Burn Patient Management in Intensive Care

Initial Assessment and ICU Admission Criteria

• The American College of Surgeons recommends that burned patients with total body surface area (TBSA) burned >20%, deep burns >5%, smoke inhalation, high-voltage electrical burns, or deep burns in functional areas (face, hands, feet, perineum) require ICU admission 1
• The American Burn Association suggests using the Lund-Browder method to measure TBSA, as it is the most accurate for adults and children 1
• The rule of nines by Wallace overestimates TBSA and is not suitable for children 1
• A practical alternative in the field is that the patient's open palm (palm and fingers) represents approximately 1% of TBSA 1
• Additional criteria for TBSA <20% include age >75 years with severe comorbidities, circular deep burns, and TBSA >10% with deep burns 3-5% 1

Fluid Resuscitation: First 24 Hours

• The American College of Surgeons recommends administering 2-4 mL/kg/%TBSA of balanced crystalloid solution (preferably Lactated Ringer's) in the first 24 hours, with half of the volume in the first 8 hours 1
• The Parkland formula can be used to calculate fluid requirements at 24 hours 1
• The goal urine output is 0.5-1 mL/kg/hour in adults 1
• Children require larger volumes (approximately 6 mL/kg/%TBSA) due to their higher surface-to-weight ratio 1
• Formal resuscitation should be initiated in children with TBSA ≥5% 1
• Fluid administration should be adjusted according to clinical response, rather than rigidly following the formula without modifications 1
• The American Burn Association warns that overestimation of TBSA occurs in 70-94% of cases, leading to excessive fluid administration, which is associated with abdominal compartment syndrome, acute kidney injury, and acute respiratory distress syndrome 2

Colloid Use (Albumin)

• The American College of Surgeons recommends starting 5% human albumin between 8-12 hours post-burn in patients with severe burns (TBSA >30%) to reduce crystalloid administration and prevent fluid overload 1
• Serum albumin levels should be maintained >30 g/L with doses of 1-2 g/kg/day 1
• Albumin reduces the volume of crystalloids needed and decreases complications related to fluid overload 1

Airway Management

• The American College of Surgeons recommends not routinely intubating patients with facial or cervical burns 1
• Specific criteria for intubation in facial burns include: deep and circular neck burns, symptoms of airway obstruction, and extensive burns (TBSA ≥40%) 1
• Unnecessary intubation in the prehospital setting occurs in almost one-third of patients and is associated with more complications 1
• Patients with facial/cervical burns exposed to vapors or smoke inhalation should be closely monitored for glottic edema risk 1

Pain Management

• The Anaesthesia journal recommends administering short-acting opioid analgesics and titrated ketamine according to validated comfort and analgesia scales 3
• Ketamine can be combined with other analgesics to treat severe burn-induced pain 3
• Burn pain is often short-lived; short-acting opioids and ketamine are likely the best drugs 3
• For highly painful lesions or procedures, general anesthesia is an effective option 3
• If the patient is stable, combine non-pharmacological techniques with analgesic drugs for dressings 3
• Inhaled nitrous oxide can be useful, especially when intravenous access is not available 3

Wound Care

• The Anaesthesia journal recommends performing wound care only after well-conducted resuscitation, in a clean environment, and with deep analgesia or general anesthesia 3
• Wounds should be cleaned with running water, isotonic saline solution, or antiseptic solution 3, 2
• Ideally, consult a burn specialist to define the most appropriate dressing and whether blisters should be aspirated or debrided 3
• Apply appropriate dressings according to burn depth, TBSA, wound appearance, and patient condition 2
• Prolonged use of silver sulfadiazine in superficial burns should be avoided, as it is associated with prolonged healing 3

Burn Cooling

• The Anaesthesia journal recommends cooling burns in adults with TBSA <20% and children with TBSA <10% in the absence of shock 3
• Cooling can limit burn depth and reduce pain 3
• Cooling times less than 40 minutes significantly reduce the need for skin grafts 3
• Prolonged use of external cooling devices should be avoided to prevent hypothermia 2

Complication Prevention and Management

Compartment Syndrome

• The American College of Surgeons recommends monitoring for compartment syndrome, especially in circular third-degree burns that can cause acute compartment syndrome of limbs or torso 1
• Escarotomy should be performed when deep circular burns cause constriction and increased compartment pressure, ideally in a burn center 1, 2
• If transfer is not feasible, obtain specialized advice before performing the procedure 1
• Escarotomy should not be delayed when indicated, as timely performance is associated with reduced morbidity 1

Hemodynamic Monitoring

• If hypotension persists despite adequate resuscitation, evaluate cardiac function with echocardiography and consider vasopressors 1
• Monitor for acute kidney injury 1

Special Considerations

• The American Burn Association recommends not underestimating fluid requirements in electrical burns, which can cause deeper tissue damage than apparent on the surface 1
• Prophylactic antibiotics should not be administered routinely unless specifically indicated for infected wounds 2
• Consider thromboprophylaxis for severe burns 2
• If transfer to a burn center is indicated, the patient should be admitted directly to the center whenever possible 2

Fluid Management in Severe Burns

Initial Resuscitation Strategy

• The American Burn Association recommends initiating resuscitation with balanced crystalloid solution, such as Lactated Ringer's, using the Parkland formula, and adjusting fluid rates hourly based on urine output to avoid fluid overload complications, particularly in patients with cardiac comorbidities 4

Albumin Administration

• The European Society of Intensive Care Medicine suggests initiating 5% human albumin between 8-12 hours post-burn in patients with TBSA >30% to reduce crystalloid requirements and prevent fluid overload complications, targeting serum albumin levels >30 g/L with doses of 1-2 g/kg/day 4
• The use of 5% albumin reduces mortality (OR=0.34, 95% CI 0.19-0.58, P<0.001) and abdominal compartment syndrome from 15.4% to 2.8% (P<0.05) in severe burns, according to the Anaesthesia guideline 4

Rationale for Albumin in Comorbid Patients

• The Anaesthesia guideline recommends avoiding hydroxyethyl starches (HES) in burn patients due to adverse outcomes, and instead using colloid administration to increase oncotic pressure and reduce fluid leakage, thereby minimizing complications like acute respiratory distress syndrome and congestive acute kidney injury 4
• For patients with heart disease, reducing total fluid volume while maintaining adequate resuscitation is essential to prevent cardiac decompensation, as stated in the Anaesthesia guideline 4

Cardiac-Specific Considerations

• The American College of Cardiology suggests considering earlier initiation of albumin (at 6-8 hours rather than 12 hours) in cardiac patients to minimize total crystalloid volume, according to the Anaesthesia guideline 4

Management of Burn Patients with Impaired Renal Function

Fluid Resuscitation Targets and Strategies

• Target an hourly urine output of 0.5–1 mL kg⁻¹ h⁻¹ as the primary endpoint for resuscitation, even when renal function is abnormal, because it best reflects adequate tissue perfusion【5】【6】.
• Use balanced crystalloid (Lactated Ringer’s) as the base resuscitation fluid; avoid normal saline, which can aggravate hyperchloremic acidosis and kidney injury【5】【6】.
• Add 5 % human albumin between 8–12 hours after the burn (or sooner if needed) to maintain serum albumin > 30 g L⁻¹, dosing 1–2 g kg⁻¹ day⁻¹; this reduces the total crystalloid volume required【5】【6】.
• Albumin therapy reduces mortality (OR = 0.34; 95 % CI 0.19–0.58; P < 0.001) and lowers the incidence of abdominal compartment syndrome from 15.4 % to 2.8 %【6】.

Renal Function Assessment

• Estimate glomerular filtration rate (eGFR) with serum cystatin C‑based formulas rather than creatinine‑based equations, because cystatin C provides greater accuracy and sensitivity in burn patients【5】【6】.
• Adjust dosing of all renally‑cleared medications (e.g., antibiotics, analgesics) according to the cystatin C‑derived eGFR【5】【6】.

Hemodynamic Monitoring and Escalation

• If oliguria persists despite adequate fluid administration, initiate advanced hemodynamic monitoring (e.g., transthoracic echocardiography, cardiac output monitoring) before attributing the problem solely to renal failure【5】【6】.
• When oliguria or hypotension is present, perform bedside echocardiography to evaluate cardiac function and intravascular volume before starting vasopressors【5】【6】.
• Additional perfusion markers—arterial lactate, mixed‑venous oxygen saturation, and oxygen extraction ratio—should be considered alongside urine output to guide resuscitation【5】.
• In cases of persistent oliguria, advanced monitoring modalities such as transpulmonary thermodilution, cardiac output measurement, or central venous pressure monitoring provide valuable information【5】【6】.

Vasopressor Use

• Vasopressors should only be introduced after confirming adequate volume status and satisfactory cardiac function with echocardiography; premature use can worsen renal perfusion and outcomes【5】【6】.

Complication Surveillance

• Monitor intra‑abdominal pressure regularly because abdominal compartment syndrome markedly impairs renal function; incidence falls from 15.4 % to 2.8 % when albumin is administered【6】.
• Prevent “fluid creep” (excessive crystalloid administration) as it predisposes to abdominal compartment syndrome, acute respiratory distress syndrome, and further kidney injury; albumin helps limit total crystalloid volume while maintaining resuscitation goals【5】【6】.

Critical Pitfalls to Avoid

• Do not withhold fluids solely on the basis of elevated creatinine or BUN; patients may be under‑resuscitated despite abnormal laboratory values【5】【6】.
• Do not delay albumin administration; timely albumin reduces the risk of fluid overload‑related kidney injury【5】【6】.
• Do not initiate vasopressors before confirming adequate intravascular volume and cardiac function with echocardiography【5】【6】.