The initial resuscitation of the burn patient in icu


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The initial resuscitation of the burn patient in icu

  2. 2. Introduction over the last half century have resulted in;  improved survival rates  shorter hospital stays  decreases in morbidity and mortality rates Factors  development of resuscitation protocols,  improved respiratory support  support of the hypermetabolic response,  infection control  early burn wound closure  early enteral nutrition.
  3. 3. Inhalation Injury • marked increase in mortality and morbidity. • associated with a 44% increase in fluid requirements • Acute upper airway obstruction occurs in 20% to 33% of burn patients with inhalation injury • Patients presenting with stridor should be intubated on presentation • Even the gold standard of bronchoscope within the first 24 hrs of admission cannot accurately predict the severity of inhalation injury • 70% of patients with inhalation injury will develop ventilator- associated pneumonia-VAP prevention Darling GE, Keresteci MA, Ibañez D, et al: Pulmonary complications in inhalation injuries with associated cutaneous burn. J Trauma 1996; 40:83–89
  4. 4. • 15% Partial or full thickness burn in adults and 10% in Extremes of ages • Suspected airway or inhalational injury • Significant burns of hands, face, feet or perineum • Chemical burns • High tension Electric burns • Major associated life threatening injuries
  5. 5. Vascular Access/Other Tubes and Catheters • Ideally, obtain peripheral intravenous access away from burned tissues. • intraosseous catheters may safely be placed in patients of any age. • Foley catheter .u/o is imp. for mgt • NGT should be considered in patients with > 20% TBSA burns, as they will experience Gastroparesis and probable emesis.
  6. 6. First-line Monitoring URINE OUTPUT AND HEART RATE - the primary modalities for monitoring, - not supported by data.  URINE OUTPUT The American Burn Association Practice Guidelines for Burn Shock Resuscitation recommend - 0.5 mL/kg/hr urine output in adults - 0.5–1.0 mL/kg/hr in children weighing < 30 kg  HEART RATE: • < 110 beats/min in adults usually indicates adequate volume • rates > 120 beats/min usually indicative of hypovolemia. • Narrowed PP is an earlier indication of shock than SBP alone
  7. 7. invasive monitoring • Noninvasive BP measurements by cuff are inaccurate • An arterial catheter placed in the radial artery is the first choice, followed by the femoral artery • Less invasive cardiac output monitoring and EVLW are useful • PAC/CVP not recommended
  8. 8. Resuscitation • one of the cornerstones of modern burn care • The intervention most directly improves patient survival. • hypovolemia/shock will develop if the burns involve > 15% to 20% total body surface area (TBSA) • The obvious challenge is to provide optimal fluid replacement to maintain perfusion without causing fluid overload.
  9. 9. excessive resuscitation as deleterious as those of under- resuscitation: pulmonary edema myocardial edema conversion of superficial into deep burns Predispose to limbs, and abdominal compartment syndrome
  10. 10. Resuscitation Formulas • Formulas :none is optimal • fluid administration has to be individualized • Factors that influence fluid requirements besides TBSA burn include: o burn depth o inhalation injury o associated injuries o age. • delay in resuscitation, need for escharotomies / fasciotomies
  11. 11. Parkland formula for burns resuscitation Total fluid requirement in 24 hours =4 ml×(total burn surface area (%))×(body weight (kg)) • 50% given in first 8 hours • 50% given in next 16 hours Children receive maintenance fluid in addition, at hourly rate of • 4 ml/kg for first 10 kg of body weight plus • 2 ml/kg for second 10 kg of body weight plus • 1 ml/kg for > 20 kg of body weight End point • Urine output of 0.5-1.0 ml/kg/hour in adults • Urine output of 1.0-1.5 ml/kg/hour in children
  12. 12. Resuscitation fluid • LR solution most closely match NL body fluids. • There has not been a clinical advantage with colloids. • comparing albumin to crystalloid showed  2.4-fold increased risk of death with albumin. • Hypertonic saline:  4-fold increase in renal failure and  twice the mortality of patients given LR solution • Fresh frozen plasma should not be used as a volume expander American Burn Association Practice Guidelines for Burn Shock Resuscitation
  13. 13. Permissive hypovolemia • The most recent iteration of this concept is the ‘Rule of 10’ developed at Fort Sam Houston (Texas, USA). The authors propose a three-step approach: • the 1st step is to estimate burn size to the nearest 10% TBSA, • 2nd step is to multiply this number by ten to derive the initial fluid rate in mL/hr (for every 10 kg body weight over 80 kg add 10 mL/h to this rate), and • 3rd is to adapt the fluid rate to the signs of organ underperfusion.
  14. 14. resuscitation protocols •there are many resuscitation protocols
  15. 15. vitals Urine output over one hour Fluid adjustment Urine output over one hour/targets Further management University of Utah protocol J Burn Care Res 2007; 28:382–392
  16. 16. A protocol for resuscitation of severe burn patients guided by transpulmonary thermodilution and lactate levels A decision tree for the adjustment of fluid and catecholamine therapy according to a permissive hypovolemia protocol with lower preload targets and lactate measurements to ensure tissue perfusion is shown Sánchez et al. Critical Care 2013, 17:R176
  17. 17. Vitamin C Resuscitation The landmark study by Tanaka et al showed that high dose ascorbic acid 66mg/kg/hr during the initial24 hrs post burn reduced  fluid requirements by 40%,  reduced burn tissue water content 50%,  and reduced ventilator days. Tanaka H, Matsuda T, Miyagantani Y, et al: Reduction of resuscitation fluid volumes in severely burned patients using ascorbic acid administration. Arch Surg 2000; 135:326–331 Dubick MA, Williams C, Elgjo GI, et al: High-dose vitamin c infusion reduces fluid requirements in the resuscitation of burn-injured sheep. Shock 2005; 24:139–144
  18. 18. Hypothermia • Metabolic responses can be minimized by treating the patient in a thermo-neutral environment (32°C). • During hydrotherapy, in the operating room, and in the burn unit, keep the room temperature at ≥30°C to minimize heat loss and decrease metabolic rate. Judkins K: Current consensus and controversies in major burns management. Trauma 2000; 2:239–251
  19. 19. Compartment Syndromes • Abdominal compartment syndrome (ACS) is a life-threatening complication caused by high-volume resuscitation Curr Opin Anaesthesiol 2001; 14:431– 435] • ACS is defined as IAP ≥20 mm Hg plus at least one new organ dysfunction. Intensive Care Med 2006; 32:1722–1732 • Simply monitoring urine output is insufficiently sensitive or specific to diagnose ACS. • Bladder pressure monitoring should be initiated in every patient with >30% TBSA burn. • Patients who receive > 250 mL/kg of crystalloid in the first 24 hrs will likely require abdominal decompression. Ann Surg 2007; 245:622–628 • Percutaneous abdominal decompression is a minimally invasive procedure that should be performed before resorting to laparotomy. J Burn Care Res 2007; 28:708–714 • The reported mortality rates for decompressive laparotomy for ACS can be as high as 88%[71] to 100%. J Burn Care Rehabil 2002;23:190–195
  20. 20. Infection/Inflammation/Sepsis • patients with large burns are in a state of chronic systemic inflammatory stimulation(SIRS) for months. Clues to infection include :  increased fluid requirements,  decreasing platelet counts > 3 days after burn injury,  altered mental status,  worsening pulmonary status, and  impaired renal function. • Any infection in a burn patient should be considered to be from the central venous catheter until proven otherwise. Change to a new site every 3 days to minimize bloodstream infections. • topical antimicrobial therapy is efficacious
  21. 21. Enteral Nutrition • Burn causes hypermetabolism, • enteral nutrition should be started as soon as resuscitation is underway • Patients with burns > 20% TBSA will be unable to meet their nutritional needs with oral intake alone. • Early feeding enhanced wound healing and shorter hospital stays. • PN should be used only if the GI tract is not functioning.
  22. 22. Anabolic Steroids • Severe burn injuries induce a hypermetabolic response, which leads to catabolism. • Anabolic steroids such as oxandrolone promote  protein synthesis  nitrogen retention  skeletal muscle growth  wound healing . • Burn patients receiving oxandrolone regain weight and lean mass two to three times faster than with nutrition alone. Demling RH, Desanti L: Oxandrolone induced lean mass gain during recovery from severe burns is maintained bafter discontinuation of the anabolic steroid. Burns 2003; 29:793–797
  23. 23. β-Blockade • β-blockers after severe burns decrease heart rate, resulting in reduced cardiac index supraphysiologic thermogenesis. • In children, treatment with propranolol attenuates hypermetabolism and reverses muscle-protein catabolism. • Propranolol is given to achieve a 20% decrease in heart rate of each patient compared with the 24- hr average heart rate immediately before administration.
  24. 24. Pain Management • intravenous opioids should be administered. • Background pain is best managed with long-acting analgesic agents. • Breakthrough pain is addressed with short-acting agents • Ketamine can be used for extensive burn dressing changes and procedures such as escharotomies. • Anxiolytics such as benzodiazepines decrease background and procedural pain. • For patients requiring mechanical ventilation, a Propofol infusion will provide sedation but not analgesia..
  25. 25. Wound Management • The primary goal is to close the wound as soon as possible, beginning at the time of injury. • daily, hydrotherapy is routine, involving washing the entire patient with chlorohexidine and warm tap water. • The practice of immersion has fallen out of favor. • Once the wound is clean, use topical antimicrobial agents, Silver sulfadiazine is the most commonly used • Silver containing sheets and compounds that may be placed on partial thickness burns and remain in place for up to 7 days • patients with full-thickness burns, prompt surgical excision of the eschar and allografting in patients with large burns, or auto grafting in patients with smaller burns, contributes to reduced morbidity and mortality.
  26. 26. GUIDELINES • This guideline provides a template for the initial resuscitation of patients with acute major burn injury encompassing 10% total body surface area (TBSA) or more. Guidelines Acute Burn Resuscitation 2013,Department of Surgical Education, Orlando Regional Medical Center Approved 12/04/2013
  27. 27. GUIDELINES-LEVEL OF RECOMMENDATION DEFINITIONS • Level 1: Convincingly justifiable based on available scientific information alone. • Level 2: Reasonably justifiable based on available scientific evidence and strongly supported by expert opinion. • Level 3: Supported by available data, but scientific evidence is lacking.
  29. 29. GUIDELINES RECOMMENDATIONS----Level 2 1. Estimate initial fluid requirements with the Parkland formula (4 mL/kg/% TBSA burned). 2. Give ½ of the fluid volume calculated over the first 8 hours from the time of the burn 3. Give the remaining half of the fluid volume over the next 16 hours 4. For ≥ 30% TBSA burns, Vitamin C infusion should be considered.. 5. Avoid the use of hypertonic saline.
  30. 30. GUIDELINES RECOMMENDATIONS-----Level 3 1-Avoid oversedation. Consider non-narcotic analgesia such as ketorolac, ibuprofen, or Ketamine. 2-In patients with burns ≥ 20% TBSA: • Insert a central venous catheter, • Insert a urinary (Foley) catheter, • Monitor intra-abdominal (bladder) pressure q 4 hours during the initial resuscitation, • Consider invasive hemodynamic monitoring to guide resuscitation
  31. 31. GUIDELINES • RECOMMENDATIONS-----Level 3 3-Resuscitation endpoints in the first 24 hours post-burn injury:  Monitor arterial lactate q 4 hours until < 2 mMol/L,  Maintain urine output at 30-50 ml/hr (50-100 ml/hr if receiving Vitamin C)  In electrical injury or rhabdomyolysis patients, serial creatinine kinase levels should be, checked daily until < 2500 mcg/L, Monitor hemoglobin to ensure that it is not trending upward
  32. 32. GUIDELINES • RECOMMENDATIONS-----Level 3 • If the patient requires ≥ 1.5 times the calculated Parkland formula volume (6 ml/kg/TBSA), consider colloid rescue: 5% albumin at 1/3 Parkland rate + 2/3 Parkland rate of Lactated Ringers OR,25% albumin at 1/15th the Parkland rate + 2/3 Parkland rate of Lactated Ringers, • Fresh frozen plasma may be used as an efficacious alternative to albumin for colloid rescue • If the patient has received > 250 mL/kg of fluid resuscitation, intraocular pressure should be measured.
  33. 33. questions?