More than 1.3 million children sustain burns each year, resulting in 40,000 admissions and more than 3000 pediatric deaths. Pediatric burn surgery has been described as excessively bloody. Strategies to reduce intraoperative blood loss include the use of topical thrombin and epinephrine, extremity tourniquets, acute normovolemic hemodilution, and hypotensive anesthesia. This study reviews the single surgeon pediatric burn experience at a children's hospital and describes a comprehensive blood conservation protocol to achieve transfusion-free pediatric burn surgery. A retrospective chart review of consecutive pediatric burn surgeries from July 2000 to April 2002 was performed. Patient demographics, burn characteristics, treatment, blood loss, laboratory values, transfusion history, and complications were reviewed. Blood loss per percent total body surface area (TBSA) treated as well as percent total blood volume (TBV) loss divided by percent TBSA treated were calculated. A total 31 burn surgeries in 23 patients were reviewed. The average age was 7 years (range, 9 months-17 years). There were 17 extremity, 6 trunk, and 2 head/neck burns. The average TBSA burned was 15% (range, 1-55%). The protocol to reduce intraoperative blood loss consisted of the debridement of full-thickness burns with electrocautery and partial-thickness burns with dermabrasion. All debrided or harvested surgical sites were treated immediately with epinephrine solution-soaked pads. All graft harvest sites were injected with an epinephrine solution before harvesting split-thickness skin grafts. The average TBSA treated per surgery was 7% (range, 1-29%). The average blood loss per percent TBSA treated was 15 mL (range, 0.7-37 mL). The average percent TBV/percent TBSA was 0.76% (range, 0.04-3.6%). All 20 patients underwent surgical debridement, 7 patients were treated with AlloDerm and ultrathin split-thickness skin grafts, 2 with full-thickness skin grafts, and 17 with split-thickness skin grafts alone. Five children required blood transfusions. These burns averaged 32% TBSA (range, 20-55%). All 5 children receiving transfusions had anemia of thermal injury and demonstrated an average preoperative drop in hematocrit of 12% (range, 10-14%). There was a 29% complication rate, with 7 patients experiencing partial graft loss, and 1 patient who developed a postgraft contracture that required revisional surgery. There was a single mortality secondary to systemic inflammatory response syndrome and acute respiratory distress syndrome. After the proposed pediatric burn treatment protocol, intraoperative blood loss requiring transfusion can be minimized or eliminated. Large TBSA burns must be surveilled for burn wound anemia that may ultimately require blood transfusion.