Emergency Treatment of Severely Burned Pediatric Patients: Current Therapeutic Strategies

Gerd G. Gauglitz; David N. Herndon; Marc G. Jeschke

Disclosures

Pediatr Health. 2008;2(6):761-775. 

In This Article

Modulation of the Hormonal and Endocrine Response

Severe burn injury leads to significant metabolic alterations, characterized by a hyperdynamic circulatory response associated with increased body temperature, glycolysis, proteolysis, lipolysis and futile substrate cycling.[93,94,95] These responses are present in all trauma, surgical or critically ill patients, but the severity, length and magnitude is unique for burn patients.[17] Modification of adverse components of the hypermetabolic response, particularly protein catabolism, appears desirable. β-adrenergic blockade, β-adrenergic supplementation, anabolic steroids, recombinant growth hormone and IGF are under active investigation. Various studies have demonstrated the potential beneficial effect of β-blockers in burn patients. In a single-center study, administration of propanolol, a non-selective β1/2-receptor antagonist, in doses that decrease the heart rate by approximately 15 to 20% from baseline values, has been shown to reduce the release of free fatty acids from adipose tissue, decrease hepatic triacylglycerol storage and fat accumulation and reversed muscle protein catabolism.[96,97,98] In a retrospective study of adult burn patients, the use of β-blockers was associated with decreases in mortality, wound infection rate and wound healing time.[99] Therefore, many burn units recommend β-blockers as the most effective anticatabolic treatment in severely burned patients. Treatment with anabolic agents, such as oxandralone, an analog of testosterone, has been shown to improve muscle protein metabolism through enhanced protein synthesis efficiency[100] and was associated with reduced weight loss and increased donor site wound healing.[101] Wolf and colleagues demonstrated in a prospective, randomized study that the administration of oxandralone 10 mg every 12 h was associated with a decrease in hospital stay[102]. We found in a large prospective, double-blinded, randomized, single-center study, that oxandrolone administered at a dose of 0.1 mg/kg every 12 h to be associated with shortened length of acute hospital stay, maintained lean body mass and improved body composition and hepatic protein synthesis.[103] The use of recombinant human growth hormone in daily subcutaneous doses has been reported to accelerate donor site healing and restore earlier positive nitrogen balance.[104,105,106] We found recombinant human growth hormone administered at a dose of 0.05 mg/kg bodyweight for 12 months postburn to significantly improve height, weight, lean body mass, bone mineral content, cardiac function and muscle strength when compared with placebo-treated burn patients.[107] However, Takala and others carried out one prospective, multicenter, double-blind, randomized, placebo-controlled trial involving 247 patients and 285 critically ill patients, and found high doses of growth hormone (0.10 ± 0.02 mg/kg bodyweight) to be associated with increased morbidity and mortality.[108] Others demonstrated that growth hormone treatment was associated with hyperglycemia and insulin resistance.[106,109] IGF-1 has been shown to decrease the metabolic rate postburn and increases whole-body anabolic activity without showing signs of hyperglycemia or insulin resistance.[110]

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