1. Respiratory Support in Burn Patients

Airway compromise from inhalation injury and systemic inflammation often necessitates mechanical ventilation. Early recognition and application of lung-protective strategies are critical to reducing morbidity and mortality.

A. Indications for Mechanical Ventilation

• Signs of Inhalation Injury: Facial or neck burns, singed nasal hairs, hoarseness, and carbonaceous sputum are strong clinical indicators.
• Bronchoscopy Findings: The presence of mucosal erythema, edema, or soot on bronchoscopy predicts the need for prolonged ventilatory support.
• ARDS Criteria: In patients with large total body surface area (TBSA) burns (>20%) or sepsis, a PaO₂/FiO₂ ratio ≤300 mm Hg with bilateral infiltrates not explained by cardiac failure indicates ARDS.
• Preemptive Intubation: Intubation should be strongly considered before the peak of capillary leak (3–48 hours post-burn) to avoid a difficult or emergent airway scenario as edema worsens.

B. Ventilator Modes & Lung-Protective Strategies

• Tidal Volume: Target low tidal volumes of 6 mL/kg based on predicted body weight to prevent volutrauma.
• Plateau Pressure: Maintain a plateau pressure ≤30 cm H₂O to minimize barotrauma.
• PEEP: Utilize moderate PEEP (8–12 cm H₂O) to prevent alveolar collapse. In complex cases, decremental PEEP trials or esophageal pressure monitoring can help optimize settings.
• Permissive Hypercapnia: Allow PaCO₂ to rise (accepting a pH ≥7.20) to facilitate low tidal volume ventilation, but avoid this strategy in patients with or at risk for intracranial hypertension.
• Recruitment Maneuvers: Apply cautiously with close hemodynamic monitoring, as they can cause hypotension in hypovolemic patients.

C. Sedation & Weaning

• Use validated sedation scales (e.g., RASS, SAS) and incorporate daily sedation interruptions (“sedation vacations”) to assess readiness for weaning.
• Conduct spontaneous breathing trials once the patient is hemodynamically stable and respiratory parameters improve.
• Minimize deep sedation to reduce ventilator duration and associated complications.

2. Hemodynamic Monitoring and Support

Thermal injury triggers a biphasic response: an early capillary leak phase causing “burn shock,” followed by a prolonged hyperdynamic, hypermetabolic phase. Precise fluid and vasoactive agent management is essential to optimize organ perfusion while minimizing edema-related complications.

A. Pathophysiology

• Capillary Leak Phase (First 24–48 hours): A massive release of inflammatory cytokines causes endothelial damage and increased vascular permeability. This leads to a profound shift of intravascular fluid into the interstitial space, resulting in hypovolemia, hemoconcentration, and risk of organ hypoperfusion and compartment syndromes.
• Hypermetabolic Phase (Days 3–14): Following resuscitation, patients enter a hyperdynamic state characterized by elevated cardiac output, tachycardia, and increased insensible fluid losses, requiring ongoing hemodynamic vigilance.

B. Fluid Resuscitation Protocols

Initial fluid resuscitation is guided by formulas, but hourly titration based on clinical endpoints is crucial.

Titrate fluid rates hourly to maintain adequate urine output and normalize serum lactate. In complex cases, dynamic assessments of fluid responsiveness (e.g., stroke volume variation, passive leg raise) can help guide therapy and prevent “fluid creep”—over-resuscitation leading to complications.

C. Vasopressors & Inotropes

• Norepinephrine: The first-line vasopressor for burn shock when mean arterial pressure (MAP) remains <65 mm Hg despite adequate fluid administration. Its potent α₁-adrenergic effects increase systemic vascular resistance.
• Titration: Adjust vasopressor doses to achieve a MAP ≥65 mm Hg while closely monitoring for signs of improved perfusion, such as warming extremities and decreasing lactate levels.
• Adjunctive Agents: Consider adding vasopressin if high doses of norepinephrine are required, as this may have a catecholamine-sparing effect.
• Advanced Monitoring: In refractory shock, invasive monitoring with arterial pulse contour analysis or thermodilution can provide real-time cardiac output data to refine titration of vasoactive agents.

3. Prevention of ICU-Related Complications

Critically ill burn patients have a heightened risk of venous thromboembolism (VTE), stress-related mucosal disease, and central line-associated bloodstream infections (CLABSI). Protocol-driven prophylaxis is key to reducing these preventable complications.

A. Venous Thromboembolism (VTE) Prophylaxis

• Pharmacologic: Low-molecular-weight heparin (LMWH), such as enoxaparin, is the preferred agent. It should be initiated 12–24 hours post-burn, once the initial risk of bleeding has subsided.
• Mechanical: Intermittent pneumatic compression devices are essential when pharmacologic prophylaxis is contraindicated (e.g., active bleeding, severe thrombocytopenia).
• Monitoring: In patients with large burns or suspected augmented renal clearance, consider monitoring anti-Xa levels to ensure therapeutic efficacy of LMWH.

B. Stress Ulcer Prophylaxis

• Indication: Initiate prophylaxis in patients requiring mechanical ventilation for >48 hours or those with a coagulopathy.
• Agent: Proton pump inhibitors (PPIs) are generally preferred over H₂-receptor antagonists.
• De-escalation: Discontinue prophylaxis once risk factors resolve to minimize the risk of adverse effects, such as hospital-acquired pneumonia and Clostridioides difficile infection.

C. CLABSI Prevention Bundles

Strict adherence to evidence-based bundles is the most effective strategy to prevent CLABSI.

4. Management of Iatrogenic Toxicities

Aggressive antimicrobial therapy and complex supportive care can lead to iatrogenic complications. Vigilant monitoring and proactive dose adjustments are necessary to mitigate harm.

A. Antibiotic-Associated Nephrotoxicity

• High-Risk Agents: Aminoglycosides (e.g., gentamicin, amikacin) and vancomycin are common culprits.
• Monitoring: Monitor serum creatinine daily. For vancomycin, target an Area Under the Curve (AUC) to MIC ratio or maintain troughs of 15–20 mg/L for severe infections, adjusting based on renal function.
• Management: In the setting of acute kidney injury (AKI), adjust dosing intervals or switch to less nephrotoxic agents. Consider early initiation of renal replacement therapy (RRT) for severe, refractory acidosis or volume overload.

B. Hematologic Toxicities

• Monitoring: Perform a daily complete blood count (CBC) during periods of critical illness and high-intensity antimicrobial therapy.
• Transfusion Thresholds: Adhere to restrictive transfusion strategies. Transfuse red blood cells for a hemoglobin <7 g/dL in the absence of active bleeding. Transfuse platelets for counts <20 × 10⁹/L or if the patient is actively bleeding.
• Causative Agents: Be aware of medications that can cause cytopenias, such as linezolid (thrombocytopenia) or beta-lactams (neutropenia).

C. Drug–Drug Interaction Surveillance

5. Multidisciplinary Goals of Care and Family Communication

The complexity and prolonged course of severe burn injury require a coordinated, multidisciplinary approach that integrates palliative services, surgical planning, and ethical discussions to align treatment with patient values and goals.

A. Early Palliative Care Integration

• Focus on aggressive management of pain, dyspnea, anxiety, and psychological distress from the outset.
• Facilitate formal goals-of-care discussions with the patient or surrogate decision-makers within the first week of admission to establish a shared understanding of the prognosis and treatment trajectory.

B. Shared Decision-Making

• Convene regular multidisciplinary meetings involving surgeons, intensivists, pharmacists, nurses, therapists, and social workers to ensure a unified plan of care.
• Use visual aids, such as wound photographs and illustrated timelines, to help surrogates understand the nature and extent of surgical interventions like debridement and grafting.

C. Ethical Considerations

• Engage the hospital ethics committee for guidance in complex situations, such as determining medical futility in the context of irreversible multi-organ failure.
• Continuously balance the burden of invasive interventions with the potential for a meaningful quality of life, ensuring that care remains patient-centered.