Clinical Challenges in Burn Surgery: Burn Resuscitation - Titrating and Troubleshooting - Part 2 of 2

Behind The Knife: The Surgery Podcast

Education, Science, Health & Fitness, Medicine

4.8 • 1.4K Ratings

🗓️ 9 September 2024

⏱️ 27 minutes

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Summary

A patient with a large TBSA burn injury is transferred to a regional burn center. You are faced with some difficult clinical decisions as the resuscitation proves to be challenging. Join Drs. Tam Pham, Rob Cartotto, Julie Rizzo, Alex Morzycki and Jamie Oh as they discuss the clinical challenges in titrating and troubleshooting during acute burn resuscitation.

Hosts:
· Dr. Tam Pham: UW Medicine Regional Burn Center
· Dr. Robert Cartotto: University of Toronto, Ross Tilley Burn Centre
· Dr. Julie Rizzo: Brooke Army Medical Center
· Dr. Alex Morzycki: UW Medicine Regional Burn Center
· Dr. Jamie Oh: UW Medicine Regional Burn Center

Learning Objectives:
· Understand the role of colloids as complement/rescue to standard crystalloid fluid titration.
· Identify the fluid threshold associated with development of abdominal compartment syndrome
· Understand the role of continuous renal replacement therapy for patients with acute kidney injury during the resuscitation phase.
· List specific patient populations who may experience a more difficult resuscitation.

References:

1. Ivy ME, Atweh NA, Palmer J, et al. Intra-abdominal hypertension and abdominal compartment syndrome in burn patients. J Trauma 2000
https://pubmed.ncbi.nlm.nih.gov/11003313/
2. Cartotto R, Johnson LS, Savetamal A, et al. American Burn Association Clinical Practice Guidelines on Burn Shock Resuscitation. J Burn Care Res 2023
https://pubmed.ncbi.nlm.nih.gov/38051821/
3. Greenhalgh DG, Cartotto R, Taylor SL, et al. Burn Resuscitation practices in North America: results of the Acute Burn ResUscitation Prospective Trial (ABRUPT). Ann Surg 2023
https://pubmed.ncbi.nlm.nih.gov/34417368/
4. Cartotto R, Callum J. A review of the use of human albumin in burn patients. J Burn Care Res 2012
https://pubmed.ncbi.nlm.nih.gov/23143614/
5. Cruz MV, Carney BC, Luker JN, et al. Plasma ameliorates endothelial dysfunction in burn injury. J Surg Res 2019
https://pubmed.ncbi.nlm.nih.gov/30502286/
6. Falhstrom K, Boyle C, Makic MBF. Implementation of a nurse-driven burn resuscitation protocol: a quality improvement project. Critical Care Nurses 2013
https://pubmed.ncbi.nlm.nih.gov/23377155/
7. Salinas J, Chung KK, Mann EA, et al. Computerized decision support system improves fluid resuscitation following severe burns: an original study. Crit Care Med 2011
https://pubmed.ncbi.nlm.nih.gov/21532472/
8. Kenney CL, Singh P, Rizzo J, et al. Impact of alcohol and methamphetamine use on burn resuscitation. J Burn Care Res 2023
https://pubmed.ncbi.nlm.nih.gov/37227949/

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Transcript

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0:00.0	Behind the surgery podcast relevant and engaging content designed to help you dominate the day. Welcome to another episode of the Behind the Knife Podcast, Clinical Challenges in Burn
0:27.1	Surgery. This is part two of the Burn Resuscitation series. To recap part one, we discuss management in the pre-hospital and
0:34.5	transfer phase covering initial food rates and the challenges that come from
0:37.8	the transfer process. Now we're going to discuss what to do when resuscitation appears to be failing and some of the tools that can help guide care.
0:46.2	We hinted at this with the mention of albumment.
0:49.2	In your institution, what are your practices in a patient who is not producing very much urine so let's say 10 to 15 c c c.
0:56.5	Despite increasing crystalloid administration so to clarify when is too much crystalloid, when do you start thinking about alternatives and
1:05.2	what are those alternatives?
1:07.6	You know at our institution, I mean we're heavy albian users.
1:11.7	In this scenario, if that urine output is dwindling we just start album and then
1:16.5	so our standard approach is that old University of Utah protocol where you
1:20.6	substitute your ringers infusion for a mixture about a 1 3rd 5% albumen and 2 3rds
1:27.0	ringers. So whatever rate you were at, you now divvy it up a 1 3rd album and 2 3rds
1:31.4	crystalloid.
1:32.7	And that would be our standard go-to thing
1:34.7	for the patient who's not doing well.
1:37.2	The marker I always look out for
1:39.2	is that total cumulative fluid in mills per kilo. and when I see that number starting to approach 200
1:46.1	225-250 in the first 24 hours that's a really worrisome sign and that's that old IV index from a paper many years ago that spurred Dr.
1:55.4	Pruitt to write the whole editorial on Fluid Creep at 250 mils per kilo in the first
2:00.7	24 hours basically kind of predicted abdominal
2:03.2	compartment syndrome.
	...

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