Burn Injury : resuscitation

and prevention of
complication including IAH
& ACS

Lisa Hasibuan
Divisi Bedah Plastik Dept. Bedah
RS Hasan Sadikin/FK UnPad
BANDUNG
Disampaikan pada Workshop on Trauma Up Date, 14 Mei 2014, Bandung
Fluid resuscitation in burn injury
Acute fluid resuscitation is
fundamental to modern burn
care
importan
t shift

numerous
frequently provides
edema-
substantial volumes related
of fluid complicatio
ns
Estim ation of fl u id needs :
Parkl and For m ul a
Adults : 3-4 ml crystalloids x kg BW x % burn
M onitoring adequacy of fl u id
resuscitation : U rine O utput
Adults : 0,5 ml/kg/hr = 30 50 ml/hour
Extra fl
uid resuscitation
Children
Inhalation injury
Electrical injury
Delayed resuscitation
Dehydration firefighter, intoxicated
patients
Infants, elderly and those with cardiac
disease should be monitored closely as
overload may be precipitated
 The consequences of this increased fluid
administration :
airway swelling requiring prophylactic
intubation,
secondary ACS,
soft tissue edema in the extremities
necessitating more frequent
escharotomies and even fasciotomies,
elevated intraocular pressures, and
an overall increased risk of death
 Fluid
Creep
Fluid Resuscitation
Abdominal Compartmen
Syndrom
Edema Larynx
How much is enough? (not too big or little)
ARDS
Which formula?
Anasarca
Orbital
What kindCompartment
of fluid?
When do Syndrome
we give?
Extremity Compartmen
How doSyndrome
we monitor ?
Do we have the equipment for accurate
resuscitation?
If > 237 ml/kg during acute
phase

Atiyeh BS, Dibo SA. Acute Burn Resuscitation and Fluid Creep: it is time for Colloid Rehabilitation.
Annuals of Burns and Fire Disaster. Vol XXV (2). June 2012
Fluid Creep
.Current research in fluid resuscitation
now concentrates on approaches to
minimize fluid creep, including tighter
control of fluid infusion rates, earlier
and more liberal use of colloids, and
the use of hypertonic saline (HTS).

RE-EVALUATION OF
EXISTING
RESUSCITATION
 Fig. 1. An elderly patient recently treated demonstrating fluid creep. The
patient had a 25% TBSA full-thickness burn but no smoke inhalation 16
hours previously. The patient had been managed without endotracheal
intubation initially. At 15 hours postburn he had received 7901 mL of
cumulative fluid, which was 62% greater than what the Parkland formula
would have predicted to this time point, despite UO averaging only 48 mL/h
(0.7 mL/kg/h) over this time period. He began to develop early signs of
edema-related upper airway obstruction and required prophylactic
Intra Abdom inalH ypertension

IAH merupakan kelainan patologik dengan

tekanan intra abdominal >12 mmHg
Klasifikasi:
- Tekanan
- Jenis
- Onset
______________________________________
Sugrue. Abdominal compartment syndrome. Curr Opin Crit Care.
2005; 11 ; 333-338
P red isp osin g C on d ition s for In tra- A b d om in al
H yp erten sion (IA H )

Hypothermia
Massive transfusions
Sepsis
Mechanical ventilation
Pneumonia
Acidosis
Excessive fluid resuscitation
Abdom inalCom partm ent Syndrom e

ACS is defined as a peak IAP value of > 20

mmHg recorded during a minimum of 2
standardized measurements that are
performed 1-6 hours apart with associated
single or multiple organ system failure
which was not previously present
(The International ACS Consensus Definitions Conference
(2006)

Tidak ada sistem 'grading' (klasifikasi)

P rim ary A C S

Injury or disease in the abdomen or pelvis

-Non-operative management solid organ
injury
-Develops after abdominal surgery
damage control
pelvic fractures
liver transplant
S econ d ary A C S

Non-abdominal conditions
-Major burns
-Sepsis
-Conditions requiring massive
fluid resuscitation

Tertiary ACS
Also known as recurrent ACS
after definitive abdominal wall closure
C ard iovascu lar Ef f
e cts of A C S

Intra-thoracic pressure transmitted

through diaphragm
Compression IVC
CVP
Preload
Afterload with PVR
P u lm on ary Ef f
e cts of A C S
Peak airway pressure
Poor compliance
End-inspiratory pressure
Mechanical impairment of diaphragm
Decreased pulmonary blood flow
V/Q mismatch
All lead to...
Decreased PaO2
Intractable hypercarbia
RenalEff
ects of ACS
Renal vein compression
Renal parenchymal compression
Shunting blood away from cortex and
functioning glomeruli
Anti-Diuretic Hormone release
Oliguria/Anuria
 IAH dan ACS
Grading of IAP as determined by intravesical pressure, & summary of clinical effects
_____________________________________________________________________________________________________________________________
Grade IAP (mmHg/ cmH20) Clinical
_____________________________________________________________________________________________________________________________

I 7.3 - 11.0 (10-15)None

IIa 11.7 - 18.3 (16-25) Oliguria, splanchnic hypoperfusion

IIIb 19.1 -25.7 (26-35) Anuria, ventilation pressure

Ivb >25.7 (>35) As above & p02

_______________________________________________________________________________
a = initial therapy aims to restore splanchnic & renal hypoperfusion by volume replacement
b = these pts will probably require urgent abdominal decompression

_____________________________________________________
Meldrum DR, Moore FA, Moore FE, et al. Am J Surg174:667; 1997
D iagnosis
Insiden 5%-15% pada critically iII patients
Mortality rate 63% - 72%.
____________________________________
IAP Normal (Sanchez NC dkk, 2001) : 0-5 mmHg
Obesitas dan hamil (IAP kronik) : 10-15 mmHg
Critically III (Malbrain ML dkk, 2006) : 5-7 mmHg
_________________________________________________________________

Insiden pada Luka bakar 2 7%

Mortality rate pada burn > 80%
 D iagnosis

IAH
Distensi abdomen
Compliance paru (PIP)
Oliguria
Hipotensi dan cardiac output

Tek vena sentral (CVP)
 Treatm ent of ACS*
Bladder Pressure Treatment
10-15 mmHg Monitor
16-25 mmHg Monitor
26-35 mmHg Decompression
> 35 mmHg Decompression & re-
exploration
* Meldrum et al, Am J Surg 1997
 The Problem s
Additional morbidity of
The
"Standard
of Care"
for ACS
is

decompres
sive
laparotom
y
Tem p orary C losu re G oals

Expeditious closure
Minimize heat and fluid loss
Minimize loss of abdominal domain
B og ota B ag
+ inexpensive
+ Readily available
+ Minimize fluid losses

- Loss of abdominal domain

- Ease of tearing
- Subsequent procedure mandatory
V acu u m -A ssisted C losu re

Decreased incidence ACS

Prevent loss abdominal domain
Need for peritoneal dialysis
Escharotom y and Paracentesis in burn
w ith IAH

If they have torso burns, the initial

treatment for rising IAP may be
escharotomy, allowing the abdominal
cavity to expand and reducing the
abdominal pressure.

Percutaneous drainage/paracentesis : to
remove the capillary leak fluid and pro
inflammatory cytokines in the abdominal
cavity reduction of intra-abdominal
pressure
W H EN CO LLO ID S?
Parkland formula : 0.3 to 0.5 mL/kg/%TBSA of 5%
albumin during the second 24 hours of
resuscitation.
Recent approach is to administer colloids as a
rescue technique when crystalloid
requirements become excessive.
start albumin at 12 hours postburn if fluid needs
are greater than 120% predicted (Yowler and
Fratienne)
albumin for persisting oliguria or infusion rates
more than twice the calculated rate for greater
than 2 hours (Saffle)
conclusions
The Parkland formula can be used as a guideline
to determine an initial rate of fluid infusion in
burn resuscitation .
The resuscitation rate and volume must be
continually adjusted based on the response of
the patient .
resuscitation should use the least amount of
fluid (ie, somewhere between 2 and 4 mL/kg/%
TBSA) necessary to achieve adequate UO and
prevent early organ failure and avoid later
complications
C on clu sion s
High risk patients should be monitored for
abdominal hypertension
Repeated measurement of IAP is mandatory
in high risk patient
Percutaneous decompression is an option to
prevent progression to decompressive
laparotomy in cases with abdomnal/torso
burn, followed by peritoneal dialysis
Definitive treatment for ACS is
decompressive laparotomy
THANK YOU
Hatur nuhun