Hemodynamics in Burn Unit

marienm, RN, CCRN · Jan 21, 2017

We get a lot of femoral CVCs and we often don't transduce a CVP. A-lines, yes, with a Phillips Vigileo monitor for the more unstable patients. (Some of our A-lines are pedal, so I question the validity, but the feeling is that it's better than nothing.) I've never used a Swan (our cardiac ICU uses them, but not us) and I just had to look up the PICCO. For reference: teaching hospital, adult Burn ICU but not an ABA burn center.

WestCoastSunRN, MSN, CNS · Jan 22, 2017

I'm at an ABA Burn unit, but we don't typically use CO measurement either. Apparently U/O is pretty much everything when it comes to resuscitation. As a former CVICU nurse I'd love to know the rationale for that. Seems like a swan or PICCO would give more detailed fluid balance info. But why wouldn't that be the case for a Burn? One could argue we don't want to be as invasive as a PA cath, but with PICCO you only need an A line and a CVC.

And fem lines. Ugh. We have a lot of those, too. I really dislike fem lines due to increase for CLABSI.

marienm, RN, CCRN · Jan 24, 2017

I found a decent article that summarizes some of the resuscitation protocols:

Fluid management in major burn injuries

But, spoiler alert, they all come down to urine output being the best indicator of fluid status and resuscitation status!

I think it's because the insensible losses with a burn are unlike any other injury. Monitoring the CO (cardiac output) is maybe helpful (and we can do that with the Vigileo...just need an A-line) but ultimately the patient's problem is not usually a cardiac problem. Their problems are vascular permeability and third-spacing that is unrecoverable, which leads to outright fluid loss. On top of that, the cellular destruction of the burned tissue can put a huge stress on the kidneys (electrolyte imbalances and rhabdomyolysis/myoglobinuria). So the best way to make sure the kidneys are really being perfused is to measure the urine output.

The only other number we pay a lot of attention to on the Vigileo is the SVV (stroke volume variation)...as nurses, we usually use it as a way to convince a hesitant resident that YES, the patient probably still needs more fluid.

I certainly don't love femoral lines either, but the upper torso often is too burned for a line. If there's an unburned area of upper arm, we usually try to get a PICC placed after the first few days. We've definitely had patients with a femoral A-line and VasCath on one side and a CVC on the other. However, I can't think of one of these patients that has survived...they didn't die of CLABSI, but it's an indicator of the overall severity of the injury.

WestCoastSunRN, MSN, CNS · Feb 5, 2017

This is great, thank you! and yes, sometimes you have to go femoral as there simply isn't any other place to go....

MDash · Feb 15, 2017

I'm in an ABA Burn ICU in a teaching hospital. We use PiCCOs, A-lines, and CVPs. Our patients will often switch back and forth between PiCCOs and A-lines, depending on how intensively their fluid status needs to be monitored. Almost without exception, A-lines are radial; PiCCOs are axillary; CVCs are IJ or subclavian. I've never seen a pedal or femoral line, even with an upper body burn or weepy SJS. We use betadine-soaked gauze if we can't get a dressing to stick.

Cdinern · Mar 19, 2018

For the longest time we've gone by U/O and then eventually use CVP. As of recently however, we have been using PiCCO. Certain attendings love it. It's a pain in the butt to gather all the supplies as we don't stock them everywhere and it's a scavenger hunt to find the catheters, transducers, etc. but once it's set up, I do find that it's helpful in directions f our fluid goals.

StudentRegisteredNurseofAnesthesia · Oct 6, 2020

You'll become an expert in the risks of Fluid Under- and Over-resuscitation in Burn Patients. You'll want to avoid hypovolemia, but also avoid ARDS which can occur with over fluid resuscitation.