonstrates the application of this approach using previously published data from a single- and multiple-dose pharmacokinetic study of the antibiotic gatifloxacin. Copyright © 2015 John Wiley & Sons, Ltd.

Clinical safety and efficacy of probiotic administration following burn injury.

Provision of probiotics has been limited postburn by questionable potential for bacterial translocation and risk of infection in an immune-compromised population. The purpose of this study was to evaluate the safety of probiotic administration in acutely burned, pediatric patients. Subjects were randomized to receive probiotic (n = 10) vs placebo (n = 10) twice daily. The investigational product was initiated within 10 days of burn, and daily supplementation continued until wound closure. Nursing staff was provided education regarding optimal procedures to minimize potential for study product cross contamination. Clinical outcomes (infection, antibiotic, antifungal, and operative days, tolerance, and mortality) were recorded. Length of stay was modified for burn size. Student's t-test, χ test, and nonparametric Wilcoxon's rank-sum test were used for comparative analysis. No differences were noted (probiotic; placebo) for age (7.1 ± 2.2; 6.9 ± 1.7), burn size (38.0 ± 5.9; 45.5 ± 4.45), full thickness (24.6 ± 5.6; 32.1 ± 5.4), postburn day admit (0.8 ± 0.4; 1.1 ± 0.4), or inhalation injury (10%; 20%). Infection days, antibiotic use, constipation, and emesis were similar between groups. Trends toward increased antifungal and laxative use as well as diarrhea incidence were evident in the controls (P < .30). Flatulence was statistically higher with probiotics. The control group trended toward higher requirement for excision/graft procedure. Medical length of stay was not significantly different between groups; however, time required to complete wound healing was shortened with probiotics. This study documents safety and provides preliminary efficacy data relative to probiotic supplementation postburn.

Relationship between zolpidem concentrations and sleep parameters in pediatric burn patients.

Zolpidem is a short-acting non-benzodiazepine hypnotic that is used to improve sleep architecture in patients with burn injuries. This study evaluated the relationship between zolpidem administration and sleep parameters in a cohort of children with severe burn injuries. Standard age-based zolpidem dosing practices were employed. Polysomnography data were recorded at 30-second intervals throughout the night. Serum concentrations of zolpidem were measured at 0, 1, 2, 4, 5, 6, and 8 hours after administration of the first dose. The relationship between zolpidem concentrations and sleep parameters was evaluated using Markov mixed-effects pharmacodynamic models. Ten children received two doses of zolpidem at 22:00 and 02:00 hours. The median total amount of sleep was 361.0 (interquartile range [IQR]: 299.0-418.5) minutes; approximately 65% of the normal reference value for an 8-hour period. Slow-wave and rapid eye movement (REM) sleep were also dramatically reduced (18-37% of normal). With two doses of zolpidem, stage 2 sleep was 99% of normal levels. Higher peak zolpidem concentrations were associated with increased stage 2 sleep (r = .54; P = .04). Despite this, a median of 120.0 (IQR: 99.5-143.5) transitions between nocturnal sleep stages were recorded, with a median of 55.5 (IQR: 36-75) night-time awakenings per patient. In pediatric burn patients, higher zolpidem serum concentrations were associated with restoration of stage 2 sleep to normal levels. Nonetheless, slow-wave and REM sleep were profoundly depressed with frequent transitions between sleep stages, suggesting that alternative hypnotic agents may be required to restore normal sleep architecture in severely burned children.

The effect of diphenhydramine on sleep in pediatric burn patients: a secondary analysis.

Adequate sleep is essential for maintaining homeostasis, especially when recovering from an illness; however, studies have shown that sleep disruption and sleep deprivation are common in intensive care unit patients, including children who have sustained burn injury. The purpose of this study was to evaluate the effect of diphenhydramine (DPH) on sleep in pediatric intensive care unit burn patients using Myra Levine's Conservation Model as the organizing framework. For this study, secondary analysis of polysomnography data and retrospective chart review were used. Twelve DPH patients were pair matched in terms of morphine, midazolam, and methadone with 12 non-DPH patients. The data were analyzed using paired t-tests for each dependent variable and χ analysis was used for frequency determinations. There was no difference in demographics between the two groups. DPH patients took 4.3 ± 1.6 minutes to fall asleep whereas non-DPH patients took 15.8 ± 1.6 minutes to achieve sleep onset (P = .06). Patients receiving DPH achieved 297.6 ± 29.9 minutes of total sleep time whereas those not receiving DPH achieved only 209.2 ± 29.9 minutes (P < .05). There was minimal difference in the mean percentage of sleep time in stages 3 and 4 between the two groups. The DPH group did have 50% more rapid eye movement sleep time compared with the non-DPH group. Even though DPH did not result in a statistical improvement in sleep quality, sleep quantity was increased in this study. More research is needed to find an effective sleep intervention in pediatric burn patients.

Preliminary assessment of zolpidem pharmacokinetics in pediatric burn patients.

PURPOSE: Severely burned patients frequently experience sleep fragmentation and insomnia. This study evaluated the population pharmacokinetics of the sleep-enhancing agent zolpidem among burned children. METHODS: Zolpidem was administered according to the following age-based dosing schedule: 2.5 mg per dose for 2-4 year olds, 5.0 mg per dose for 5-10 year olds, and 10 mg per dose for older than 10 years. Serum samples were collected before and 1, 2, 4, 5, 6, and 8 hours after dosing. The population pharmacokinetic analysis modeled zolpidem concentrations using nonlinear mixed effects models. RESULTS: Eleven patients with a mean (±SD) age of 8.3 ± 4.0 years and a mean total burn surface area of 56% ± 22% were recruited. Seventy-three zolpidem concentrations were measured with a mean Cmax of 291 ± 140 ng/mL. A 2-compartment model with first-order absorption best described the data. Zolpidem clearance was estimated at 0.03 L·h(-1)·kg(-1) (relative standard error, 55%) and increased with body weight (P < 0.05). The central compartment volume of distribution was estimated at 0.05 L/kg (relative standard error, 25%), which was inversely related to the proportion of the body surface with third-degree burns (P < 0.001). CONCLUSIONS: A population pharmacokinetic model has been developed that reliably characterized the pharmacokinetic parameters of zolpidem when used as a sleep-enhancing agent among pediatric burn patients. Additional studies are needed to link this pharmacokinetic model with pharmacodynamic data, which may include an assessment of the effects of higher zolpidem doses and/or more frequent administration upon sleep architecture.

Quantity and quality of nocturnal sleep affect morning glucose measurement in acutely burned children.

Hyperglycemia after severe burn injury has long been recognized, whereas sleep deprivation after burns is a more recent finding. The postburn metabolic effects of poor sleep are not clear despite reports in other populations demonstrating the association between sleep insufficiency and deleterious endocrine consequences. The aim of this study was to determine whether a relationship between sleep and glucose dynamics exists in acutely burned children. Two overnight polysomnography runs (2200 to 0600) per subject were conducted in 40 patients with a mean (± SEM) age of 9.4 ± 0.7 years, 50.1 ± 2.9% TBSA burn, and 43.2 ± 3.6% full-thickness injury. Serum glucose was drawn in the morning (0600) immediately after the sleep test. Insulin requirements during the 24-hour period preceding the 0600 glucose measurement were recorded. Generalized linear models were used by the authors to evaluate percent time in each stage of sleep, percent wake time, total sleep time, sleep efficiency, and morning serum glucose, accounting for insulin use. Increased time awake (P = .04, linear; P = .02, quadratic) and reduced time spent in stage 1 sleep (P = .03, linear) were associated with higher glucose levels. Sleep efficiency (P = .01, linear; P = .02, quadratic) and total sleep time (P = .01 linear; P = .02, quadratic) were inversely associated with glucose level. Morning glucose levels appear to be affected by the quality and quantity of overnight sleep in children who have sustained extensive burn injuries. Future research is needed to elucidate the metabolic and neuroendocrine consequences of sleep deprivation on metabolism after burns.

Burn center journal club promotes clinical research, continuing education, and evidence-based practice.

The purpose of this study was to characterize the structure, policy, implementation, and outcome measures of a burn team journal club to assess its effectiveness in promoting multidisciplinary education relative to research competency, clinical knowledge, and evidence-based practice. After 2 years of a new multidisciplinary format, an anonymous quality assurance survey was distributed to staff members of a regional pediatric burn center to evaluate the impact of the journal club on clinical and research indicators. The 24 journal club meetings evaluated in this study included a variety of topics, among which were wound healing, infection, nutrition, metabolism, sleep, medications, alternative medicine, research compliance, and child abuse. The speakers included a variety of hospital personnel: 26% researchers, 23% physicians, 20% registered nurses, and 31% other disciplines and attendance mean was 29 participants per session (range 17-50). Survey results from 30 respondents indicated that 100% judged the program to be valuable to personal educational needs and 83% indicated that format did not warrant change. According to self-report data, the journal club enhanced medical knowledge (90%), patient care (73%), research competency (70%), critical thinking (63%), and evidence-based practice (63%). Results indicate that the journal club program was well received by participants, and promoted enhanced knowledge and improved patient care. In the future, barriers to research initiatives and integration of research findings into practice warrant follow-up study. Journal club should be incorporated into the learning curriculum of burn practitioners as a means to promote critical thinking, research competency, and evidence-based clinical practice.

Comparison of sleep parameters obtained from actigraphy and polysomnography during the rehabilitative phase after burn.

The evaluation of sleep is an important aspect of holistic care. Polysomnographic assessment is not always possible or justified. Actigraphy has gained popularity as an alternative sleep/wake monitor. The purpose of this study was to determine whether actigraphy has reasonable validity within the special population of rehabilitating burn patients. Total sleep time, sleep efficiency, number of arousals, wake time after sleep onset, and latency of sleep onset as assessed by actigraphy (proportional integration mode [PIM] and zero crossing mode [ZCM]) were compared with polysomnography in 36 children an average of 10.5 years after burn injury during an overnight hospital stay. The subjects' mean age at the time of study was 14.4 years; original burn injuries involved 63% TBSA, 41% of that full thickness. Polysomnographic data demonstrated the mean total sleep time to be only 5.25 hours of sleep per night. This study reaffirms previous findings of significantly increased wake time and N1 sleep with a reduction in rapid eye movement compared to normal. Although both the ZCM and PIM did not accurately derive total sleep time using polysomnography results as the benchmark, PIM was more precise in the estimation of the number of sleep arousals and ZCM more accurately characterized sleep latency. In conclusion, actigraphy provides a fairly good indication of sleep for the rehabilitating burn patient as long as clinicians and researchers remain mindful of its limitations. Additional field testing is warranted to determine its application in adult and critically ill populations after injury and the usefulness of actigraphy in the home setting.

A pilot review of the long-term impact of burn injury on sleep architecture in children.

Distorted sleep patterns exist in the acutely burned pediatric population. No prior study has used polysomnography to assess sleep proficiency in children years after discharge. The objective of this retrospective, pilot investigation was to examine sleep in children multiple years after burn injury to characterize the long-term impact of burns on sleep. Twenty-two subjects (mean age, 13.0 ± 0.9 years; 9.3 ± 0.7 years after burn; burn, 56.4 ± 6.1% TBSA; full-thickness burn, 52.0 ± 8.9%) whose parents reported disturbed sleep at home or in whom problematic sleep was exhibited during an inpatient stay, underwent overnight polysomnography. The amount of time children spent in various sleep stages, as well as sleep efficiency, were compared with norms. Sleep latency and number of arousals also were reviewed. Patients in the late burn recovery phase experienced significantly increased time in wake (P < .0001) and N1 stages (P < .0001) and nearly reached statistical significance in stage N2 (P = .07) in comparison with age-matched and sex-matched norms. Subjects exhibited decreased time in N3 (P = .07) and significantly less time in rapid eye movement sleep than normal controls (P < .0001). Sleep efficiency also was significantly decreased from the norm in the burn group (P < .0001). Marked reduction in the restorative phases of sleep persists for years after burn. Sleep efficiency also was significantly diminished in pediatric burn patients multiple years from injury. Evaluation of sleep adequacy should be a routine component of outpatient assessment in pediatric burns with consideration of referral to a sleep specialist as indicated.

Clinical assessment of sleep among pediatric burn patients does not correlate with polysomnography.

A vast amount of sleep research relies on subjective, observational assessments of wakefulness and sleep. The authors had the unique opportunity to compare observational and polysomnographic (PSG) determinations of sleep in a randomized crossover study of sleep-inducing medication in a group of pediatric burn patients. Pediatric burn patients were randomized to one of two regimens with sleep-inducing agents over a 2-week period. PSG was conducted for three consecutive nights each week, between 7-13 and 14-20 days postburn. The first night of monitoring each week was conducted without medication to serve as a baseline. Observational sleep assessments (awake, drowsy, or asleep) were simultaneously recorded every 15 minutes. PSG concordance with observation was based on the PSG sleep stages identified during the 2 minutes before the observations. If all 30-second epochs in the two minutes were designated as sleep stage 1 or above, then the PSG record was categorized as asleep. If all epochs demonstrated wakefulness, an awake status was recorded. Otherwise, the corresponding PSG finding was classified as mixed. Forty patients were enrolled into the study, with a mean age of 9.4 ± 0.6 years, TBSA burn of 50.1 ± 2.9%, and third-degree burn surface area of 43.2 ± 3.6%. Patients were judged according to observational criteria to be awake 9% of the nocturnal study period compared with PSG recordings indicating that the patients were awake 52.3% of the time. The correlation between observation and PSG was poor regardless of sleep agent administration. In conclusion, observational determination of wakefulness in pediatric burn patients correlates poorly with PSG; therefore, PSG is vital in the accurate evaluation of sleep-inducing medications among burn patients.

The effect of ketamine administration on nocturnal sleep architecture.

Substantial evidence exists in the acute, rehabilitative and outpatient settings demonstrating the presence of significant sleep pattern disturbances after burn injury. Although the etiology is multifactorial and includes environmental, injury, and treatment mediators, previous clinical studies have not analyzed the critically important relationship of various medications to sleep architecture. The purpose of this investigation was to describe the after-effect of ketamine on sleep patterns in seriously ill burn patients. Forty pediatric patients with a mean TBSA burn of 50.1 ± 2.9% (range, 22-89%) and full-thickness injury of 43.2 ± 3.6% (range, 24-89%) were enrolled in this sleep study. Twenty-three of the 40 patients received ketamine on the day of polysomnography testing. Standard polysomnographic sleep variables were measured from 10:00 pm until 7:00 am. Chi-square test and t-test were used for comparison of descriptive variables between the ketamine and nonketamine groups. A logarithmic transformation was used for analysis when necessary. Ketamine administration was associated with reduced rapid eye movement (REM) sleep when compared with patients who did not receive ketamine on the day of the sleep study (P < 0.04). Both ketamine and nonketamine groups were clearly REM deficient when compared with nonburn norms. There was no relationship between ketamine use and effect on nocturnal total sleep time, number of awakenings, or percent of time awake or in stage 1, 2, or 3 + 4 sleep. In conclusion, ketamine was associated with altered sleep architecture as evidenced by a reduction in REM sleep. This finding does not seem to be clinically significant when considering the magnitude of overall REM sleep pattern disturbance observed in both the ketamine and nonketamine groups compared with nonburn norms. Further research is required to identify potential mechanisms of disturbed sleep so that appropriate interventions can be developed.

Sleep apnea: a risk factor for obese burned children during the rehabilitative phase of injury.

Obesity is associated with sleep disturbances that negatively impact general health. Recent reports indicate a high prevalence of obesity in burned children during the rehabilitative phase of injury. This retrospective review examined the relationship between sleep apnea and obesity in children recovering from burn injury. Nineteen subjects (mean age 14.0 ± 0.9 years, 8.0 ± 0.9 years postburn, TBSA burn 55.6 ± 7.0%, full-thickness burn 52.7 ± 8.7%) were examined for polysomnographic and respiratory outcomes. The groups were differentiated by body mass index (BMI). The obese group was defined as having a BMI ≥90th percentile according to age and gender specifications as defined by the Centers for Disease Control and Prevention. The BMI of the nonobese group was below the 90th percentile. Using t-test or χ, sleep and respiratory recordings were compared between the obese and the nonobese groups. The mean age, percent burn, percent full-thickness burn, years following acute injury, and the percentage of patients with burns to the neck region were similar in both groups; however, by design, BMI was significantly different. Total sleep time; sleep efficiency; sleep latency and time spent in stages 1, 2, 3; and rapid eye movement were similar between groups. Nonetheless, the number of apneic episodes, respiratory disturbance index, and oxygen desaturation measures were significantly higher in the obese group. In view of the significant respiratory disturbances apparent in pediatric burn survivors, routine appraisal of respiratory symptoms during sleep is recommended. In comparison to their normal weight counterparts, obese burned children appear to be at substantially greater risk of sleep-related respiratory compromise multiple years after an acute burn injury.

Overweight and obesity: overrepresentation in the pediatric reconstructive burn population.

Pediatric burn patients are predisposed to excessive weight gain in the reconstructive period, but the cause is unclear. An overweight (OW) or obese (OB) condition is associated with numerous health risks, decreased physical function, and increased morbidity. The purpose of this study was to compare the frequency of OW status in reconstructive, pediatric burn patients with the prevalence in the US population. The authors reviewed the records of 1533 pediatric patients, >1 year from acute burn, admitted for an elective reconstructive procedure. Body mass index between 85th and 95th percentile, according to the National Center for Health Statistics for 2000 growth charts, was classified as OW, and body mass index >95th percentile was classified as OB. Frequency of OW and OB and racial disparity was calculated as a percentage of total patients and compared with pediatric data from National Health and Nutrition Examination Survey for 1999 to 2006, a nationally representative sample. The rate of OW and OB was 16.3 and 24.1%, respectively, in the authors' pediatric burn population. White patients had OW and OB rates of 15.9 and 23.6%, respectively, compared with 18.2 and 30.2%, respectively, in black patients. All OW and OB rates were outside the 95% confidence interval of the nationally representative National Health and Nutrition Examination Survey population. The rates of OW and OB in pediatric reconstructive burn patients exceed the US population standard across age and race stratifications. The prevention and treatment of excessive weight gain should be a component of rehabilitation in pediatric burns.

Enhancing patient safety: the effect of process improvement on bedside fluoroscopy time related to nasoduodenal feeding tube placement in pediatric burn patients.

Nutrition support is essential in the care of burn patients. Early in the course of treatment, postpyloric feeding tube placement permits initiation of enteral nutrition, minimizes risk of aspiration, and may also attenuate hypermetabolism. Fluoroscopy aids in postpyloric feeding tube placement, yet concerns remain about safety. The purpose of this study was to measure fluoroscopy-associated radiation exposure during bedside feeding tube placement in pediatric burn patients and to take appropriate action to improve hospital protocols that minimize radiation exposure. During a 19-year period, radiation doses were measured before and after performance improvement of radiation safety initiatives. This plan included mandatory training for surgical house officers, measurement of maximum midline dosage for each procedure, limitation of radiation exposure to 5 minutes, and development of standardized policies and protocols for feeding tube placement. Phase 1 of the study retrospectively determined fluoroscopy time required for enteral tube placement. Phase 2 used thermoluminescent chips to measure the amount of radiation during fluoroscopy to establish an acceptable midline radiation dose. Phase 3 evaluated fluoroscopy times following implementation of improved safety processes. There were 357 procedures in phase 1 and mean fluoroscopy time was 4.1 minutes. Of the 10 procedures in phase 2, mean fluoroscopy time decreased to 2.7 minutes. There were 1804 procedures in phase 3, and mean fluoroscopy time was 2.3 minutes. Mean radiation exposure was significantly reduced following implementation of standardized policies and the development of a clinical protocol for bedside fluoroscopy (P<.0001). With proper processes, fluoroscopy procedures result in minimal radiation exposure for patients and staff.