Page 1668 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 123: Critical Care of the Burn Patient 1187

■ COMPARTMENT SYNDROMES this trend. As in nonburn patients, careful observance for thrombocyto-

A life-threatening complication caused by high-volume resuscitation is penia after the first week of hospitalization will alert the practitioner to
make the diagnosis in burn patients. Although the incidence of HIT
6,82
abdominal compartment syndrome (ACS), defined as intra-abdominal
32
pressure >20 mm Hg plus at least one new organ dysfunction. ACS was relatively low (1.6%) in one study, the complications of HIT in those
74
patients were profound, including arterial and deep venous thromboses
has been associated with renal impairment, gut ischemia, and car- 82
diac and pulmonary malperfusion. Clinical manifestations include and increased number of surgical procedures.
ance, hypercapnia, and oliguria. Simply monitoring urine output is ■ NEUTROPENIA
tense abdomen, decreased lung pulmonary and chest wall compli-
insufficiently sensitive or specific to diagnose ACS. 17,75,76 Vigilant moni- Transient leukopenia is common, primarily due to a decreased neutro-
toring and aggressive treatment should be instituted to avoid this deadly phil count. Maximal white blood cell depression occurs several days
complication. 75,76 Appropriate intravascular volume, appropriate body after admission with rebound to normal a few days later. Although use
positioning, pain management, sedation, nasogastric decompression if of silver sulfadiazine has been associated with this transient leukopenia,
appropriate, chemical paralysis if required, and torso escharotomy are resolution is independent of continued silver sulfadiazine. 1
Patients who receive >250 mL/kg of crys- ■
all interventions to increase abdominal wall compliance and decrease
intra-abdominal pressures. 76,77 STRESS ULCERS
talloid in the first 24 hours will likely require abdominal decompression, Level 1 data exist that patients with major burn injuries are at risk for stress
based on the Ivy score. Percutaneous abdominal decompression is a ulcers and should receive routine prophylaxis beginning at admission. 83
12
minimally invasive procedure that should be performed before resorting
to laparotomy. 75,78 The International Conference of Experts on Intra- ■ ADRENAL INSUFFICIENCY
abdominal Hypertension and Abdominal Compartment Syndrome rec- Although absolute adrenal insufficiency occurs in up to 36% of patients
ommends that if less invasive maneuvers fail, decompressive laparotomy with major burns, there is no correlation between response to cor-
should be performed in patients with ACS that is refractory to other ticotropin stimulation and survival. Those with massive burns have
treatment options. The reported mortality rates for decompressive higher cortisol levels but may be resistant to serum cortisol increases
76
laparotomy for ACS can be as high as 88% to 100%. 75,78 in response to stimulation. The clinical relevance of this finding has not
Exuberant fluid resuscitation beyond the protocols attached here in been established. 84,85
Figures 123-1 and 123-2, such as what may be required with delayed
fluid resuscitation or severe inhalation injury may lead to compartment
syndromes in other areas, including brain, chest, and extremities. If the INFECTION/INFLAMMATION/SEPSIS
significantly more fluid than predicted, consideration should be given to ■ CONSENSUS PAPER ON SEPSIS AND INFECTION-RELATED DIAGNOSES
patient exhibits deterioration in mental status and the patient is requiring
obtaining a head CT to rule out increased intracranial pressure, cerebral Current definitions for sepsis and infection have many criteria rou-
edema, and even transtentorial herniation. The orbit is a compartment tinely found in patients with extensive burns without infection/sepsis
limited to expansion and may require lateral canthotomy to successfully (eg, fever, tachycardia, tachypnea, leukocytosis). Burn experts recently
reduce intraocular pressure to normal. The need for increased ventila- developed standardized definitions for sepsis and infection-related diag-
80
tory requirements beyond what is usually anticipated should prompt noses in burn patients from which we will summarize key discussion
the team to consider chest or abdominal compartment syndromes. points and recommendations. Patients with large burns have a baseline
6
Continuously assessing compartments for increased pressure, includ- temperature reset to 38.5°C, and tachycardia and tachypnea may persist
ing extremities, will allow for immediate escharotomy if the need arises. for months. Continuous exposure to inflammatory mediators leads to
Bladder pressure monitoring should be initiated as part of the burn fluid significant changes in the white blood cell count, making leukocytosis
resuscitation protocol in every patient with >30% TBSA burn. 22,32,77 a poor indicator of sepsis. Use other clues as signs of infection or sepsis
Extremity compartment syndromes can also result from extensive such as increased fluid requirements, decreasing platelet counts 3 days
edema formation. Patients may require escharotomies, fasciotomies, or after burn injury, altered mental status, worsening pulmonary status,
both for the release of extremity compartment syndrome. 17,79 Patients and impaired renal function. The term systemic inflammatory response
with circumferential full-thickness burns are also at risk of requiring syndrome should not be applied to burn patients because patients with
escharotomies. Impaired capillary refill, paresthesia in the involved large burns are in a state of chronic systemic inflammatory stimulation.
54
6
extremity, and increased pain develop earlier than decreased pulses. Any infection in a burn patient should be considered to be from the
■ DEEP VENOUS THROMBOSIS central venous catheter until proven otherwise. In burn patients,
6
central catheters should be changed to a new site every 3 days to mini-
86
The incidence of deep venous thrombosis in burn patients is estimated mize bloodstream infections. Although prophylactic systemic anti-
to be 1% to 23%. In the absence of level 1 evidence, deep venous biotics have no role in thermal injury, topical antimicrobial therapy is
81
1
thrombosis chemoprophylaxis is routinely practiced in many burn efficacious. Systemic antibiotic therapy should be culture directed and
centers. What remains unknown is when to begin chemoprophylaxis administered for the shortest time possible.
and how the size of the burn affects the dosage of effective chemo-
prophylaxis. It has been suggested that a patient with larger burns will METABOLISM/NUTRITION
require significantly higher doses of enoxaparin than unburned patients.
Based on the hypermetabolic state present during the early burn phase, ■ ENTERAL NUTRITION
once daily chemoprophylaxis will be inadequate, and twice daily As hypermetabolism can lead to doubling of the normal resting energy
enoxaparin dosing will be necessary. Although not in routine use yet, expenditure, enteral nutrition should be started as soon as resuscita-
monitoring antifactor Xa levels and administering enoxaparin based on tion is underway with a transpyloric feeding tube. Patients with burns
those levels provides a scientific rationale for chemoprophylaxis. >20% TBSA will be unable to meet their nutritional needs with oral
■ HEPARIN-INDUCED THROMBOCYTOPENIA (HIT) intake alone. Patients fed early (during the first 48 hours postburn)
have significantly enhanced wound healing and shorter hospital stays.
87
Early thrombocytopenia occurs in the postburn course in patients with Feeding with a postpyloric feeding tube during the operative procedure
extensive injury. Complications after burn injury such as pulmonary has also been shown to optimize the nutritional levels while being
infections, multiorgan failure, sepsis, and bleeding disorders accentuate safe and not increasing the risk of aspiration. The kind of nutritional

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