1.dr.Lisa Hasibuan-PPT whats new inBurn Injury 28 Jan dr lsa

Report
Burn Injury : WHATS NEW IN
BURN RESUSCITATION
Lisa Hasibuan
Divisi Bedah Plastik Dept. Bedah
RS Hasan Sadikin/FK UnPad
BANDUNG
Disampaikan pada Acute Care Surgery- Februari 2015- Bandung
WHATS NEW IN BURN RESUSCITATION
• GAMBARAN SAAT INI
▫ MASALAH YANG TIMBUL
▫ KEMAJUAN YANG SUDAH DITEMUKAN UNTUK
MENGATASI MASALAH-MASALAH TERSEBUT
GAMBARAN RESUSITASI SAAT INI
• AIRWAY
▫ INTUBASI DINI UNTUK PASIEN DENGAN
KECURIGAAN TRAUMA INHALASI
• BREATHING
▫ PEMBERIAN OKSIGEN 100% VIA NRM
• CIRCULATION
▫ RESUSITASI CAIRAN
AIRWAY DAN BREATHING
• MASALAH YANG TIMBUL SAAT INI
▫ INTUBASI DINI PADA PASIEN DENGAN
KECURIGAAN TRAUMA INHALASI
 Ching J, et al (2014) meneliti 47 pasien dengan temuan
singed nasal hair, carbonaceous sputum, facial burns
yang diintubasi dengan bronkoskopi. Hasil bronkoskopi
normal ditemukan pada 66% (31 pasien), sehingga
ketiga temuan tersebut bukanlah indikasi kuat untuk
dilakukan intubasi.
 Cancio LC (2009) merekomendasikan fiberoptic/direct
laryngoscope untuk visualisasi dini sebelum dilakukan
intubasi
 Mackie DP (2013) penggunaan ventilator meningkatkan
resiko terjadinya ARDS dan ventilator-associated pneumonia
 Eastman AL (2010) meneliti dalam jangka waktu 23 tahun,
dari 1.272 pasien yang datang sudah terintubasi, 26,3%
diintubasi karena kecurigaan trauma inhalasi dan terbukti
dengan bronkoskopi pada 88,6% pasien tersebut.
Dari 879 pasien luka bakar (survivors) yang diintubasi, 28%
pasien diintubasi sebagai profilaksis, 34,1 % diintubasi karena
pembengkakan jalan nafas, 13,2 % diintubasi untuk keperluan
ventilasi dan oksigenasi.
• Apabila jelas kecurigaan trauma inhalasi dari
anamnesis, pemeriksaan fisik, bila mungkin
bronkoskopi/direct laryngoscope maka harus
dilakukan intubasi, walaupun belum ada tanda
respiratory distress
AIRWAY DAN BREATHING
▫ PEMBERIAN 100% O2 VIA NON-REBREATHING
MASK / ETT
 TARGET : SpO2 >92%
 COHb <5%
CIRCULATION
• RESUSITASI CAIRAN
RESUSITASI CAIRAN PADA LUKA BAKAR
Resusitasi cairan akut merupakan
aspek mendasar pada perawatan
luka bakar modern
important
shift
Seringkali sudah dapat
memenuhi kebutuhan
cairan
BERLEBIHAN
PERKIRAAN KEBUTUHAN CAIRAN:
Parkland Formula
Dewasa : 3-4 cc kristaloid x kg BB x % luka bakar untuk 24 jam
Anak : 3-4 cc kristaloid x kg BB x % luka bakar
ditambah maintenance : 5% Glucose in 0,45%(½ normal) saline
(D5½NS)
• 100 ml/kg untuk 10 kg pertama
• 50 ml/kg untuk 10 kg kedua
• 20 ml/kg selebihnya
Cairan maintenance untuk anak diberikan dalam kecepatan tetap
selama 24 jam
PENILAIAN KECUKUPAN RESUSITASI
CAIRAN  Urine Output
Dewasa : 0,5 ml/kg/jam = 30 – 50 ml/jam
Anak (< 30 kg) : 1,0 ml/kg/jam (range 0,5-2 ml/kg/jam)
Guidelines of the American Burn Association :
0.5 - 1 mL/kg/jam (dewasa) dan 1 - 1.5 mL/kg/jam (anak)
24 jam kedua = koloid
• 0,5 ml albumin 5% x kg BB x % luka bakar
RESUSITASI CAIRAN TAMBAHAN
PADA KASUS:
• Anak
• Trauma inhalasi
• Trauma listrik
• Resusitasi terlambat/ tertunda
• Dehidrasi : pemadam kebakaran, pasien keracunan
Bayi, usia lanjut, dan pasien dengan penyakit
jantung harus dimonitor ketat karena resusitasi
cairan dapat memperberat overload
MASALAH YANG TIMBUL
Abdominal Compartment Syndrom
Edema Larynx
ARDS
Fluid
Anasarca
Creep
Orbital Compartment Syndrome
Extremity Compartment Syndrome
Bila > 237 ml/kg sepanjang fase akut
Fluid Creep
Gambar 1. pasien usia lanjut dengan “fluid creep”.
▫ 25% TBSA luka bakar full-thickness tanpa inhalasi asap 16 jam
sebelumnya
▫ 15 jam setelah terjadi luka bakar pasien menerima total cairan 7901 cc
(62% lebih besar dari perhitungan Parkland)
▫ Namun urine output hanya rata-rata 48 cc/jam (0,7 cc/kg/jam)
▫ Pasien mulai menunjukkan tanda awal obstruksi jalan nafas atas karena
edema dan membutuhkan intubasi profilaksis
JADI PADA RESUSITASI CAIRAN
• Seberapa banyak “cukup” (tidak lebih tidak
kurang)?
• Menggunakan perhitungan yang mana?
• Jenis cairan apa?
• Kapan memberikannya?
• Bagaimana cara memonitor?
• Adakah peralatan memadai untuk resusitasi akurat?
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
Penelitian terkini mengenai resusitasi cairan
difokuskan pada pendekatan untuk mencegah
fluid creep, termasuk di dalamnya:
Kontrol ketat kecepatan infus cairan,
penggunaan koloid awal dan secara liberal, dan
penggunaan hypertonic saline (HTS)
RE-EVALUASI
RESUSITASI YANG SUDAH
ADA
Protokol Monitoring Pasien Luka Bakar
Tanggal……………………..
Nama Pasien
:…………………………
Berat badan waktu masuk:………………………
Usia
:…………………………
Penyebab dan luas luka bakar:…….… /..………………
No Medrec
:…………………………
Cairan inisiasi/urine inisiasi (cc)
:…..……/..………………
Balans cairan:(Cairan masuk per oral (cc) + cairan masuk per infus) – ( urine (cc) + IWL(insensible water loss cc))
IWL (cc/jam) = (25+%luka bakar) x TBSA , sebelum luka ditutup dengan occlusive dressing
IWL (cc/jam) = (25+%luka bakar)x TBSA/2, setelah luka ditutup dengan occlusive dressing
Cairan masuk (jumlah cairan masuk dalam cc / jam)
Jumlah cairan
(cc)/jam
0
1
2
3
4
5
6
7
8
9
10 11
12 13
14
15 16 17 18
19
20
21 22 23 24
Cairan keluar (jumlah urine output dalam cc / kg BB/ jam)
Jumlah cairan
(cc)/kgBB/jam
Pkl……………………………………………………………………………………………………………………………………………………………
0
jam
IWL
Tensi(mm/hg)
Nafas
Nadi
Suhu (0C)
CVP(CmH20)
Nyeri (VAS)
……………..
1
2
3
4
5
6
7
8
9
10 11
12 13
14
15 16 17 18
19
20
Waktu
21 22 23 24
Intra Abdominal Hypertension
• 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
Faktor predisposisi
Intra- Abdominal Hypertension
(IAH)
•
•
•
•
•
•
•
Hipotermia
Transfusi Masif
Sepsis
Ventilasi mekanik
Pneumonia
Acidosis
Resusitasi cairan berlebihan
Abdominal Compartment Syndrome
• Definisi ACS = nilai puncak tekanan intraabdomen
>20 mmHg yang tercatat minimal dua kali
menggunakan pengukuran terstandar dengan
interval 1-6 jam
▫ Disertai dengan kegagalan organ multipel yang
sebelumnya belum ada
(The International ACS Consensus Definitions Conference (2006)
• Tidak ada sistem 'grading' (klasifikasi)
ACS Primer
• Cedera atau penyakit di abdomen atau pelvis
• Penanganan non-operatif pada cedera organ padat
• Muncul setelah operasi abdomen
▫ Damage control
▫ Fraktur pelvis
▫ Transplantasi hepar
ACS Sekunder
Dari luar abdomen
• Luka bakar luas
• Sepsis
• Kondisi yang
membutuhkan
resusitasi cairan masif
Efek Kardiovaskuler dari ACS
• ↑ tekanan intra toraks ditransmisikan melalui
diafragma
• Penekanan Vena Cava Inferior
• ↑ CVP
• ↓ Preload
• ↑ Afterload dengan ↑ PVR
Efek Pulmonal dari ACS
•
•
•
•
•
•
↑ Peak airway pressure
Poor compliance
↑ End-inspiratory pressure
Gangguan mekanis diafragma
Penurunan aliran darah pulmonalflow
V/Q mismatch
▫  PaO2
▫ Intractable hypercarbia
Efek Renal dari ACS
• Kompresi vena renalis
• Kompresi parenkim ginjal
• Mengalihkan aliran dari korteks dan glomeruli yang
berfungsi
• ↑ produksi Anti-Diuretic Hormone
• 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
Diagnosis
• Insiden 5%-15% pada pasien kritis
• Angka mortalitas 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%
• Angka mortalitas pada luka bakar > 80%
Diagnosis

IAH
Distensi abdomen
Compliance paru ↓ (PIP↑)
Oliguria
Hipotensi dan cardiac output ↓
Tek vena sentral (CVP) ↑
Penatalaksanaan ACS*
Bladder Pressure Treatment
• 10-15 mmHg
Monitor
• 16-25 mmHg
Monitor
• 26-35 mmHg
Dekompresi
• > 35 mmHg
Dekompresi dan reeksplorasi
• * Meldrum et al, Am J Surg 1997
The Problems
The "Standard
of Care”
untuk ACS
adalah
LAPAROTOMI
DEKOMPRESI
Sasaran Penutupan Sementara
(Temporary Closure)
• Waktu yang dibutuhkan singkat
• Minimalisasi kehilangan panas dan cairan
• Minimalisasi kehilangan abdominal domain
Bogota Bag
• + lebih murah
• + lebih mudah tersedia
• + mengurangi kehilangan
cairan
• - kehilangan abdominal
domain
• - mudah robek
• - wajib dilakukan tindakan
selanjutnya (definitif)
Penutupan Vacuum-Assisted
• Mengurangi insidensi ACS
• Mencegah kehilangan abdominal domain
• ↓ kebutuhan untuk dialisis peritoneal
Eskarotomi dan Paracentesis pada
pasien luka bakar dengan IAH
• Jika pada pasien terdapat luka bakar di batang
tubuh (torso), tatalaksana pertama untuk
peningkatan tekanan intraabdomen mungkin
eskarotomi, supaya rongga abdomen dapat
meregang dan mengurangi tekanan intraabdomen
• Paracentesis/ drainase perkutaneus : untuk
mengeluarkan kebocoran cairan dari kapiler dan
sitokin proinflamasi dari rongga abdomen 
mengurangi tekanan intraabdomen
Protokol Resusistasi Cairan Luka Bakar Pasien Dewasa
Resusistasi cairan dewasaR
Berat badan awal…..kg
Mulai Resusistasi cairan…….cc Ringer Lactat
Ukur urine output tiap jam
Tanda vital tidak stabil: Nadi >140, MAP<60
Tanda vital stabil: Nadi <140, MAP>60
Urine output <15cc
(jika <15cc selama 2
Urine output
15-29 cc
Urine output
30-50 cc
Urine output
>50 cc
Urine output
>200 cc
Konsultasi ahli
jam, lihat kotak 3
Tingkatkan cairan
infus 20% atau 200
cc/jam
Tingkatkan cairan
infus 10% atau 100
cc/jam
Pertahankan
tetesan
cairan
Turunkan cairan
infus 10% atau 100
cc/jam
Pertimbangkan untuk menurunkan
cairan infus tiap 30 menit sebanyak 10
%; cek GDS, tekanan darah, nadi, asam
lactat, Hb sebelum turunkan jumlah
cairan infus.
Ulangi langkah pertama setiap jam sampai:
Urine output <15cc
(selama 2 jam meskipun
sudah meningkatkan
cairan infus
Ukur cairan maintenance, bila kadar
sudah tercapai dan dipertahankan
selama 2 jam dan pasien sudah dirawat
setidaknya 24 jam pasca trauma
Protokol Albumin
Jika pasien memerlukan > jumlah
maintenance cairan atau memiliki
komplikasi edema
Konsultasi ahli untuk
memulai protocol
albumin
Resusistasi cairan komplit
Ganti cairan dengan D5 0,45
NS + KCL 20 mEq/l dengan
mempertahankan sesuai
jumlah maintenance.
Jika pasien menjadi oliguria atua hemodinamik
tidak stabil, konsultasi doktrer ahli atau ulangi
kembali pemberian RL dengan jumlah cairan
dinaikan 10 % atau 100 cc/jam
Jika pasien membutuhkan resusistasi
koloid, konsultasikan untuk pemberian
5 % albumin pada 1/3 jam pertama,
dilanjutkan RL 2/3 jam berikutnya.
Ulangi langkah 1 sampai urine output
> 30 cc/jam
Setelah mencapai target, ganti dengan
RL selama 2 jam
Jika pasien sudah mencapai urine out
adekuat selama 2 jam dan sudah 24
jam pasca trauma, resusitasi cairan
telah selesai, ganti dengan D5 0,45 NS
+ KCL 20 mEq/L pada kadar
maintenance
Kapan KOLOID digunakan?
• Parkland formula : 0.3 to 0.5 mL/kg/%TBSA 5% albumin
selama 24 jam kedua dalam resusitasi
• Pendekatan terkini adalah pemberian koloid sebagai teknik
“rescue” ketika kebutuhan kristaloid menjadi berlebihan.
• start albumin pada 12 jam pertama postburn jika kebutuhan
cairan lebih dari 120% dari prediksi.(Yowler and Fratienne)
• albumin untuk oliguria atau kecepatan infus lebih dari dua
kali dari perhitungan selama lebih dari 2 jam.(Saffle)
• 5% albumin pada 12-18 jam pertama, jika perkiraan
kebutuhan 24 jam melebihi 6 mL/kg/%TBSA (Chung et al).
Algoritma Survey Primer pada Pasien Luka Bakar
Airway (jalan nafas)
Terganggu atau ada risiko
akan terganggu?
Breathing (bernafas)
Terganggu?
Circulation (sirkulasi)
Gangguan perfusi –eschar
melingkar
ntubasi
Penyebab
Eschar melingkar di dada
escharotomy
Carboxyhemoglobin
Intubasi dan ventilasi O2 100%
(evaluasi kembali)
Inhalasi asap
Nebuliser
(jelaga jalan nafas,
Ventilasi non invasive (CPAP)
edema laring, stridor
Ventilasi invasiv
Blast injury
Ventilasi invasiv
Chest drains
escharotomy
Disabilitas Nerurologi
GCS <15
Penilaian terhadap dalam dan luas luka bakar
Penilaian lengkap terhadap trauma lain
(pasien tetap dihangatkan)
Fluids (cairan-atasi syok)
Hitung jumlah resustitasi cairan berdasarkan
luas luka dan waktu sejak kejadian luka bakar
Pertimbangkan
y ia le el
b
y
lemia
aluasi kembali
Hettiaratchy S.Initial Management of Majir Burns:I-Overview.In ABC of Burns.
BMJ.Vol 328; 2004
KESIMPULAN
• Perhitungan menggunakan formula Parkland dapat
digunakan sebagai acuan untuk menentukan kecepatan
awal infus cairan pada resusitasi luka bakar
• Kecepatan dan jumlah cairan harus terus disesuaikan
dengan respon pasien.
• Resusitasi cairan harus menggunakan jumlah cairan
yang paling sedikit (antara 2-4cc/kgBB/%TBSA) yang
dibutuhkan untuk mencapai urine output yang cukup
dan mencegah kegagalan organ dan mencegah
komplikasi.
KESIMPULAN
• Pasien dengan resiko tinggi harus selalu dimonitor untuk
hipertensi abdomen
• Pengukuran berulang IAP (Intra Abdominal Pressure)
harus dilakukan pada pasien resiko tinggi
• Dekompresi perkutaneus adalah salah satu pilihan untuk
mencegah progresi ke laparotomi dekompresi pada
kasus luka bakar abdominal/batang tubuh, diikuti
dengan dialisis peritoneal
• Tatalaksana definitif untuk ACS adalah laparotomi
dekompresi
• ACS as an intra-abdominal pressure greater than 20 mm
Hg with evidence of new organ dysfunction (typically
manifested as oliguria, impaired mechanical ventilation
with high peak airway pressures, worsening metabolic
acidemia, and hemodynamic instability).
• When cumulative volumes reach 250 mL/kg or more
intra-abdominal pressure measurements (by bladder
pressure transduction) should be performed every 2
jams and conservative measures to reduce intraabdominal pressure should be considered
penting
• IAH and possibly early ACS may be reversed by the
insertion of peritoneal dialysis catheters to remove
peritoneal fluid, but this does not treat the edema of
the intra-abdominal tissues and organs, and with
more severe ACS, particularly with massive burn
injury, definitive treatment by decompressive
laparotomy may be required.
• Mortality following surgical decompression for ACS
is reported to be between 50% and100%.
• ACS is defined as a peak IAP value of ≥ 20 mACS is
defined as a peak IAP value of ≥ 20 mmHg recorded
during a minimum of 2 standardized measurements
that are performed 1-6 jams apart with associated
single or multiple organ system failure which was
not previously present
• Bladder pressure is not routinely measured by 22
(69%) burn physicians, and staff at 17 centers (53%)
wait until the abdomen is tense to measure
abdominal pressure. Tense abdomen, along with
elevated peak inspiratory pressures (PIP), is used in
most centers (94%) to determine IAH/ACS, followed
by oliguria (88%), and difficulty ventilating (78%).
Resuscitation formulae used are primarily the
Parkland/modified Parkland in 24 (75%) burn centers
Other Techniques for Temporary
Closure
•
•
•
•
Running nylon and/or towel clips
Absorbable (Dexon/Vicryl) mesh
Plastic sheet (loban)
Wound VAC
Excessive Fluid Resuscitation
•
•
•
•
Post-resuscitation pulmonary edema
Conversion of superficial -> deep burn
Need for unburned limb fasciotomies
Abdominal compartment syndrome
• After more than four decades of acceptance of the
Parkland formula as a cornerstone of burn
care, and despite the fact that this approach has
provided effective resuscitation that has markedly
reduced the incidence of burn shock-induced acute
renal failure, several reports have recently surfaced
that show that modern burn
• Currently, some experts recommend maintenance
of UO of 30 to 50 mL/h in adults and 1 to 2 mL/kg/h
in children weighing less than 30 kg,49whereas
current Practice Guidelines of the American Burn
Association advise maintenance of UO at
approximately 0.5 to 1 mL/kg/h in adults and 1 to 1.5
mL/kg/h in children.50
• This increase in capillary permeability is most profound
acutely and may remain elevated for several days
postburn. The severity and duration of the leak is
directly proportional to the extent of the burn.
• When the burn size approaches 25% to 30% TBSA or
larger, edema in the unburned skin and soft tissues
develops.24 Acutely, within the first few jams postburn,
there is an increase in capillary permeability (s), which
may be caused by the systemic dissemination of
inflammatory mediators.
• The more pressing problem for the modern burn clinician is fluid creep,
which is the unpredictable trend toward provision of larger and larger
resuscitation fluid volumes to burn patients who do not fit into the welldefined subgroups identified previously.
• A number of recent studies have found that crystalloid fluid resuscitation
volumes for the initial 24 jams postburn among burn patients have
ranged between 4.8 and 6.7 mL/kg/ %TBSA,13–18 in many instances
independent of the presence of a documented inhalation injury.
• The consequences of this increased fluid administration are similarly well
characterized, and include airway swelling requiring prophylactic
intubation58 (see Fig. 1), secondary ACS,59 soft tissue edema in the
extremities necessitating more frequent escharotomies and even
fasciotomies,58 elevated intraocular pressures,60 and an overall
increased risk of death.18 The development
• Rigid adherence to a fluid infusion rate prescribed by a formula is
potentially harmful. Rather, the clinician should continually adjust
the infusion rate based on the patient’s response. Practically, this is
based on evaluation of the UO at 1- to 2- jam intervals. A protocol,
such as that describedby Saffle,69 is one of several ways to achieve
this goal. In this strategy, an jam of UO less than 15 mL calls for an
increase in the infusion rate by 20% or 200 mL/h, whichever is
greater; an jam with UO 15 to 30 mL gets an increase of 10% or 100
mL/h, whichever is greater; and jam with UO 30 to 50 mL prompts
no change in the infusion rate. Conversely, for UO greater than 50
mL/h the infusion rate for the next jam is decreased by 10% or 100
mL/h, whichever is greater. Within this particular protocol,
persistent oliguria or escalating fluid infusion rates are managed
by institution of albumin, described next.
• Not surprisingly, as a consequence of these large
resuscitation volumes, complications related to
edema formation led chiefly by secondary
abdominal compartment syndrome (ACS), have also
appeared. 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).
Systemic Changes
• Correction of the hypoproteinemic state with infusions of albumin
or plasma hinders the development of nonburn soft tissue
edema.25,38
• The most important consequence of the aforementioned fluid
shifts is a reduction in circulating plasma volume. Cardiac output
(CO) falls, largely because of hypovolemia and reduced preload,but
interestingly in larger burns (R40% TBSA), an immediate fall in CO
has been repeatedly observed before any measurable decrease in
the plasma volume, suggesting that depressed myocardial
contractility plays a role. Earlier literature suggested that an
uncharacterized ‘‘myocardial depressant factor’’ was
responsible,39–42 and it is now thought that inflammatory
mediators from the burn wound, distributed systemically, are
responsible
• Simultaneous with the acute reductions in plasma volume and CO, systemic
vascular resistance increases because of sympathetic-mediated peripheral
vasoconstriction and the effects of increased viscosity of the blood because of
hemoconcentration. The elevation in systemic vascular resistance is an additional
factor that contributes to the acute depression of CO.45 Organ perfusion,
particularly renal blood flow, is compromised as a result of the hypovolemic state,
depressed CO, and peripheral vasoconstriction, especially if fluid resuscitation is
delayed. As resuscitation proceeds, CO slowly climbs back to normal and in
patients with major burn injuries, a hyperdynamic picture with supranormal CO
develops by 36 to 72 jams postburn as part of the hypermetabolic response. The
intended goal of fluid resuscitation is to re-expand the plasma volume, restore
CO, and improve organ and tissue perfusion. It should be evident from the
foregoing discussion that crystalloid resuscitation fluids, although necessary to
achieve the goal of restoring tissue perfusion, are also subject to the altered
Starling forces and as such, large amounts of the resuscitation fluid necessarily
end up as interstitial and cellular edema fluid.
• The development of intra-abdominal hypertension
(IAH) and the ACS deserve special mention because
these are perhaps the most dangerousand
frequently reported consequences of fluid creep in
association with massive burn resuscitation (Fig.
4).59,61–64 The most recent Consensus Guidelines
define IAH as an intra-abdominal pressure (obtained
by transduction of bladder pressure) greater than or
equal to 12 mm Hg and
• ACS as an intra-abdominal pressure greater than 20 mm
Hg with evidence of new organ dysfunction (typically
manifested as oliguria, impaired mechanical ventilation
with high peak airway pressures, worsening metabolic
acidemia, and hemodynamic instability).65 ACS is
considered secondary when there is no demonstrable
intraabdominal pathology,65 as in the case of a burn
where bowel and mesenteric edema and increased
peritoneal fluid are the cause of the raised intraabdominal pressures. Left untreated, ACS is invariably
fatal, and probably was the cause of early ‘‘death due
resuscitation failure’’
• When cumulative volumes reach 250 mL/kg or more
intra-abdominal pressure measurements (by bladder
pressure transduction) should be performed every 2
jams and conservative measures to reduce intraabdominal pressure should be considered.62,66 These
include use of neuromuscular relaxants and increased
sedation in mechanically ventilated patients; extension
of escharotomies on any anterior trunk burns (Fig. 5);
and possible judicious use of diuretics if adequate
intravascular volume can be confirmed by placement of
a pulmonary artery catheter, which demonstrates
pulmonary capillary wedge pressures greater than 18
mm Hg.62,66,6
• The trend toward abandonment of colloids over the past
two or three decades may also have contributed to the
subtle advance of fluid creep.69 Baxter’s original
approach included use of plasma at 24 jams, and two
well-conducted randomized prospective studies both
demonstrated that early use of colloids significantly
reduced 24-jam resuscitation volumes, compared with
use of crystalloids alone.70,71
• An intriguing theory on fluid creep has been described
by Saffle,69 who suggests that
• jamly urine output is still the cornerstone of monitoring of burn
resuscitation despite the emergence in the past decade of more
sophisticated approaches, such as the use of malperfusion markers
(arterial base deficit and serum lactate); cardiac index
determinations; measurements of oxygen delivery and uptake
variables; and intrathoracic blood volume estimations. The fluid
infusion rate should be adjusted to achieve a UO of 0.5 to 1
mL/kg/h in adults and 1 to 1.5 mL/kg/h in children. 50 It has never
been specified whether this should be based on actual or predicted
weight, but in heavier and obese patients, aiming for a UO at the
lower end of the range seems to make sense to use the least
amount of fluid possible. The arterial base deficit and serum
lactate are well-recognized markers of tissue malperfusion that
have been used to monitor resuscitation in trauma and critically ill
populations.
• Criteria for abdominal decompression is based on
bladder pressures alone in 25 centers (78%); 16/32
(50%) use PIP, and 10/32 (31%) staff use other
criteria including organ dysfunction or increased
lactate. Eleven physicians (34%) advocate
percutaneous decompression before decompressive
laparotomy.
Research Questions Asked at the
University of Iowa
• What is the etiology of the ACS in acute thermal
injury ?
• Is decompressive laparotomy the only method of
treatment?
• Criteria for abdominal decompression is based on
bladder pressures alone in 25 centers (78%); 16/32
(50%) use PIP, and 10/32 (31%) staff use other
criteria including organ dysfunction or increased
lactate. Eleven physicians (34%) advocate
percutaneous decompression before decompressive
laparotomy.
Materials & Methods
•
•
•
•
•
Intra-abdominal pressure measurement
(bladder transducer) for >40% TBS A burns
Percutaneous peritoneal lavage catheter
placement if pressure >25 mmHg
Decompressive laparotomy if PD failed
Resuscitation Fluid
•
•
•
•
•
•
Standard: Modified Parkland Formula
- 4ml/kg/%TBSA
- 6mi/kg/%TBSA if Inhalation injury also
Study Patients
- 3.7 cc/kg/%TBSA
- (range =2-5 cc/kg/%TBSA)
PD vs PD+Laparotomy
•
•
•
•
N=6
Dead: PD
n=10
Dead:PD+Lap
•
•
•
•
Age (yrs) 40 54 37
%TBSA 46 30 80
Vent/LOS 0.7 0.9 1.0
Bladder
• 29 29 37
Nonsurvivors had:
•
•
•
•
•
↑ ............../............
- ↑ bladder pressure
- ↓ peritoneal drainage
- ↑ fluid intake
- Lower Pa02/Fi02 ratios, p<0.02
Findings
•
•
•
•
•
Patients with < 80%TBSA & inhalation
injury responded to PD
Patients with >8Q%TBSA & inhalation
injury tailed PD
Autopsy: no intra-abdominal sepsis or bowel
complications seen
Secondary ACS
•
•
•
•
•
Non-abdominal conditions
-Major burns
-Sepsis
-Conditions requiring massive
fluid resuscitation
Tertiary ACS
• Also known as recurrent ACS
• Develops after treatment of 1o
• or 2o ACS
• Recurrent or new episode
• after definitive abdominal wall
• closure
Measuring Methods
• Direct
• Direct needle puncture and transducer
• Intermittent Indirect
• Bladder pressure transducer
• Continuous Indirect
• Continuous bladder irrigation method
This phenomenon, coined ‘‘fluid
creep’’ by Pruitt
• It is increasingly recognized that fluid resuscitation is
anything but a rote, standardized process, and that
there is an urgent need for re-evaluation of existing
resuscitation approaches to avoid fluid creep.
• The more pressing problem for the modern burn
clinician is fluid creep, which is the unpredictable trend
toward provision of larger and larger resuscitation fluid
volumes to burn patients who do not fit into the welldefined subgroups identified previously.
Predisposition for ACS in Burns
• Large volume fluid resuscitation
• Circumferential torso burns
• Inhalation Injury
How Do We Define Abdominal
Compartment Syndrome?
• IAP > 20 mm Hg AND
• new onset single/multiple organ failure
• There is no grading system

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