Resuscitation targets in severe burns. ASMIC 2015 Dr Kamal Bashar Abu Bakar 14th August 2015
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1 Resuscitation targets in severe burns ASMIC 2015 Dr Kamal Bashar Abu Bakar 14th August 2015
2 Disclaimer
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5 Resuscitation targets in severe burns
6 Resuscitation Aim of resuscitation 1. Re-expanding the intra vascular volume 2. Limiting progression of burns 3. Restoration of cellular transmembrane potential 3. Correcting life threatening electrolytes disturbance 4. Correcting hypoprotenemia and increasing oncotic pressure 5. All the above without worsening burn odema
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11 Q: What is the consensus of resuscitation targets in severe burns?
12 Q: What is the consensus of resuscitation targets in severe burns? A: There is NO consensus!
13 Why is burns resuscitation so difficult? Burns : Hypovolemic shock Distributive shock Cardiogenic shock
14 Pathophysiology Severe Burns : TBSA > 15%-20% Trigger local and systemic inflammation Severity of inflammation proportionate to severity of burns 2 major pathway : i. Burns shock ii. Burns odema JK Chan, SJ Ghosh. Fluids resuscitation in burns: an update. Hong Kong Journal of Emergency Medicine. Vol 16(1) 2009
15 Patho-physiology NORMAL BLOOD CAPILLARY POSTBURN BLOOD CAPILLARY Water molecule Protein molecule Water is the smallest molecule that can pass through the capillary pores. Slides from Dr Harsh Amin. Permeability is increased, which allows large molecules such as proteins to pass through the capillary pores easily.
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17 Pathophysiology Leakage peaks at 8H and normalise after 24-48H CI, acidosis and lactate improves within 24-48H Additional fluids did NOT hasten recovery of CI Preload remains depressed despite improving CI
18 End points Physiological Biochemical Measure device
19 Physiological Urine output Skin turgor, Capillary refill MAP Pulse rate PP
20 Urine output UO 0.5mls/kg/h used by 95% respondent as end point of resuscitation * Most agree additional parameters required as end points Poor UO suggest renal hypoperfusion but good UO may NOT be an indicator of adequate perfusion * Glycosuria and use of hypertonic saline impairs usefulness Greenhalgh DG; Burns resuscitation: The result of the ABA/ISBI survey. Burns 2010, 36: Sanchez et a. A protocol for resuscitation of severe burn patients guided by transplumonary thermodilution and actate levels: a 3 year prospective cohort study. Critical Care 2013, 17: R176
21 Q1: Outcomes in burns : Alternative end points vs UO Alternative end points : ITBVI, SVV, PCWP,
22 Methodology
23 Mortality
24 Mortality
25 Renal failure
26 Others Fluids volumes: Conflicting results Odema related complication: nil Sepsis: no different Conclusion: Limited evidence of improvement in outcome using alternative burns resuscitation end points UO remains the most practical method Only healthy patients included? Role of alternative end points in cardiac/renal comorbidities
27 Biochemical Lactate ScvO2 Base Excess Renal function HCT
28 High lactate+ failure of lactate clearance associated with poor prognosis High lactate NOT an indicator of hypoperfusion Likely due to protective mechanism against metabolic stress?use of serial lactate for resuscitation Other causes of high lactate
29 Equipment Pressure : PA / CVP Volume PiCCO,Vigileo Imaging TEE / TOE 24-48H required in majority of subjects to achieve normal values None have shown to be superior than UO Czermak C et.al Fluids therapy and haemodynamic monitoring in burns schock. Chirug 75(6): , 2004 Aboelatta Y et. Al. Volume overload of fluids resuscitation in acutely burned patients using thermodilutions technique. J Burn Care Res 34(3): ,2013
30 Summary Burns resuscitation end points remains elusive Too little and too much fluids are equally bad Normalizations of physiological parameters will require 24-48H regardless of intensity of resuscitation UO remains the most practical and widely used end points despite its limitations UO on its own is not sufficient as the deciding factor especially in difficult cases Use of additional parameters may improve decision making in subgroup of patients
31 Today, more than three decades after Baxter and Shires, we still do not know the answer to the basic questions: what kind of fluids to give, when to give and how much? Holm C. Resuscitation in shock associated with burns. Tradition or evience based medicine? Resuscitation 2000, 44(3):
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