KinderenmetbrandwondenAcuteopvangenintensivecaremanagement

JorisLemson

Intensivecarekinderen

(Potentiële)belangenverstrengeling Geen

Voorbijeenkomstmogelijkrelevanterelatiesmetbedrijven

•Geen

•Sponsoringofonderzoeksgeld•Honorariumofandere(financiële)vergoedingen•Aandeelhouder•Andererelatie

•Geen•Geen•Geen•Geen

DisclosurebelangenverstrengelingvoordesprekersvandeAZOscholingsavond

CocoanutGroove1942

http://www.cocoanutgrovefire.org/home

Ann surg 1947;126:1010-1045

Ann N Y Acad Sci 1968;150:874-894

InflammaGon

Sepsis Surgery

Myocardialdysfunc3onCapillaryleakageVasodila3onFeverAutonomicdysregula3on

youngerchildrenmoresuscepBve?EurJofCardio-thoracicSurg1997;12:862–868

PediatrCritCareMed2003;4:299–304CardiovascularResearch2007;73:26–36

CritCareMed2007;35:1599–1608

InflammationTraumaBurns

• Systemic inflammation (> 15%) • peak effect at aprox. 24 hours • high TBSA => long lasting inflammation • capillary leak

• edema (+ overzealous fluids => abdominal compartment syndrome)

• Circulating catecholamines • Loss of skin => loss of proteins and fluids • Loss of temperature control • Hyper-metabolic response • Colonisation en infections • Muscle weakness • . . . . .

Pathophysiology of severe burns

Pathofysiologyofsevereburns

Cell Rep. 2015 Nov 24;13(8):1538-44

• Consider mechanisme (blast, electrocution, inhalation trauma, etc)

• ABCDEFG • Cooling (be aware of hypothermia) • iv / io access • Pain and anxiety control (consider sedation+intubation) • Fluids • CO en cyanide intox, tetanus etc • Woundcare • Determine burn surface • . . . .

First treatment

Name Volume crystalloid Colloid Glucose Rest

Cope and More 75ml/%TBSA oralelectrolytre 75 ml/%TBSA

2000 ml fruit juice PO or 2000 mlGlucose 5%

Half first 8 hours, half next 16 hours

Evans 1 ml/kg/%TBSA 1 ml/kg/%TBSA 2000 ml 5% glucose

Half first 8 hours, half next 16 hours

Brooke 1,5 ml%TBSA LR none none Half first 8 hours, half next 16 hours

Gelin none 2-3 ml/kg/%TBSA none Half first 8 hours, half next 16 hours

Parkland 4 ml/kg/%TBSA none none Half first 8 hours, half next 16 hours

Revised Brooke 3 ml/kg/%TBSA none none Half first 8 hours, half next 16 hours

Burns & Trauma (2017) 5:26

Fluidschedules

Fluidcreep

Anaesthesiology Intensive therapy 2015;47:5:xxx

Complicationsoverzealousfluidtherapy• Often >>> 4 ml/kg/TBSA% • Edema • Intra abdominal hypertension / abdominal compartment

syndrome • Decreased abdominal and thoracic compliance • Bowel edema => bowel obstruction • Reduced wound healing • Pulmonary edema • Limb compartment syndrome • Death

Cri3calCare2011,15:R118

Cri3calCare2011,15:R118

CIinchildrenwithsevereburns

Cri3calCare2011,15:R118

EVLWIinchildrenwithsevereburns

Anaesthesiology Intensive therapy 2015;47:5:xxx

ACS

No ACS

survivors

non-survivors

EVLWIandabdominalcompartmentsyndrome

Anaesthesiology Intensive therapy 2015;47:5:xxx

Monitoring• CVP, urinary output, blood pressure, HR

=> all unreliable

• Advanced monitoring (echo, PiCCO etc) => Efficiency unknown but useful info

• Recent knowledge => Try to maintain low CVP with adequate CO/MAP

Anaesthesiology Intensive therapy 2015;47:5:xxx

n = 56 78.6% = IAH Mortality 26,8%

Hoste et al Br J Anaesth 2014

JSurgRes2012E1-8

• Children > 30% burns • Age 8 (SD 0,6) • 76 treated conventionally • 76 monitored with PiCCO • No RCT!

JSurgRes2012E1-8

PiCCOversuscontrol

Non-surgicalmanagement• Early aggressive fluid therapy when necessary • PICU management with careful fluid strategy

• No standard formula after emergency care • MAP, HR, urine production, CVP as usual • Advanced hemodynamic monitoring (PiCCO) • Monitor abdominal pressure • Monitor energy expenditure • Laboratory testing • Vasoactive drugs when necessary • Propranolol?????

Soussi et al. Ann. Intensive Care (2016) 6:87

• Lower HD variables have predictive value, fluids not • Target CO/MAP instead of ml/kg

World Journal of Emergency Surgery (2017) 12:11

World Journal of Emergency Surgery (2017) 12:11

• Lower HR • Less hypermetabolisme?

Questions