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CHAPTER 123: Critical Care of the Burn Patient 1189

in the best possible outcome for the patient. Letters of agreement often controversial in part because current end points have not yet been
exist between burn centers so that if the closest burn center is unable to demonstrated to reflect tissue perfusion status independently and
care for a critically burned patient, the patient can be sent to the next accurately. 22,97 Vital signs and urine output in burn patients do not fulfill
closest burn center. Verified burn centers in the United States will gladly these criteria. Defining better end points of resuscitation to avoid exces-
42
provide assistance to nonburn centers in arranging the optimal patient sive volume administration is a high priority for future investigations.
21
transfer and transport. Future improvements in preventing burn shock will include a com-
plex ballet of pharmacologic interventions, encouraging rapid surgical
ADDITIONAL THERAPIES removal of necrotic tissue, and provision of a dynamic range including
fluid types and delivery rates. The continuing challenge for burn clini-
The psychosocial care of the burn patient is just as important as the cians and researchers is to collaborate in large multicenter studies to
physical care but is easy to overlook. Compared to the nonburned critically evaluate and establish resuscitation end points and therapies. 17,22
critically ill patient, the burn patient will be faced with a lifetime of
rehabilitation therapy and lifelong alterations in appearance, ability to
exercise and work, and often, overall quality of life. Beginning to attend KEY REFERENCES
to psychological issues early, for example, at the time of admission, will
assist the patient in dealing with the oftentimes permanent lifestyle • Demling RH, Desanti L. Oxandrolone induced lean mass gain
changes. In addition to the patient, the family will have to deal with during recovery from severe burns is maintained after discontinu-
many issues and should be given every support. All burn team members ation of the anabolic steroid. Burns. 2003;29:793-797.
can provide informal support, but dedicated social workers and a burn • Herndon DN, Hart DW, Wolf SE, et al. Reversal of catabolism
unit chaplain can aid in the acute phase. Knowing that up to 60% of burn by beta-blockade after severe burns. N Engl J Med. October 25,
survivors will develop posttraumatic stress disorder (PTSD) means that 2001;345:1223-1229.
more advanced therapy must be available from the time of admission • Ivy ME, Atweh NA, Palmer J, et al. Intra-abdominal hyperten-
to the burn center. This advanced psychological support should include sion and abdominal compartment syndrome in burn patients.
the routine involvement of psychiatric nursing for every inpatient, with J Trauma. 2000;49:387-391.
dedicated pediatric psychiatry or psychology for the younger patients. • Klein MB, Hayden D, Elson C, et al. The association between fluid
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When more severe psychopathology is found, psychiatric services administration and outcome following major burn: a multicenter
should be involved. Dressing changes and procedures in children should study. Ann Surg. 2007;245:622-628.
be coordinated with child life therapists. Sleep deprivation is a problem
in many intensive care units, and for the burn patient, is no exception. • Liang CY, Wang HJ, Yao KP, et al. Predictors of health-care needs
Sleep deprivation can lead to delirium, fatigue, difficulty concentrating, in discharged burn patients. Burns. March 2012;38(2):172-179.
and even psychosis. Regular rest periods throughout the day as well • Porro LJ, Herndon DN, Rodriguez NA, et al. Five-year outcomes
as scheduled sleep times and use of sleeping aids at night will prevent after oxandrolone administration in severely burned children: a
lack of sleep from becoming problematic for the patient. Burn support randomized clinical trial of safety and efficacy. J Am Coll Surg.
groups such as the local support group, Survivors Offering Assistance 2012;214:489-504.
through Recovery (SOAR), and the Phoenix Society can provide support • Saffle JR. The phenomenon of “fluid creep” in acute burn resusci-
for adolescents and adults. Burn camps associated with burn centers tation. J Burn Care Res. 2007;28:382-392.
and often supported by community donations provide support for the • Tanaka H, Matsuda T, Miyagantani Y, et al. Reduction of resuscita-
pediatric burn survivor. tion fluid volumes in severely burned patients using ascorbic acid
administration. Arch Surg. 2000;135:326-331.
CONCLUSIONS • Venter M, Rode H, Sive A, et al. Enteral resuscitation and early

Not many topics in acute burn care are more hotly debated than fluid enteral feeding in children with major burns: effect on McFarlane
resuscitation and monitoring. Burn management is still not as evidence response to stress. Burns. 2007;33:464-471.
based as in other areas of acute medicine. However, there does seem • Warden GD. Fluid resuscitation and early management. In:
32
to be agreement among burns surgeons that: (1) the modified Parkland Herndon DN, ed., Total Burn Care. 3rd ed. Philadelphia, PA.
formula provides for a hypovolemic resuscitation; (2) patients with inha- Elsevier Saunders;2007;107-118.
lation injury will require more fluid than that prescribed by the Parkland
formula; and (3) overresuscitation leads to excessive burn edema,
abdominal compartment syndrome, need for fasciotomies on unburned REFERENCES
limbs, pulmonary edema, and prolongation of mechanical ventilation.
Type of monitoring to use during the early resuscitation period remains Complete references available online at www.mhprofessional.com/hall

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