Closed-loop and decision-assist resuscitation of burn patients.
ABSTRACT Effective resuscitation is critical in reducing mortality and morbidity rates of patients with acute burns. To this end, guidelines and formulas have been developed to define infusion rates and volume requirements during the first 48 hours postburn. Even with these standardized resuscitation guidelines, however, over- and under-resuscitation are not uncommon. Two approaches to adjust infusion rate are decision-assist and closed-loop algorithms based on levels of urinary output. Specific decision assist guidelines or a closed-loop system using computer-controlled feedback technology that supplies automatic control of infusion rates can potentially achieve better control of urinary output. In a properly designed system, closed-loop control has the potential to provide more accurate titration rates, while lowering the incidence of over- and under-resuscitation. Because the system can self-adjust based on monitoring inputs, the technology can be pushed to environments such as combat zones where burn resuscitation expertise is limited. A closed-loop system can also assist in the management of mass casualties, another scenario in which medical expertise is often in short supply. This article reviews the record of fluid balance of contemporary burn resuscitation and approaches, as well as the engineering efforts, animal studies, and algorithm development of our most recent autonomous systems for burn resuscitation.
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ABSTRACT: BACKGROUND: One of the major determinants for survival of severely burned patients is appropriate fluid resuscitation. At present, fluid resuscitation is calculated based on body weight or body surface area, burn size, and urinary output. However, recent evidence suggests that fluid calculation is inadequate and that over- and under-resuscitations are associated with increased morbidity and mortality. We hypothesize that optimizing fluid administration during the critical initial phase using a transcardiopulmonary thermodilution monitoring device (pulse contour cardiac output [PiCCO]; Pulsion Medical Systems, Munich, Germany) would have beneficial effects on the outcome of burned patients. METHODS: A cohort of 76 severely burned pediatric patients with burns over 30% of the total body surface area who received adjusted fluid resuscitation using the PiCCO system were compared with 76 conventionally monitored patients (C). Clinical hemodynamic measurements, organ function (DENVER2 score), and biomarkers were recorded prospectively for the first 20d after burn injury. RESULTS: Both cohorts were similar in demographic and injury characteristics. Patients in the PiCCO group received significantly less fluids (P<0.05) with similar urinary output, resulting in a significantly lower positive fluid balance (P<0.05). The central venous pressure in the PiCCO group was maintained in a more controlled range (P<0.05), associated with a significantly lower heart rate and significantly lower incidence of cardiac and renal failure (P<0.05). CONCLUSIONS: Fluid resuscitation guided by transcardiopulmonary thermodilution during hospitalization represents an effective adjunct and is associated with beneficial effects on postburn morbidity.Journal of Surgical Research 06/2012; DOI:10.1016/j.jss.2012.05.058 · 2.12 Impact Factor
Article: Acute Burn Care[Show abstract] [Hide abstract]
ABSTRACT: LEARNING OBJECTIVES: After studying this article and accompanying Supplemental Digital Content, the participant should be able to: 1. Explain current burn-prevention strategies and criteria for referral to a burn center. 2. Summarize the current advances made in the critical care of acute burn patients. 3. Outline the recent developments in burn depth assessment and burn wound dressing technology. 4. Describe the common psychosocial aspects of postburn rehabilitation. SUMMARY: Burn patients require interdisciplinary care in which the plastic surgeon plays a prominent role. Appropriate referral, assessment, treatment, and posttreatment supports are essential to achieving favorable outcomes following burn injury. The authors reviewed the current literature on epidemiology, prevention, referral criteria, critical care, wound assessment, wound dressings, and psychosocial aspects of burn injury. Recent advances in burn care are highlighted and have been made possible through ongoing collaborative epidemiologic, clinical, and basic biomedical research. A systematic interdisciplinary approach to the evaluation and treatment of acute burn injuries is pivotal to providing patients with the greatest chance of functional recovery. Plastic surgeons treating burn patients must remain current in a wide variety of areas, ranging from critical care to psychosocial rehabilitation.Plastic and Reconstructive Surgery 08/2012; 130(2):349e-358e. DOI:10.1097/PRS.0b013e318258d530 · 3.33 Impact Factor
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ABSTRACT: Background Burn resuscitation, including titration of fluids and administration of colloids, is often driven by physicians' orders. Inconsistencies in burn resuscitation cause overresuscitation, which has adverse consequences. Methods Retrospective chart reviews were completed to evaluate fluid resuscitation and complications for 12 months before and after development and implementation of a nurse-driven burn resuscitation protocol. Results Before implementation of the protocol, results at 24 hours after injury indicated that 58% of patients were overresuscitated, had a serum level of lactate of at least 2 mmol/L (100%), and had complications (pulmonary edema 20%, abdominal compartment syndrome 7%, acute lung injury/acute respiratory distress syndrome 30%) within the first 5 days. Two outcomes differed from before to after implementation of the protocol: serum level of lactate at 24 hours (t(37.8) =2.38, P =.007) and central venous pressure at 48 hours (t(31) =2.27, P =.03). After implementation of the protocol, no patients had abdominal compartment syndrome develop. Conclusions Implementation of the nurse-driven burn resuscitation protocol improved nurses' awareness and assessment of fluid status during resuscitation and improved patients' outcomes.Critical Care Nurse 02/2013; 33(1):25-35. DOI:10.4037/ccn2013385 · 1.07 Impact Factor