Burns injury - PACT - ESICM

Q. If bleeding continues despite an absence of a surgical bleeding site, what is the
approach?
A. Check platelet and coagulation indices (in the aftermath of a substantial fluid/blood
transfusion) and prescribe therapy (usually fresh frozen plasma and platelets) as indicated.
Old hydroxyethyl starch HES solutions are associated with long lasting
pruritus.
After surgery she is hypothermic and hypotensive, but after some hours of fluid
management she stabilises. On day four, temperature approaches 40 C, CRP is 300 mg/L
and PCT is 10 µg/L. Blood pressure is normal. PaO 2 /FiO 2 ratio is declining (20 kPa).
Q. Sepsis is the apparent cause of this deterioration. What is the likely aetiology?
A. In view of her deteriorating respiratory state, a pulmonary source is likely but, in
patients with thermal injuries, a wound infection is always a possibility. Differentiation
will require clinical evaluation.
Sepsis
Burn wound infection
Respiratory infection
Q. In your search for the source of infection, what will be the target(s) of your clinical
evaluation?
A. The search for a source of sepsis will include: respiratory and urinary systems; operative
site, (in this case extensive burn wounds); indwelling catheters including CVC access and
arterial access and other bloodstream infections (including cardiac valves). Other
possibilities are acalculous cholecystitis, Clostridium difficile infection (particularly if the
patient has been on antibiotics and/or has diarrhoea), sinusitis, otitis media, and decubitus
ulcers.
If, on clinical examination there is no other evident source for the sepsis, and
CRI (catheter-related infection) is suspected, the CVC, arterial catheter or other
intravascular device is removed or changed (and catheter tip and blood cultured).
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