NEW TRENDS IN BURN RESSUSCITATION

1. DR GHALEB ALMEKHLAFI
CONSULTANT MEDICINE AND CRITICAL CARE
PSMMC AUG 2014

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.

8. 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

11. • 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

12. 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.

13. 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

14. 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

16. 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.

17. 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

18. 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

19. 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

20. 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

21. 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.

22. resuscitation protocols
•there are many
resuscitation
protocols

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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.

30. 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

31. 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.

32. 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..

33. 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.

34. 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

35. 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.

36. GUIDELINES
RECOMMENDATIONS
• Level 1 None

37. 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.

38. 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

39. 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

40. 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.

41. questions?