Page 1669 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

1188 PART 10: The Surgical Patient

supplementation and whether specific amino acid supplementation is deep partial or full-thickness burns, prompt surgical excision of the
necessary remains a subject of study and debate. Patients will require eschar and allografting in patients with large burns, or autografting in
more protein per kg every day than nonburn critically ill patients. There patients with smaller burns, contributes to reduced morbidity and mor-
is a great deal of current interest in glutamine supplementation for burn tality. If one considers an unexcised burn the same as an undrained
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patients. Although the data supporting glutamine supplementation abscess, then the time urgency to excise a burn becomes obvious. A host
are not robust, it may prove useful in an immune enhancing mode to of temporary wound coverage products are available. The ideal dressing
decrease bacteremia. Unless the patient is vitamin deficient prior to is easy to perform, painless, and flexible enough to allow physical and
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the burn injury, packaged formulas will provide the needed vitamins occupational therapy throughout the day.
and minerals. Pediatric patients should receive a vitamin supplementa-
tion due their increased metabolic needs and rapid rate of growth. In PAIN MANAGEMENT
the patient where a vitamin deficiency is suspected, a prenatal vitamin
will provide the needed vitamins and minerals. In the rare case that Burn patients may experience pain that is multifaceted and constantly
precludes use of the gastrointestinal tract, parenteral nutrition should be changing as the individual undergoes repeated procedures and wound
used only until the gastrointestinal tract is functioning. manipulation. Inconsistent and inadequate pain management has
■ ENDOCRINE AND GLUCOSE MONITORING sal treatment standard for pain management, required opioid doses
been well documented in burn patients. Although there is no univer-

Strict glucose control of 80 to 110 mg/dL can be achieved using an often significantly exceed recommended standard dosing guidelines. 70,94
Practice Management Guidelines for the Management of Pain by the
intensive insulin therapy protocol, leading to decreased infectious com- Committee on the Organization and Delivery of Burn Care of the
plications and mortality rates. 89,90 The risks of hypoglycemia with a strict American Burn Association recommend that once intravenous access
glucose control approach can be prevented with adherence to protocols is obtained and resuscitation started, intravenous opioids should be
that provide for glucose containing compounds anytime the patient is administered. Background pain is best managed through the use of
not willing or able to tolerate oral intake. long-acting analgesic agents. Breakthrough pain is addressed with
■ ANABOLIC STEROIDS short-acting agents via an appropriate route. Ketamine can provide
conscious sedation for extensive burn dressing changes and procedures
Severe burn injuries induce a hypermetabolic response, which leads such as escharotomies routinely performed in the burn unit. Anxiolytics
to catabolism. Anabolic androgenic steroids such as oxandrolone pro- such as benzodiazepines decrease background and procedural pain.
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mote protein synthesis, nitrogen retention, skeletal muscle growth, and For patients requiring mechanical ventilation, infusions of propofol or
decreased wound healing time. Burn patients receiving oxandrolone dexmedetomidine provide sedation but not analgesia. All medications
regain weight and lean mass two to three times faster than with nutri- should be given intravenously, orally, or rectally due to erratic absorp-
tion alone. Oxandrolone started within the first week postburn can be tion with intramuscular/subcutaneous administration.
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administered safely well into the rehabilitation phase of care, and has
been shown to enhance long-term recovery in height, cardiac work, and PHYSIOTHERAPY
muscle strength for up to 5 years postburn. 92
■ ß-BLOCKADE Rehabilitation therapy begins at admission to maximize functional recov-
ery. Burn patients require special positioning and splinting, early mobi-
1
ß-blockers after severe burns decrease heart rate, resulting in reduced lization, strengthening and endurance exercises to promote healing.
The position of comfort is the position of deformity, so proper position-
cardiac index and decreased supraphysiologic thermogenesis. In ing from the time of admission can help prevent contractures. At regular
3,93
children with burns, treatment with propranolol during hospitalization intervals throughout the day and night, the neck must be maintained in
attenuates hypermetabolism and reverses muscle-protein catabolism. full extension, arms out to the side in an airplane fashion, hips and legs
Propranolol should be given to achieve a 20% decrease in heart rate of straight with ~10° of flexion at the knees. Splints of the hands and feet
each patient compared with the 24-hour average heart rate immediately placed on and off at regular intervals will provide time for appropriate
before administration. 93
positioning while allowing nurses and therapists the opportunity to
perform range of motion exercises. The patient must be repositioned
WOUND MANAGEMENT at frequent intervals, being sure to protect skin from any decubitus
ulceration in areas of contact. Fluid air loss mattresses that promote skin
Before undertaking wound care, the functions of intact skin must be management are useful adjuncts for burn patients. Regularly ambulating
kept in mind: thermoregulation, water retention, infection barrier, patients on ventilators out in the hallways (something known as “Bag
water storage, pain receptors, biosynthetic properties, and cosmesis. All ‘N Drag” in our burn center) with a multiteam approach comprised of
of these functions are altered or destroyed in the patient with a severe the patient, nurse, respiratory therapist, and physical therapist has been
burn injury. The primary goal for burn wound management is to close shown to enhance outcomes in critical care areas. This practice is espe-
the wound as soon as possible, beginning at the time of injury, because cially relevant in burn centers and can be safely performed even during
every day that a wound is open increases scarring risk. Burn centers are the resuscitation period.
uniquely set up to provide optimal wound care. Beginning on admis-
sion and then daily, hydrotherapy is a routine part of care, involving TRANSFER CRITERIA
washing the entire patient with chlorhexidine and warm tap water. The
goal is to gently debride the nonviable tissue while leaving any newly The American Burn Association has established criteria for burn
formed dermis/epidermis. The practice of immersion in large tanks or patients who should be acutely transferred to a burn center: >10%
other standing bodies of water has fallen out of favor, as bacteria from TBSA partial thickness burns, any size full-thickness burn, burns to
the fecal fallout zone would quickly colonize the entire burn wound. special areas of function or cosmesis, inhalation injury, serious chemical
Once the wound is clean, topical antimicrobial agents limit bacterial injury, electrical injury including lightning, burns with trauma where
proliferation and fungal colonization in the burn wound. Silver sulfa- burns are the major problem, pediatric burns if the referring hospital
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diazine is the most commonly used topical antimicrobial, being readily has no special pediatric capabilities, and smaller burns in patients
available, affordable, and well tolerated by the patient. There are also with multiple comorbidities. Based on the needs of the burn patient
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silver-containing sheets and compounds that may be placed on partial meeting these criteria, transferring burn patients meeting any of these
thickness burns and remain in place for up to 7 days. For patients with criteria to a burn center will provide the best possible care and result

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