BTK Burn Resuscitation, part deux-titrating and troubleshooting

Welcome to another episode of the Behind the Knife podcast, clinical challenges in burn surgery. This is part two of the burn resuscitation series. To recap part one, we discussed management in the pre hospital and transfer phase covering initial fluid rates and the challenges that come from the transfer process.

Now we're going to discuss what to do when resuscitation appears to be failing and some of the tools that can help guide care. We hinted at this with the mention of it. In your institution, what are your practices in a patient who is not producing very much urine, so let's say 10 to 15 cc's per hour, despite increasing crystalloid administration?

So to clarify, when is too much crystalloid? When do you start thinking about alternatives and what are those alternatives? You know, at our institution, I mean, we're heavy albumin users. In this scenario, if that urine output is dwindling, we just start albumin. And so our standard approach is that old University of Utah protocol where you substitute your ringer's infusion

for a mixture about a one third, 5 percent albumin and two thirds ringer.

So whatever rate you were at, you now divvy it up at one third albumin, two thirds crystalloid. And that would be our standard go to thing for the patient who's not doing well. The markers I always look out for is that total cumulative fluid in mls per kilo. And when I see that number starting to approach 200, 225, 250 in the first 24 hours, that's a really worrisome sign.

And that's that old IV index from a paper many years ago that spurred Dr. Pruitt to write the whole editorial on fluid creep. That 250 mls per kilo in the first 24 hours basically kind of predicted abdominal compartment syndrome. Dr. Pham, any other comments? What we'll do about the SAM is to substitute colloid for a third of crystalloid.

So we've adopted some of the same thing. We do a crystalloid first and then we supplement, but that's not true everywhere. There's a lot of relativity when you travel around and see what's done elsewhere and done successfully. For

example, I was in a hospital in Shanghai several years ago. They do a one to one colloid and crystalloid, and they use pressures to help them titrate to be in a very narrow range.

Colloids do reduce the total volume that you have to give. That does not need to be proven anymore. I think the bigger question is when, what kind of patients, and how soon. Yeah, the timing is a really difficult question, and when we looked at this in our practice guideline, the one worrisome study that really continued to throw us off a little bit, it was done a long time ago, back in the 80s, small, but well done, randomized controlled trial out of U.

S. Army. And the patients who got albumin early, and that was like, as soon as they presented, they ended up getting more lung water in that first post burn week. So there's always been this lingering concern that really, really early administration of albumin might carry a risk of worsening lung edema.

But we don't know that for sure. And quite clearly, many places start colloids right off the bat. And if you look at the whole history of

burn resuscitation, colloids were used early on for decades. But for that reason, we still don't know about the appropriate timing. And I personally sort of wait about eight to 12 hours, but I know other centers don't necessarily do that.

This is one where we couldn't make a good recommendation for practice guidelines, and we suggested it should be studied in a research forum, which is a bit of a cop out. It was a statement based on wanting to make a safe recommendation because we just don't know. Julio, what are your thoughts? I'm an early albumin user.

I've seen myself started as early as six hours and those patients not doing well, right out of the gate, high doses of multiple pressures, not volume responsive to titration. We try to keep it simple. The more math you have to make somebody do when they're stressed, the tougher it is. And so it's 50, a hundred, 150 albumin, depending on how burned you are and kind of just go from there.

It's for us starting it based on what the burn navigator says in terms of watching the cumulative volume and the predicted 24 hour volumes, the

dreaded 250 IV index makes us get scared at 200, the numbers start going from, if you're projected to be at 200, all of a sudden your green line becomes yellow and you're like, Ooh, I don't like yellow, but you definitely don't want red.

And so that will encourage us to start albumin as well. Until we can study it and maybe find the patient population that will greatest benefit from early albumin initiation. I know some centers, they base it on admission albumin levels, and they base their use of albumin based on trending their albumin levels like we trend lactate and we trend based deficit.

Is there a certain patient population that that would truly benefit them? We don't know. And that's why you got to harmonize some existing burn resuscitation databases. Tintin, Dr. Cortado, and then plan our big randomized controlled trial. Cortado. I wonder if you could give our listeners a sense of the reasoning from albumin as a rescue over using crystalloid.

What albumin

does is it helps maintain a plasma colloidal oncotic pressure. And then that allows better intravascular expansion, better cardiac filling. And the reason it does that is because there's all kinds of parts of the body that are not burned. And we know that there's this leaky microvasculature everywhere right after a major burn.

But in those non burned areas, we know that that begins to probably subside and repair itself around that magical 8 to 12 hour mark. So colloids do have an effect in that non burn tissue. In the burn tissue, it doesn't matter. That area remains leaky for 48, 72 hours. So you can give all the colloids you want.

There's still going to be fluid flux out of the burn wound into the interstitium. It's not going to do anything, but it's really to maintain that plasma colloidal oncotic pressure. not in the burn wound. And you know this from doing resuscitation. I mean, if you do a pure crystalloid resuscitation, you'll see that albumin level plummet within the first day.

And that creates real problems because albumin contributes to about 80 percent

of the plasma colloid oncotic pressure. It's incredibly important. Do you have any experience resuscitating with plasma? Only about 35 years ago when I was a resident, we used a lot of it and it worked great, but it's coming back into vogue.

I'd love to hear what the other panelists have to say about plasma. I see Dr. Rizzo there smiling about plasma. So all of my teaching, all of my training has been to be downrange. And so when I talk to the combat flight paramedics and I talk to the combat support hospitals, which are now called field hospitals, I say, everything that you do is always in the context of having limited resources, limited people, limited time.

And fresh frozen plasma is just such a valuable resource for that guy that comes in with the gunshot wound to the liver to think that I used it to resuscitate a burn patient. When I have a viable alternative in albumin. Restoring oncotic pressure, as Dr. Cartado

said, it's hard for me to teach FFP. Now, in the age of the military transitioning away from component therapy entirely, and using only cold stored, low titer, old whole blood, and then obviously always the availability of the fresh whole blood through a walking blood bank, Teaching the use of FFP downrange may just become a moot point because you're not going to have it.

Now, if we get freeze dried plasma ever approved for humans and not just military working dogs, maybe the discussion would come in. But from a physiologic standpoint, it makes great sense, demonstrating that it stabilizes the glycocalyx. And that you're able to retain that intravascular volume and it allows you to be more responsive to intravascular volume resuscitation is obviously a valid point.

And that's why it is resurging in industrialized countries who have the benefit of having plasma. But I teach to go downrange and so you train how you fight and that's why we remain big albumin users, however, totally willing to participate in the

FFP trial if it works out. It makes sense in the military setting why FFP would be preferentially used for bleeding and trauma.

Dr. Cartado, you talked about how you used to use it 35 years ago and then stopped despite it working really well. What prompted that change? Well, it was the issue of contamination of the blood supply in Canada, many people using a lot of FFP during burn resuscitation. Like, we routinely would start an FFP infusion on anybody over 30 percent TBSA.

But there was an immense problem in Canada with contamination, HIV and hepatitis, and that shut down the use of blood products heavily in Canada. But I would point out too that that happened historically in the U. S. military as well, back in the fifties and sixties, because a lot of the resuscitation was done with colloid at that time.

And it was plasma. And there was a huge problem with viral hepatitis, particularly in the Korean war and Vietnam war. And that steered U. S.

military away from using a lot of colloid. And that's how it shifted more to that crystalloid based resuscitation, which ultimately became the modified Brook formula.

So, safety is really important, and Dr. Rizzo's comments on freeze dried plasma are really important because the French military has a lot of experience with the freeze dried plasma, and it appears to be very safe, so this may be an avenue. And you can carry it in a pack. It's a lot lighter. The thing Dr.

Rizzo mentioned about stabilization and repair of the glycocalyx, that is really important. Like that's kind of the hot new area. And a lot of that research comes out of MedStar in D. C. Some really interesting work in their labs showing that that endotheliopathy seems to reverse and repair itself in the animals that are resuscitated with FFP.

It's very interesting to see how that differs from an albumin resuscitation. It's quite a marked difference. The FFP is quite superior. So it seems to have some intrinsic value above and beyond what albumin does.

Albumin is really a protein. FFP's got all this other extra stuff in it. So Dr. Rizzo mentioned earlier that burn surgeons will spend 48 hours at the bedside helping to direct the resuscitation, which is quite a bit of work.

There might be other ways to handle the hour by hour changes. Dr. Pham, you know, at our institution, do you mind just explaining how the hourly updates are handled and how some of that burden might be shared between all of the team members rather than just the physicians? Yes, we've essentially transitioned to a co management system between physicians and nurses at this point.

So for a long time, we were a burden unit that resuscitated based on a nursing report every hour, asking the provider on call, typically a surgery resident, to make a decision to go up, to go down, or stay the same. But that wasn't working so well, we realized, because the resident was always busy seeing consults in the ER, for example, and there was often a delay in implementing a new plan

every hour.

Hence, fluids were not titrated fast enough, many hours, and so a decade ago, we decided it was time to empower the nurses. We had also adopted a computer decision support system developed by the U. S. Army Bone Center around the same time. So it was time to let the nurses take the lead with input from the support tool and simply ask the resident to vet the nursing plan.

We create a secure group chat for every patient needing resuscitation. The nurse reports the data hourly with their plan, taking in consideration the decision support tool. And if others on the chat don't jump in to modify within the next 10 minutes, The nursing plan is carried out within that time frame.

So in the past decade, our total resuscitation volumes have gone down a lot. We believe that this is in part because we have empowered the nurses to co manage the resuscitation phase. That might be a good time to describe a burn navigator, Dr. Rizzo, you mentioned it earlier and you mentioned the yellow and the red color.

Do you mind just describing for our listeners what this tool is and sort of what goes into making it work? The Burn Resuscitation Decision Support Tool developed in conjunction between the ISR and the University of Texas Medical Branch at Galveston. This was invented to go downrange. It was for the family practice doctor or PA in a tent by himself in the middle of nowhere to help him or her make decisions on how to resuscitate a patient that they're just inexperienced in doing.

It uses a complex algorithm and a set of business rules that relies on the patient's weight, the estimated TBSA. the time of burn injury and the patient's urine output for the previous hour. And it recommends the crystalloid infusion rate for the following hour. It does not talk to you at all about colloid.

You can input it as an input variable, but it will never recommend a change in colloid value. One of the nicest things about it is it facilitates communication, kind of like Dr. Pham was

talking about, so that the nurses and the doctors are working together. In this tool, which is now in a variety of digital platforms, but the original physical tablet would allow the nurse to be able to communicate consistently the same values and the same variables and there's warning signs that prompt the nurse to ask the physician.

Hey, the urine output may have been 50 an hour, and we're happy with that, but the patient's hypotensive. What would you like to do? And they come up with a decision plan together, and that really has revolutionized burn care at our facility. The other very nice feature is a variety of graphical interfaces and tabular interfaces that allow you to track the course of a resuscitation.

And one of the nice things you always like to see in the table is it goes up over the first 12 to 15 hours, and then goes down, and it shows you peaked at how much fluid you were giving, and then you were able to get better. And the urine output went down, and now it picks back up. You want the urine

to be in the green and you want your fluid curves to be in the green gets to yellow.

It makes you take notice. It gets to the red. Okay, fix it. And so that's also been a very nice teaching tool, a very nice way to track their resuscitation. And for the continuum of care from the patient, goes to a tent with a pa, to getting to a trauma surgeon that may not be that experienced with burns back to the burn surgeon, wherever they may be.

This tablet can go with them. And that way you can see the course of their resuscitation and then it just allows you to kind of understand where they've been and where they're at now and what has been done. And so, I'm obviously a big fan and I think it has really brought a lot to burn care and most importantly to the deployed provider caring for burn service members.

Dr. Katata, what is the practice in your institution for that hourly titration? Yeah, we're a little bit old fashioned, so it'll be the doc at the bedside for long periods of time. What we have noticed with the ABREP2

study is that really is a protocolized resuscitation algorithm. That's been known for a long time.

So called nurse driven protocols work quite well and they can do it very, very accurately. It's basically following an algorithm, so I'm kind of hoping we shift more toward that. The thing is, though, that I do like having the trainee element there, like I think it is important for trainees to be at the bedside and seeing what's happening with the resuscitation, looking at how the fluids are going, what's the urine doing, repeated exam, that's all part of burn resuscitation, that's sort of the art part of the burn resuscitation, so it's, it's important for teaching.

Well, I think this is something that we as fellows struggle with the most and I think as sperm providers in general and these are the patients who come in with specific past medical histories that make their resuscitation difficult. Mainly, I'm thinking of those patients with hemodialysis dependence or heart failure, concomitant trauma, or concurrent drug use.

Those are some of the things that stick out in my mind as posing challenges, and I'm

wondering if you guys could maybe comment on those. So concurrent IV drug use, as meth becomes more prevalent, that poses a unique challenge for patients undergoing burn recess. They require higher recess volumes.

Patients with alcohol, they have that inappropriate diuresis early and then you play catch up from it and they end up getting more fluid but it's almost predictive and those meth users don't have that same thing. Now that meth is being laced, at least here, with a variety of stuff to include forced tranquilizer, they're now coming in with an increased IV fluid requirement for resuscitation and a depressed EF.

And so we're getting relatively young patients with depressed EF and an increased need for fluid and now you're balancing, not overloading. So that's definitely a population that has been difficult. And then always the adage goes, it's better to be burnt than burnt and broken. You know, the concomitant trauma just presents to you a whole different world of resuscitation.

How do you complement a blood based resuscitation for hemorrhagic shock with a concurrent high voltage electrical injury? That remains a very difficult question for us to answer. And in the recent conflict with a lot of IED blasts where they were both burnt and very broken, it proved very difficult.

Yeah. The one I find most challenging is kind of following up on what Dr. Rizzo said, it's the polysubstance abuse patient because they're impossible to sedate, they come in and you're running two or three infusions just to keep them quiet and all those agents have hemodynamic effects and then you're running into problems supporting the blood pressure.

The other one that's problematic are patients with advanced liver disease. And I don't totally understand why, but they become very difficult to resuscitate. They're hypoalbuminemic. They can be a big challenge. Well, Dr. Cartato, it's the other old adage, cirrhosis plus X equals death. And I think their profound hypoalbuminemic state, their inability to respond to albumin infusions has been

something I've seen quite a bit.

It's probably one of the very few patient populations where I've switched from 5 percent to 25%. to gain just that ounce of oncotic pressure back and it's short lived. They obviously are usually coagulopathic which makes the burn surgery even more enticing. Yeah. Yeah, the population that scares me is the older patients.

Nobody wants to give them too much fluid. But yet, in practice, what happens is they're often malnourished, they have low protein stores. Tachycardic older patients have a low body weight by definition, and we have a hard time supporting them, so it's very, very easy to exceed Parkland estimates and descriptions.

I'm cautious and a little bit scared of patients with existing renal failure, that you have to use other indices for resuscitation, you titrate fluids based on hemodynamic parameters and keep checking the hematocrit sometimes, every two to four hours, and hoping to keep it within the same range so that we're not too hemo concentrated or too hemo diluted.

I think we did that on a recent patient, Jamie. And

I'll add that we also resuscitated based off lactate based deficit. In those patients who fail resuscitation, Lillian and Yurik, when do you consider CRRT limit? Is there a volume limit? That has to do with the psychology of the provider. You have to accept that the patient is going into renal failure, and sometimes that's hard to do.

And it also has to do with who controls the CRRT machine in your unit. So, in many units where the critical care doctor does not control a CRRT machine, there is often a long delay between wanting CRRT and starting the therapy. So the earlier the better in this discussion, in order to bring providers on board, because many patients won't meet the classic criteria for dialysis, but they can use some volume offloading.

A CRRT sometimes is like a pop off valve. All the numbers get better, hemodynamic numbers, and it allows you to safely transition the patient to the operative phase, meaning that who wants to go to the OR with a rapidly rising potassium level.

I am fortunate enough that Dr. Kevin Chung introduced Burn Surgeon and Burn Intensivist run renal replacement therapy early on in the war.

So we are very early users. I feel like by the time I put the CRT order in the nurses have it connected and running. And that was due to a large lag in asking for renal replacement therapy and the patient not meeting the conventional indications for intermittent hemodialysis as the nephrologists see it.

And it's just, for us, it's that patient with that persistent acidosis you can't clear. If the pressures are going into a pH of seven, it's not going to work. Point that Dr. Pham made about being able to get them to the operative phase and to remove that inflammatory evil that is driving all this, when renal replacement therapy lets us do that, and then we're fortunate enough that we have burn ICU nurses that will come to the operating room and keep them running on the circuit during your case.

I mean, it's just proven invaluable. I will brag. We were able to actually do it on

patients in the air. We brought a patient from Singapore, 60 percent high voltage electrical injury. And we ran him on renal replacement therapy, flying over the Pacific. And he's actually now my neighbor and takes me fishing.

So it was, I think the single thing that saved his life. Yeah. It's all about getting buy in or just being able to do it yourself. We don't have good access to CRRT in our unit. So, very important who controls the CRRT in your hospital. And in our burn center, it's not us. I just realized Alex, that you didn't answer the second part of your question.

Is there a volume limit for you to have to pay by CRRT? And I just want to bring back to the discussion about that volume that you would spec into abdominal compartment syndrome. What they said in that paper, which was most interesting, Even though you get to 250 mils of fluid, most of these patients still did not need abdominal decompression.

Most of them you were able to get away with by tuning down fluids, tangential excision of the eschar,

or sometimes using chemical process strategy. So don't think that that 250 mils is a, Oh my God, I have to go decompress the patient. So I'm not sure what the volume limit is, but recognizing early that you're going to exceed the expected formula is important to do all your rescue strategies.

If you've initiated a CRT, what do you do with the subsequent volume that you're putting in, and how do you set sort of the volume coming out to the machine? So I'll go on the aggressive end of the spectrum. I set them at a standard dose of 30 to 35, and more often than not, I'm doing it for correction of acidosis.

So unless I have a ridiculous volume going in, anything six per and above, I don't have to be aggressive at removing their fluid. If I'm doing it for volume removal, I pull until the patient tells me to stop. And that's rapidly increasing pressure doses, tacky arrhythmias. A 25 year old

combat casualty can sit at a heart rate of 140 for days and be fine.

That 70 year old guy ain't gonna do the same, right? And so I am aggressive with using CRT for volume removal when the patient permits me. And I will allow myself to go up on pressers to a reasonable level. And obviously everyone's reasonable level is different. But if it's just for acidosis, usually trying to match their ends, if I think they're appropriately volume resuscitated.

But if I'm using it to truly try to prevent sequelae of over resuscitation, I pull until they beg me to stop. But I'm on the probably wicked aggressive side of CRRT because I am blessed with ICU nurses that can run that machine like The best I've ever seen any other comments regarding CRT. Yeah, we have more limited goals here.

We just try to really bridge them to operative care. You don't have to achieve zero balance. You don't have to achieve net negative balance in order to do that. Told

you I was going to be the wicked aggressive one. So along those lines, like Kevin would talk about high dose. So you're not going that high, though.

No, so we studied that primarily in burn induced sepsis. And as Dr. Chung's paper showed, you're not going to make a lot of difference in mortality in burn patients because all the stuff they presented with are the stuff you can't change. But it did decrease their vasodepressor dependency. I'm not aiming to do that early on in the recess.

I have no problem taking a patient to the operating room on vasopressin. Am I excited to skin graft someone on Levophed? No, but I think we've gotten progressively more comfortable with grafting on LEED and knowing it doesn't have the peripheral vasoconstriction at the level of the skin per skin grafts.

You don't wanna be on rocket fuel when you do it. But yeah, the high dose we reserve for the sickies later on, and I do think that is of benefit. You do have to have a team that is very comfortable with running high dose, high flow rates, you're getting those labs every

six hours, and you're going to see a lot more rapid change than when you use it in burn recess in which you're running a standard flow rate and a standard dose, sorry, I'm a CRT nerd.

I could talk about this all day. That's what we like about you among other things. Well, I think that wraps up our session. Thank you all for joining us. It's nice that we had a transcontinental panel today and nice to be not the only Canadian this time on this podcast. Otherwise, we look forward to seeing you potentially for the next one.

All right. Well, as always dominate the day.