Burns injury - PACT - ESICM

ut this risk increases over time. Also, the patients may have ongoing septic
problems, where the treatment is surgery and wound revision.
Added to these points are other specific needs of these patients.
Difficulties in maintaining body temperature.
Specific needs for ventilator support as, in the larger injuries, there is a risk
for early ARDS and the possible effects of inhalation injuries.
With these listed problems, good outcome crucially depends on good patient
monitoring. Therefore most units use:
Pulse oximetry/capnography; invasive blood pressure measurements, central venous
pressure monitoring, and cardiac output/systemic vascular resistance assessment.
Repeated measurements of haemoglobin, (or haematocrit) and blood gas assessment
including Na/K and glucose are common during surgery in the most severely injured
patients.
In cases with concomitant respiratory compromise, conventional lung mechanics
parameters (airway pressures; dynamic and static compliance) provided by the
ventilator are also used for surveying the status of the patient.
Perioperative considerations
Early fluid treatment during surgery
In cases where surgery is performed within 24 hrs post burn, the regular strategy for
fluid treatment is followed (Parkland formulae). This strategy is not altered as
surgery is performed. Many units provide blood transfusion according to losses and
with no further addition. At times evaporative losses may be larger and these should
then be included also in the calculation of fluid losses. It is important to note that
after the start of surgery, the diuresis often decreases due to the added stress
response of surgery and attention should be directed to the fluid balance. When the
necrotic skin is removed, diuresis may increase.
Significant intraoperative fluid loss is common in this group of patients.
Haemorrhage may be complicated by coagulopathy, requiring transfusion of blood
and blood products. Care is taken to limit the potential for hypothermia.
Perioperative blood loss and severe sepsis
The dominant risk and difficulty with burn surgery has been the blood loss
encountered in these events, when at the same time it is difficult to assess
quantitatively how large this loss is. Furthermore intraoperative bacteraemia and
sepsis may contribute to the hypotension.
A common rule is to pay extra attention to the blood pressure recordings in addition
to the assessment of the wounds. Decreasing blood pressure is a sign of a negative
transfusion balance. Other measures that can help in this assessment are pulse
pressure variations (with respiration) and effects on the plethysmographic part of the
oximetry signal. Blood loss may vary substantially between patients and burn excision
in the face, neck, torso and hands constitutes the major problem. It underlines the
need to follow the circulatory surveillance parameters.
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