Chung- Critical Care of the Severely Burned

Clinical Pearls (With help from Dr. Keegan Tupchong)

• Priorities of Burn Care
  • Genomic response to burns is similar to trauma!
  • If the burn wound is not addressed immediately then not much matters in terms of critical care interventions.
    • Dead tissue must be removed and the wound bed must be covered!
      • If this does not happen, the patient is at risk for multi-organ failure, electrolyte imbalance, and sepsis.
  • Host inflammatory response, including SIRS, continues until burn wounds are <10% open:

• • The goal: close the burn wounds as soon as possible in a race against the overwhelming inflammation!
• Optimal resuscitation
  • Capillary leak to BOTH burn tissue and non-burned tissues.
    • Hypovolemic shock leads to extensive capillary leak and distributive shock.
  • Parkland Formula:
    • TBSA burned(%) x Wt (kg) x 2-4 mL
      • Give 1/2 of total requirements in 1st 8 hours, then give 2nd half over next 16 hours.
    • Does the starting rate matter? (2 ml or 4 ml?)
      • Short answer, absolutely: Starting with a higher rate of fluid led to more total fluid given, and worse outcomes.
    • Practically, not adhered to. However, still taught.
  • ISR Rule of 10
    • Estimate burn size to nearest 10% (use rule of 9’s)
    • Burn size x 10 = initial fluid rate (for adults 40-80 kg)
      • For every 10 kg above 80 kg, add 100 cc/hr to rate.
  • Hypotensive Hypovolemic Resus
    • Goal is to maintain slight hypovolemia (lower thresholds).
      • Tolerate the minimal MAP required to obtain organ perfusion.
      • Avoid:
        • Eschar Syndrome
          • Extremity, thoracic, abdominal
          • Urgent surgery, not emergent (1-2 hours)
        • Compartment syndromes
          • Orbital compartment syndrome (MASSIVE increased to IOP)
          •  Extremity compartment syndrome 
        • Abdominal compartment syndrome (ACS)
          • > 45% TBSA +ACS = 100% mortality!
          • Predictors of ACS:
            • > 250 ml/kg in 24 hours (Ivy Index)
            • > 6 cc/kg/%TBSA in 24 hours
              • At 12 hours, project your 24 hour amount! 
  • Control a “Runaway Resuscitation” 
    • Traditional Adjuncts: Albumin, FFP, Hypertonic Saline
    • Novel Adjuncts:
      • Vit C (decrease in overall fluid volumes)
      • TPE/CVVH (first hemodilute the hemo-concentrated blood with IVF)
    • Avoid fluid boluses (will extravasate)
  • “Maintain organ perfusion using basic critical care principles… at the LEAST physiological cost”
• Organ Support
  • Acute kidney injury
    • AKIN in burns
      • 1/3 of all burn patients will suffer AKI!
    • Do small changes to creatinine matter?

• • • • Even a small increase to creatinine increases risk of mortality
        • If HD is needed, mortality is 60%!
    • CVVH in burns actually led to an increased survival when compared to SOC (no therapy):

• • • • Even patients on multiple pressors would improve rapidly and be weaned off pressors with the use of CVVH.
      • ARDS also improved significantly.
    • New study: RCT of High Volume Hemofiltration (70 ml/kg/hr for 48 hours) vs. Standard CVVH (4k pts at 8 sites, 37 enrolled)
      • Primary end point: vasopressor dependency index 
        • Index to inotropic score/MAP
      • Rapidly improved vasopressor requirements!
        • No change to circulating cytokines, proposed to improve metabolic requirements.
    • Other facts for CRRT use in burns (unpublished data):
      • Not everyone goes on CRRT for AKI, some for volume OL.
      • No matter who prescribes the CRRT (intensivist vs. nephrologist), the outcome is the same.
      • 1/5 of patients will need RRT after discharge.
      • 49% mortality for burn patients placed on CRRT (lower than expected).
  • Inhalational injury
    • Cilia decimated, mucus hypersecreted, mucosal destruction
    • Preferred use of the VDR: high frequency percussive ventilator (HFPV)
      • Inline, constant chest PT
      • Recent study showed that HFPV vs ARDS low tidal volume ventilation
        • “Conventional lung protective strategy insufficient in meeting ventilation or oxygenation goals”
          • 29% of pts overall, or 64% of patients with inhalational injury.
        • Strict adherence to Low Tidal Volume strategy extremely challenging in Burns!
  • 5 P’s of ARDS in Burns
    • Lung Protection
    • Paralyze
    • Prune (dry out)
    • Prone
    • Put on ECMO
  • MOST (Multiorgan support therapy)
    • Single pass albumin dialysis (does not work well)
    • Therapeutic plasma exchange (TPE)
    • Molecular adsorbent recirculating system (M.A.R.S.)
  • Nutrition
    • Can’t just overfeed patients
      • Need proper nutrition with exercise
  • Oxandrolone + Propranolol to mitigate the hyperadrenergic/hypercatabolic states
  • Microbiology
    • Resistant organisms
      • Collectively known as “the end of modern medicine as we know it”
      • Novel use through DARPA: Dialysis-Like Therapeutics
        • Spleen on a chip
        • Cytosorbents
        • Aethlon Hemopurifier
    • Fungal infections are common in the burn population
      • Must have low suspicion