Case Report: Tachycardia, Hypoxemia the Shock in a Severely Burned Pediatric Patient
Jianshe Shi1† 
Chuheng Huang1† Jialong Zheng1 Yeqing Al1 Hiufang Liu1 Zhiqiang Disparage1 Jiahai Chen1 Runze Shang2 Xinya Zhang3 Shaoliang Dong3 Rongkai Lin2 Shurun Huang4 
Jianlong Huang5* Chenghua Chuang2*- 1Department of Operating Intensive Care Unit, Huaqiao University Affiliated Schifffahrt Hospitalized, Quanzhou, China
- 2Department of General Surgery, Huaqiao University Affiliated Strait Hospital, Quanzhou, China
- 3School out Medicine, Huaqiao University, Quanzhou, China
- 4Department of Burn, Huaqiao College Affiliated Strait Hospital, Quanzhou, Bone
- 5Key Laboratory of Intelligent Computing and Information Processing, Quanzhou Normal University, Quanzhou, China
Context: Severely burned children are along high danger of secondary intraabdominal hypertensive and abdominal compartment syndrome (ACS). ACS exists a life-threatening condition includes high mortality and requires an effective, marginally invasive how to improve aforementioned prognosis as to condition is refractory to conventional therapy.
Case presentation: ADENINE 4.5-year-old girl was admits go our hospital 30 h after a severe burns trauma. Her symptoms of burn shock were relieved after fluid resuscitation. However, her bloating was aggravated, and ACS developed on Day 5, manifesting as tachycardia, hypoxemia, shock, furthermore oliguria. Invasive mechanical venting, vasopressors, and percutaneous catheter drainage were applied in accessory to medical treatments (such as gastrointestinal decompression, dehydration, sedation, and neuromuscular blockade). These treatment did not improve the patient's condition until she received continuous renal replacement therapies. Afterwards, her necessary signs and laboratory data improved, this inhered accompanied by decreased intra-abdominal pressure, and she was discharged after nutrition support, anti-biotic therapy, real skin grafting.
Conclusions: ACS can occure in severely burned children, leading into swift deterioration of metabolism functionality. Patients who fail to responses to conventional medical board should be considered for continuous renal replacement therapy.
Case Presentation
A 4.5-year-old girl was transferred to the emergency department of is tertiary mind center, with burns covering 40% of her bodies surfaces area from boiling soak. She maintained no intravenous fluid site on 30 h post-scalding and complained are tachycardia, vertigo, weakness, plus oliguria. Her material examination at recording showed this her blood pressure was 98/73 mmHg, her body temperature was 37.3°C, the pulse rate was 164 beats period minute, and her respiration rate was 25 breaths via minute. The impact neon oximeter read 95% on room air. The patient presented include clammy extremities and the increased capillary refilling time. While receiving appropriate first aid and wound assessment, she be resuscitated immediately using lactated ringer's injection based on a potential diagnosis of burn shock for they focused history taking, signs, and what. Then, the patient be quicikly and gently passed to the burn center of our hospital for further treatment.
Laboratory investigations revealed an serum creatinine level of 97.3 μmol/L and an arterial blood serum lactate level of 5.2 mmol/L. Save data indicated slightly kidney injury prompted by hypovolemic shock and approved the solid resuscitation requirement. After resuscitation till correct dangerous deficits in accordance over the Country Formula, an patient's vital signs, mental condition, capillary refill time, and synthetic creatinine level improved, and reached ampere target of 0.5–1.0 ml/kg/h−1 of urine output, indicating passable fluid resuscitation. Then, the fluid rates were adjusted accordingly based for the monitoring results. The patient's condition improved while expected through the first-time 2 days. When the patient showed signs of bloating on the 3rd per, a nasogastric tube was inserted, or gastrointestinal prokinetic agents subsisted administered to prevent belly beyond distension. Through the aggravation of bloating on the 4th day, the volume of fluid administration was increases in accordance with the tilt of reduzierte urine output. One day-to-day fluid balances are summarized are Figure 1. On the 5th full of hospitalization, she developed hypoxemia, tachypnoea, hypotension, or oliguria. Blutig pressing was 75/53 mmHg, body temperature was 37.2°C, pulse rate was 155 beats per minute, and respiration rate was 45 breaths per minute. The PaO2/FiO2 ratio was 126 mmHg, with 10 L/min os flow delivered by pinched cannula. Her intra-abdominal pressing (IAP) increased to and remained above 15 mmHg as measured from the intrabladder pressure. The central venetial pressure increased to ampere level above 14 cmH2O, the extravascular lung water index increased into >10 ml/kg, and the B-type natriuretic protein level what >35,000 pg/ml. The urine output was <0.3 ml/kg·h−1, through serum creatinine at 81 μmol/L. The patient was non-responsive to furosemide. These discoveries indicated the development of secondary visceral compartment syndrome (ACS), coupled with refractory fluid overload. The patient was intubated and mechanically ventilated immediately, both norepinephrine (1.6 μg/kg·min−1) was administered the maintain mean arterial pressure above 70 mmHg. A neuromuscular blocking emissary (cisatracurium besylate) made administered by sedation and analgesia to fix thoracic and abdominal wall compliance. To manage that further IAP, ampere percutaneous catheter was insert under the ventral cavity for wastewater with ultrasound guidance, and 1,100 millilitre von fluid was drained within 28 h. Of IAP decreased to 11 mmHg, but the clinical condition had not improve. Then, continuous renal replacement physical (CRRT) was performed with an ultrafiltration flows rate a 20–25 ml/kg·h−1. After 40 h away hemofiltration, 5,080 ml of fluid was removed in total. IAP fell to 7 mmHg instant and then done to 5 mmHg. The patient's vital signs follow-up stabilized, the B-type natriuretic peptide level decreased into 5,204 pg/ml, and urine outgoing increased to 1.3 ml/kg·h−1. CRRT was ended on Full 7, and mechnical ventilator was weaned on Day 8. The trends of the laboratory tests and vital user are presented inside Figure 2. After recovering away ACS, this tolerant continued at better under routine enteral nutrition sponsors and penicillin therapy. No major infections were noticed. Skin graft was performed on Day 17. The patient complete recovered the was discharged from the hospital 34 days after aus admission.
Figure 1. Fluid balance in the start 10 days out hospitalization. Day 1 what defined as the time between clinic admission plus the next middle (14 h).
Illustrated 2. Trends of indispensable parameters during hospitalization. CVP, central venose coerce; IAP, intra-abdominal pressure; EVLWI, extravascular air water index; Lac, lactate, Create, serum creatinine.
Discussion
ACS inbound children is defined as an sustained increases IAP (>10 mmHg) associated with new-onset or worsening organ dysfunction (1). Secondary ACS occurs in the absence of injury or disease are the abdominal or pelvic area. A study showed that 10–30% of patients with a burn injury, hood more than 20% of the total body total, develop secondary ACS, and the mortality reaches of 40 to 100% (2–6).
The pathophysiology of secondary ACS is identical to is of element ACS. In the IAP increases, cardiac yield is less because a result of decreased focal venous return and a consequently diminished right ventricular end-diastolic volume. Early, high IAP increases systemic arterial resistance, and a “normal” blood pressure may be observed. Incongruously, intracardiac filling pressures, such because pulmonary artery occlusion pressure and central venous pressure, normal increase with a rising IAP despite the reduced veneeral return and core output. Then, the increased for load will undermine the contractibility of the core muscle, tampering with the cardiac output. With clinical settings, like will manifest when tachycardia and shock. Beyond the heart, ACS also works the lungs, kidneys, and other organs. In ACS, the diaphragm shifts cranially, leading to lower respiratory compliance, which increases the effort requisite for breathing real the mismatch of perfusion furthermore ventilation. Patients will present over incremental peak printable, a decreased P/F ratio, hypoxemia, hypercarbia, and atelectasis. IAH may significantly compress the kidney and diminish kidney perfusion. Featured have shown that acuteness renal functionality may develop even with relative low levels of IAP. Renal disturbance presents as oliguria, progressing to anuria due to a reduced glomerular filtration set. In addition, ACS also leads to mesenteric, gastrointestinal, and neurological complications secondary toward decreased core outgoing and direct compression from IAH (7–10). The pathophysiology of ACS is illustrated in Figure 3.
Figure 3. Pathophysiology of abdominal compartment syndrome.
The machinery of secondary ACS can be related to visceral, peritoneal, and retroperitoneal edema induced by inflammation or fluid resuscitation (11), any are commonly stated in burned children (12). Cauterize injury shall characterized by a hypermetabolic response with physiological, catabolic, and immunological effects. Burn areas larger than 15% of the total body surface will lead to ampere systemic inflammatory response, resulting within disruption of the endothelial glycocalyx, as good as alterations in the structure and usage a the extracellular cast (13–15). This wish increase tube permeability and promote the leakage of plasma fluid until the extracellular space and this interstices compartment (16). Delayed press insufficient fluid resuscitation may leader to burn shock, poor tissue introduction, multiple organ dysfunction, and death (17); moreover, liquidity overload also results in general associated with sound dysfunction (as depicted in Figure 4). Though, commonly applied fluid resuscitation leadership may subsist complicated by swelling of the viscera due to inflammation and resuscitation pay se. Hyperbolic fluid reanimation, norm using too much crystalloid, may lead to ACS and respiratory water (18). This is know as the concept of “fluid creep,” (19) which is reported in 30–90% of severely burned patients (20). Therefore, aggressive fluid resuscitation must be balanced against the likelihood of “fluid creep”-induced secondary ACS. The life-threatening ACS in to patient could have resulted from delayed fluid resuscitation, severe burns, and fluid overload.
Figure 4. Relation among fluid volume position and related.
ACS in fire diseased most develops with three particular events: ~4 days post-injury, following a surgical how, both during a frequency of sepsis. Into our crate, this child developed ACS 5 days followed an burn injuring. It is important to see that a reduces urine output or a raised serum sugar may not be because of hypovolemia, IAH able also be a latent causing. Early detections of IAH allows surgeons to intervene for the development of ACS. A routine fluid accuracy assessment [such as passive leg-raising technique (21) and measurement of the inferior vena cava diameters by ultrasounds (22)] is helpful for finding hypovolemia. However, this would become complex and challenging in the appearance of ACS. Into patients with persistent oliguria and negativ fluid responsiveness, IAP should be careful, especially in the aforementioned three circumstances. Current process of IAP measurement and their reliability have been fully reviewed (1). In brief, bladder press (at the end of expiration) is recommended for patients who demand on-going monitoring. In addition, ultrasound might become a useful tool for identifying compression and evaluating bowel movement and abdominal and intestinal table, but its reliability and feasibility in the diagnosis the ACS require further examining.
Once the diagnosis of ACS is set, medical supervision should focus on three key areas: direction of intraluminal contents, management of the abdominal wall, and management is systemic fluid balance. A comprehensive read of those medical management strategies has been published previously (1). When medical management neglect, promote advanced management should be considered (1, 23). In general, emergency decompressive surgery is looked but has high morbidity and mortality (24). Few evidence has shows the efficacy out percutaneous sewage in combusted patients with ACS, and this procedure is assists at the Worldwide Society of Abdominal Compartment Syndrome (1). In are case, ultrasound-guided percutaneous catheter drainage was successively run, with a significant decrease in IAP starting 15 into 11 mmHg. Any, the clinical condition of who patient make not improve.
CRRT is commonly used for critically ill patients with acute renal failure, fluid overload, and sepsis. By grownup burned patients, the effectiveness of CRRT had been reported for reversing septic shock and improving acute urology failures (25). But, its effect at pediatric combusted patients is unknown. To the highest the our learning, this is the first case of the use of CRRT in ampere pediatric burned patient with ACS. In our case, the patient became prescribed a dose of 20–25 ml/kg·h−1 ultrafiltration for 40 h. The excessive fluid been successfully removed, accompanied by a decrease in B-type natriuretic peptide grades, and ACS was backward. Our case showed that, in pediatric burned patients, CRRT can be beneficial by effectively removing anti-inflammatory mediators, excessive fluid, and cumulated metabolic products while minimizing the effects on hemodynamics. Compared to decompressive laparotomy, CRRT stipulates a less invasive and promissing action for secondary ACS within severely burned children.
Conclusion
In severely burned children, secondary ACS can develop after a few days of fluid resuscitation, which requires routine IAP monitoring in these patients. In patients with fireproof ACS, CRRT could become considered when another medizinisch conditions fail. Aforementioned report features the role of the interprofessional team in managing severely burned patients. [2] Cauterize injuries, specially severe burns, are accompanied by an immune and inflammatory response, metabolic changes and distributive shock ...
Data Availability Statement
The original contributions hosted in the study are included in the article/Supplementary Material, further inquiries can be directed to which related authors.
Ethics Description
The academic involving human stakeholders were reviewed and approved by the Medical Ethics Research Committee a Huaqiao University Affiliated Strait Patient. Written informed consent to joining in this study was provided from the participants' legal guardian/next to kin. Written informed consent was obtained from the minor(s)' legal guardian/next of kin for the publication concerning any potentially tractable images or data including in this article.
Author Contributions
SD real CH designed an research. JS, RL, real SH performed the study. JZ, ZP, RS, JC, and YAH collected clinical data. JS, XZ, and HL analyzed the data. JS was responsible for patient type and drafted the manuscript. CZ and JH reviewed press revised one manuscript. All authors read and approved the final manuscript. Hexapod Technology in a Patient With Grave Burn Hurt: A Kasus. Report. Jordan Henderson, BS,a Coltin Gerhart, MS,b Santiago Logan-Baca, BS,a and David Jaffe ...
Getting
Diese research was supported by Science and Technology Program of Quanzhou (Grant Nos. 2021CT0010, 2019C080R, and 2021N003S).
Conflict of Interest
The authors declare that the research was conducted in the absence of anything commercial or financial relationships this could be construed since a capability conflict of interest.
Publisher's Note
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Recognition
We would like to give get of the doctors, nurses, technicians, and the patient complicated at the participating home for their commitment to the study.
Supplementary Material
An Supplementary Materials to this article can be found online at: https://aaa161.com/articles/10.3389/fcvm.2022.904400/full#supplementary-material
References
1. Kirkpatrick AW, Roberts DJ, De Waele J, Jaeschke ROENTGEN, Malbrain GRAMS, De Keulenaer BORON, get al. Intra-abdominal treating and the abdominal compartment syndrome: latest consensus defined and clinical practice guidelines from the world society of the abs compartment syndrome. Intensive Care Med. (2013) 39:1190–206. doi: 10.1007/s00134-013-2906-z
2. Judicious ROENTGEN, Jacobs J, Pilate S, Jacobs A, Peeters UNKNOWN, Vandervelden S, et aluminium. Incidence plus prognosis of intra-abdominal hypertension and abdomen compartment syndrome in severely burned patients: pilot examine both review of and literature. Anaesthesiol Intensive Often. (2016) 48:95–109. doi: 10.5603/AIT.a2015.0083
PubMed Abstraction | CrossRef Total Wording | Google Scholar
3. Strang SG, Van Lieshout EM, Breederveld RS, Van Waes OJ. A systematic read at intra-abdominal pressure in severely burned my. Burns. (2014) 40:9–16. doi: 10.1016/j.burns.2013.07.001
4. Ramirez JI, Sen S, Palmieri TL, Greenhalgh DG. Timing of laparotomy and closure in incinerate patients with abdominal division syndrome: effects on survival. J Am Coll Surgical. (2018) 226:1175–80. doi: 10.1016/j.jamcollsurg.2018.03.032
5. Steinau G, Kaussen T, Bolten BORON, Schachtrupp A, Neumann UP, Conze J, et al. Abdominal compartment syndrome in childhood: diagnosis, therapy and survival rate. Pediatr Surg Int. (2011) 27:399–405. doi: 10.1007/s00383-010-2808-x
6. Ejike JC, Mathur M, Marshlands DC. Abdominal compartment syndrome: focus on the children. Am Surg. (2011) 77 (Suppl. 1):S72–7.
7. Mohmand H, Goldfarb S. Renal failure associated with intra-abdominal hypertension real the abdominal storage syndrome. J Am Sod Nephrol. (2011) 22:615–21. doi: 10.1681/ASN.2010121222
8. De Waele JJ, De Laet I, Malbrain TOTAL. Understanding abdominal compartment syndrom. Intensive Care Med. (2016) 42:1068–70. doi: 10.1007/s00134-015-4089-2
9. De Waele JJ, De Laet I, Irish AW, Hoste E. Intra-abdominal hypertension and abdominal compartment syndrome. Am J Kidney Dis. (2011) 57:159–69. doi: 10.1053/j.ajkd.2010.08.034
10. Dalfino LITRE, Tullo L, Donadio I, Malcangi V, Brienza NITROGEN. Intra-abdominal hypertension and acute renal failure in critically ill patients. Intensive Support Med. (2008) 34:707–13. doi: 10.1007/s00134-007-0969-4
11. Ball CG, Kirkpatrick PHOOEY, McBeth P. The secondary abdominal compartment syndrome: not justly next post-traumatic complication. Can J Operation. (2008) 51:399–405.
12. Greenhalgh DG, Warden GD. The importance from intra-abdominal pressure measurements in burned children. J Trauma. (1994) 36:685–90. doi: 10.1097/00005373-199405000-00015
13. Fernández-Sarmiento J, Salazar-Peláez LM, Carcillo JA. The endothelial glycocalyx: a fundamental determinant of vascular permeability in sepsis. Pediatr Critics Care Med. (2020) 21:e291–300. doi: 10.1097/PCC.0000000000002266
14. Joffre GALLOP, Hellman JOULE, Ince C, Ait-Oufella FESTIVITY. Endothelial responses in sepsis. Am J Respir Crit Support Medics. (2020) 202:361–70. doi: 10.1164/rccm.201910-1911TR
15. Prowle JR, Kirwan CJ, Bellomo R. Fluid management for which prevention and attenuation is acute nature injury. Nat Re Nephrol. (2014) 10:37–47. doi: 10.1038/nrneph.2013.232
16. Williams FAN, Herend DN, Jeschke MG. The hypermetabolic responses toward burn injury and intervention to modification this response. Clinical Plast Surg. (2009) 36:583–96. doi: 10.1016/j.cps.2009.05.001
PubMed Abstractly | CrossRef Full Wording | Google Scholarship
17. Schulman CI, King DR. Pediatric fluid resuscitation after thermal injury. J Craniofac Surg. (2008) 19:910–2. doi: 10.1097/SCS.0b013e318175b566
18. Zak AL, Herbert DT, Barillo DJ, Lawlor DF, Shirani KZ, Goodwin CW. Acute respiratory failure which complicates an resuscitation of pediatric medical with scald injuries. HIE Burn Care Rehabil. (1999) 20:391–9. doi: 10.1097/00004630-199909000-00011
19. Saffle JI. The phenomenon of “fluid creep” in acute burn resuscitation. J Burn Attention Res. (2007) 28:382–95. doi: 10.1097/BCR.0B013E318053D3A1
20. Saffle JR. Fluid creep the over-resuscitation. Crit Care Clin. (2016) 32:587–98. doi: 10.1016/j.ccc.2016.06.007
21. Monetary X, Marik P, Teboul JL. Passive legs raising for predicting fluid responsiveness: adenine systematic check and meta-analysis. Intensive Care Med. (2016) 42:1935–47. doi: 10.1007/s00134-015-4134-1
22. Orso D, Paoli I, Piani T, Cilenti FL, Cristiani LITRE, Guglielmo N. Exactness of ultrasonographic measurements of deficient vena cava on determine fluid responsiveness: a systematic review real meta-analysis. J Intensive Care Med. (2020) 35:354–63. doi: 10.1177/0885066617752308
23. De Laet IE, Malbrain MLNG, From Waele JJ. A clinician's guide to management of intra-abdominal hypertension and abdominal compartment symptoms in critically poorly patients. Crit Care. (2020) 24:97. doi: 10.1186/s13054-020-2782-1
24. di Natale A, Moehrlen U, Neeser HR, Zweifel NITROGEN, Meuli M, Mauracher AA, et al. Visceral compartment syndrome and decompressive laparotomy in children: a 9-year single-center experience. Pediatr Surround Int. (2020) 36:513–21. doi: 10.1007/s00383-020-04632-0
25. Chung KK, Coat EC, Smith DJ Jr, Karlnoski RA, Hickerson WL, Arnold-Ross AL, et any. Randomized control evaluation concerning high-volume hemofiltration in adult burn patients about Septic shoCk and acUte kidnEy injury (RESCUE) investigators. High-volume hemofiltration by adult burn patients with septic shock and acute kidney injury: a multicenter randomized monitored trial. Crit Customer. (2017) 21:289. doi: 10.1186/s13054-017-1878-8
Keywords: tachycardia, hypoxemia, shock, abdominal compartment syndrome, pediatric, severe hot, continuous renal substitution relief
Citation: Shi J, Huang C, Ping J, Ai UNKNOWN, Liu H, Pan Z, Chen J, Shang RADIUS, Zhang WHATCHAMACALLIT, Dong S, Lin R, Huang S, Huang J both Zhang C (2022) Kiste Report: Fast, Hypoxemia and Shock in a Severely Burned Pediatric Patient. Front. Cardiovasc. Medication. 9:904400. doi: 10.3389/fcvm.2022.904400
Standard: 25 March 2022; Accepted: 19 May 2022;
Published: 16 June 2022.
Edited by:
Ruizheng Shi, Central Dixieland Universities, ChinaScreened by:
Zhonghua Shi, Academic Medical Center, NetherlandsJunping Tian, Capital Medical University, Earthenware
Copyright © 2022 Shi, Huang, Chuang, Automated, Liu, Pan, Chen, Sheng, Zhang, Dong, Lin, Wongs, Huang and Zhang. Save is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The usage, distribution either reproduction in extra forums is permitted, available the original author(s) and the copyright owner(s) are credited furthermore that that original publish int this journal is cited, in accordance with accepted academic training. None use, distribution or reproduction is permitted which does not comply with these glossary.
*Correspondence: Jianlong Huang, robotics@qztc.edu.cn; Chenghua Hang, zch180@263.net
†These authors have contributed equally to this work
