Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 863 - файл
.pdf
302
https://t.me/med1917
302
CHAPTER33 Cost ofburn care
Cost containment
A cost containment programme is achieved by robust data collection, updated treatment protocols, outcomes and quality assurance measures, and
lastly optimizing resources. In practice early surgical excision and modulation of the hypermetabolic response were shown to improve outcomes
and reduce hospital stay. This is an excellent example of evidence- based
cost containment. Lack of evidence- based medicine in burn care is a major
factor that contributes to the increasing cost of burn care as new products
and technologies are produced. Research can provide the tools that enable
us to achieve better outcomes and cost eciency.
6
Prevention programmes in developed and developing countries should
be regarded as the most cost containment programme in burn care.
Further reading
Barret JP. Cost- containment and outcome measures. In Herndon DN. Total burn care, 4th edn.
London:WB Saunders 2012;707– 14.
Klein MB, Hollingworth W, Rivara FP, etal. Hospital costs associated with pediatric burn injur y.
Journal of Bur n Care Research 2008;29:632– 7.
References
1. Macario A. What does one minute of operating room time cost? Journal of Clinical Anesthesia
2010;22:233– 6.
2. Dasta JF, McLaughlin TP, Mody SH, Piech CT. Daily cost of an intensive care unit day:the contri-
bution of mechanical ventilation. Critical Care Medicine 2005;33:1266– 71.
3. Klein MB, Hollingworth W, Rivara FP, etal. Hospital costs associated with pediatric burn injury.
Journal of Bur n Care & Research. 2008;29:632– 7.
4. Hemington- Gorse SJ, Potokar TS, Drew PJ, Dickson WA. Burn care costing:the Welsh experi-
ence. Burns 2009;35:378– 82.
5. WHO. Health statistics and information systems. Estimates for 2000– 2012. Disease burden.
http:// www.who.int/ healthinfo/ global_ burden_ disease/ estimates/ en/ index2.html (accessed
27 September 2015).
6. Pruitt BA Jr, Wolf SE. An historical perspecti ve on advances in burn care over the past 100years.
Clinics in Plastic Surgery 2009;36:527– 45.
https://t.me/med1917
Chapter34
303
Paediatric burns
Introduction to paediatric burns 304
Initial evaluation 304
Resuscitation 305
Assessment of resuscitation 306
Evaluation and management of airways 307
Hypermetabolism 307
Nutrition 308
Thermoregulation 308
Management of burn wounds 309
Pain management 309
Reference 309
304
https://t.me/med1917
304
CHAPTER34 Paediatric burns
Introduction topaediatric burns
According to the World Health Organization, there are about 180,000
deaths from burns per year worldwide,1 and 96,000 of these occur in
children. Children are particularly vulnerable to burns, and infants are at
a greatest risk. House res are among the leading causes of burn- related
deaths in children. Scalds are common in children less than 3years old.
The many physiological dierences between children and adults, in addition to anatomical dierences, must be considered in the care of pediatric
burn patients.
Initial evaluation
• Immediately remove child from the source of burn
• Remove clothing and jewellery, as these can prolong the burning process
• Avoid pouring cool water onto the burn in cases of large burns
• Cover child with a blanket or sheet to keep warm
• Irrigate chemical burns with a copious amount of water for at least
30minutes
• Identify and treat any potential life- threatening traumatic injuries
• Aurinary drainage catheter is essential for burns >20%
• Nasogastric tube placed in major burns
• Burn size and depth determined promptly
Airway
• The airway should be assessed rst
• Administer 100% oxygen and obtain arterial blood gas and
carboxyhaemoglobin level if inhalation injury is suspected
• Stridor and hoarseness indicate an imminent airway crisis due to
inhalation injury or oedema, and immediate intubation should be
considered
Chest burn
• Circumferential full- thickness chest burn can impede chest expansion
• If ventilation is compromised, escharotomy of the chest should be
performed
https://t.me/med1917
Resuscitation
IV access
• Should be established immediately
• Peripheral IV access preferred
• May go through burned skin if needed
• Consider suturing IV lines
• Central venous line when peripheral IV not attainable
Intraosseous line
• When vascular access not available
• Fluid administration via intraosseous line can be performed in all children
• Proximal tibia most common site
Fluid losses
• Proportionally greater in children due to their small body weight- to-
body surface area ratio
• Normal blood volume in children approximately 80 mL/ kg body weight
and 85– 90 mL/ kg in neonates
Burn size
• ‘Rule of nines’ is useful in adults but does not accurately reect the
burned body surface area of children under 15years of age
• Lund– Browder chart is more accurate way of determining burn size in
children
Resuscitation formulas
• Common resuscitation formulas are mostly weight- based and have been
developed using adult patients
• Use of weight- based resuscitation formulas in children results in under-
or over- resuscitation
• Pediatric burn patients should be resuscitated using formulas based on
body surface area
• One formula uses 5,000 mL/ m2 total body surface area (TBSA) burned
for resuscitation uid plus 2,000 mL/ m2 TBSA for maintenance uid
given over the rst 24 hours after burn
• Half the volume is administered during the initial 8 hours, and the
second half is given over the next 16 hours
• Over the subsequent 24 hours, 3,750 mL/ m2 TBSA burned for
resuscitation uid plus 1,500 mL/ m2 TBSA for maintenance uid should
be used.
Estimation ofthe amount ofuid required
• Amount of resuscitation uid should be titrated according to the
patient’s response
• Lactated Ringer’s solution is the most commonly used resuscitation uid
for the rst 24 hours after burn
• Fluid boluses, if indicated, should be administered in amounts
appropriate for the size of the child (20 mL/ kg)
• Children under 1year of age should also receive a separate maintenance
uid containing dextrose to prevent hypoglycaemia
RESUSCITATION
305
306
https://t.me/med1917
306
CHAPTER34 Paediatric burns
Assessment ofresuscitation
• Children have remarkable cardiopulmonary reserve
• They often do not show clinical signs of hypovolaemia until > 25%
of the circulating volume has been lost and complete cardiovascular
decompensation is imminent
• Hypotension and low urine output are late manifestations of shock in
the pediatric patient
• Distal extremity colour, capillary rell, pulse pressure, and mental status
reect volume status
Capillary rell
• Indicator of volume status
• Decreased capillary rell suggests imminent cardiovascular collapse
Lactic acid and base decit
• Measurement of lactic acid or arterial pH with base decit is important
in pediatric burn population, and reect decreased tissue perfusion
• Correction of lactic acid or base decit shows eective resuscitation
Urine output
• Assessed hourly
• Resuscitation uid should be adjusted to achieve a urine output of
1mL/ kg/ h in children and 2 mL/ kg/ h in infants
Over- resuscitation
• Must be avoided
• Can lead to pulmonary oedema, abdominal compartment syndrome,
extremity compartment syndrome, and cerebral oedema
https://t.me/med1917
HYPERMETABOLISM
Evaluation and management ofairways
• Airway evaluation and management given priority in pediatric patients
• Children are more prone to airway obstruction
Early intubation
• Considered when severe inhalation injury is present, a patient has a
large burn and is likely to develop airway oedema with a large amount
of uid resuscitation, or a long transfer is anticipated
Inhalation injury
• Any patient with ame burn, especially if conned in a closed space,
should be evaluated for inhalation injury
• Signs of potential inhalation injury include facial burns, carbonaceous
sputum, singed nasal hair, respiratory distress such as hoarseness,
stridor, dyspnoea, wheezing, or altered mental status
• If inhalation injury is suspected, patient should be placed on
100% oxygen
• Arterial blood gas and carboxyhaemoglobin level should be obtained
• The initial carboxyhaemoglobin level should be calculated from the time
the admission level is drawn back to the time of the burn injury using a
nomogram.
• The denitive method of diagnosis is direct visualization of the airway
with bronchoscopy
Treatment modalities forinhalation injury
• Airway maintenance, clearance, and pharmacological management
• Mainly supportive and includes humidied air, pulmonary toilet, and
ventilator support if necessary
• Nebulized heparin and N-acetylcysteine have shown to decrease
reintubation rates and mortality
307
Hypermetabolism
• Children with large burns demonstrate a profound hypermetabolism
• Prolonged hypermetabolism can lead to marked loss of lean body mass
and increased morbidity and mortality
• Marked upregulation of catabolic agents leads to increased energy
expenditure; loss of lean body mass and body weight; delayed wound
healing; and immune depression
• Pharmacological agents have been used to attenuate hypercatabolism in
burn injury
• Attenuation of lean body mass loss can be achieved in paediatric burn
patients by administration of anabolic hormones such as recombinant
human growth hormone and insulin; anabolic steroids such as synthetic
testosterone analogue oxandrolone; and adrenergic antagonists such as
propranolol
308
https://t.me/med1917
308
CHAPTER34 Paediatric burns
Nutrition
• Nutrition is an important part of treatment in pediatric burns
• Patients with >30% TBSA burns are placed on enteral tube feeding to
supplement oral nutrition
• Patients with smaller burns are placed on a high- protein,
high- calorie diet
Early enteral nutrition
• Provides nutritional support in hypermetabolic children with
severe burns
• Can lessen the hypermetabolic response
• Improves intestinal blood ow and motility, and preserves gut mucosal
integrity
• Enteral nutrition can be initiated within a few hours of admission
Formulas
• Several formulas are available to estimate caloric requirements in
burned children
• Caloric support is given in amounts calculated based on body surface
area in children as caloric demands are related to burn size
• Aseries of formulas based on body surface area are available to meet
the diering requirements of various age groups
• One formula uses 1,500 kcal/ m2 TBSA burned plus 1,500 kcal/ m2 TBSA
• Commercially available enteral formulas are hyperosmolar and should
be diluted to 1/ 2– 3/ 4 strength because of the high incidence of
diarrhoea in burned children.
Thermoregulation
• Infants and toddlers are particularly susceptible to hypothermia
• Extensive heat loss occurs after major burn through convection and
evaporation
• Energy demands and evaporative water losses can be reduced by
maintaining ambient temperatures at 30– 33°C and humidity at 80%
https://t.me/med1917
Management ofburn wounds
Topical antimicrobials
• The most commonly used treatment in partial- thickness burns
• Use can be painful during dressing change
Long- term dressing
• For partial- thickness burns, dressings such as silver- impregnated
dressings can be applied
• Application of silver-impregnated dressings leads to less pain and
shorter hospitalizations than topical antimicrobial
• Most silver- impregnated dressings on partial- thickness burns can be left
on for up to 7days and reduce pain associated with dressing changes
Early surgical excision and grafting
• Reduces the incidence of wound infection and sepsis
• Leads to decreased length of hospital stay and reduced mortality
Pain management
• Children do not always express their pain in the same way as adults
• Children may display pain through anxiety, agitation, depression,
withdrawal, and regression
Morphine sulfate
• One of the most commonly used analgesics in paediatric burn patients
• Given intravenously
Fentanyl oral
• Used eectively for dressing change and wound care (10 µg/ kg)
• Outpatients treated with hydrocodone/paracetamol or other oral
opioid derivatives
• Some require addition of longer- acting narcotics such as methadone or
morphine sulfate controlled release
• Other analgesics include intranasal remifentanil and sufentanil
• Anxiolytics such as dexmedetomidine, midazolam, and diazepam can be
used as adjuncts
REFERENCE
309
Reference
1. WHO factsheet 365. 2018. http:// www.who.int/ mediacentre/ factsheets/ fs365/ en. Accessed 2
October 2018).
310
https://t.me/med1917
https://t.me/med1917
Chapter35
311
Non- accidental injury (NAI)
inchildren
Introduction to NAI in children 312
Assessment 312
Parents’ and children’s characteristics 313
Patterns of NAI 313
Dierential diagnosis 314
Further reading 314
Соседние файлы в папке @xirurgi_2025