macken on burn resuscitation
TRANSCRIPT
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Burn Resuscitation
– “Another bag of Hartmann’s?”
LEWIS MACKEN
Intensive Care UnitRoyal North Shore Hospital
November 2015
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Think about that bolus of fluid you’ve just given.
It has to go somewhere.
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Burn resuscitation
1. Over-resuscitate2. Success 3. Monitor4. Rescue5. Summary
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Burn injury is a systemic injury >20% TBSA
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Don’t try to get things to normal during the first 24 hours.
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Case• 15 y old girl• Explosion BBQ• Intubated at scene• 30% TBSA burns• Parkland estimation (@ 70kg, 4ml/kg) = 8.4 L in 24 hrs • 6L given pre-hospital and ED in first 6 hours
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What’s happening to her skin right now ?
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Jackson’s Burn Model
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Zone of stasis
• compromised but viable cells• decreased perfusion
• platelet aggregation• injured rbc• fibrin deposition
• endothelial swelling vasoconstriction• convert to complete tissue loss if:
• hypoperfusion / infection / oedema /ongoing heat
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mh
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Why do we give resuscitation fluids ?
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Why do we give fluids in burns ?
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Primary Goal
Maintain adequate tissue perfusion to end-organs and prevent ischaemic injury at the lowest physiological cost.
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Universal Consensus for Burn Shock Resuscitation ?
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Ann NY Acad Sci 1968
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• Initial higher fluid volumes higher final volumes at 24 hours
• Initial lower fluid volumes lower volumes, no complications
J Trauma 2009
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Why are we giving more fluid ?
1. Over-estimation of burn size2. Reluctance to decrease fluids3. ‘Opioid creep’4. ‘Normalise’ by maximising preload
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Major burns & physiological derangement …
• Restoration of preload & cardiac function• Resolution of acidosis
24 – 36 hours
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Determinants of success in burn resuscitation ?
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Advanced haemodynamic monitoring to guide resuscitation ?
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• ITBVI (ITTV & PTVGEDVITBVI) = R & L heart & pulmonary blood volumes at end-diastole
• CI only increased in GDT group at 24 hours, all identical at 48 hours• 60% failed to reach target• 56% more fluid (17 vs. 27L)• No difference in mortality, ICU days, ventilator days, pH, lactate, vasopressors
• “pure crystalloid solution is incapable of restoring cardiac preload during period of burn shock”
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• ITBVI & CI• PiCCO 10L vs 7L standard• significant tissue oedema, even though the study group had 2x more u/o.
• the attempts to achieve normal haemodynamics were associated with significant tissue oedema, causing resuscitation attempts for some patients to stop
• “probably impossible to generate normal CO and normovolaemia during early post-burn period”
J Burn Care Res 2013
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• Targets: CI .2.5L & normal ITBVI & lactate• Initially: low ITBVI/CI 2.68/lactate elevated• ITBVI remained low at 32 hours - but with normalisation of CI and lactate
= can achieve adequate resuscitation without normal preload• 4.75ml/kg/TBSA% & 23% mortality & 31% ARF (11.4% RRT) & 24.2%
ARDS & 12% ACS & 22 days mean on ventilator for mean TBSA 35%
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Burns patients are different
• Restoration of preload & CO & resolution of acidosis takes 24-48 hrs
• Permissive hypotension• Permissive hyperlactataemia
CLOSE CLINICAL SUPERVISION
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Rescue # 1
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Colloid
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Colloid Administration Normalizes Resuscitation Ratio and Ameliorates “Fluid Creep”
J Burn Care & Res 2010
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Rescue # 2
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1. Modified Parkland formula
2. Urine output + examine patient + other haemodynamic parameters
3. Slow early
4. Turn down
5. Rescue
6. Cardiac index sometimes
7. Don’t normalise
Summary
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