DTIC ADA629614: A Burn Intensive Care Unit Nurse's Perspective

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by  Defense Technical Information Center

A Burn Intensive Care Unit
Nurse’s Perspective
AndrewWallaceJr,RN,ASN
KEYWORDS
(cid:127) Burncare (cid:127) Nursing (cid:127) Intensivecare (cid:127) Perioperativecare
Forburnpatients,thedayofsurgerycancomeasquicklyashoursoraslateasdays,
possibly even weeks, after the initial injury. With reconstructive and scar revision
proceduresthepatient’ssurgicaljourneymaynotenduntilyearsaftertheburn.Itis
the first few surgical procedures that concern the burn intensive care unit (BICU)
nursingstaffthemost.Afteralargeburnencompassing30%totalbodysurfacearea
or greater, the first excision and grafting (E&G) procedures are the most critical.
ExperiencedburnsurgeonsandBICUstaffknowthatthereisnosubstituteforearly,
aggressiveexcisionoftheburnwoundinpatientswithlargeburns.
DeeporFullthicknessburnsproduceaninflammatoryresponsewheretheeschar
(thedeepcutaneousnecrotictissueproducedbythermalburnorcorrosiveapplica-
tion) and the viable tissue meet. This area is where bacterial growth in the eschar
attracts polymorphonuclear leukocytes (neutrophils) that release large amounts of
proteolyticenzymesandinflammatorymediators.1Asaresult,thesemediatorsstart
separatingescharfromthegranulatingtissuethatproducesnonsurgicalburnscars.
Theseuntreatedburnsresultinlimitedmobilityanddisfiguringscars.Byremovingthe
burnedanddevitalizedtissue,burnsurgeonsareabletosavethepatient’slifeaswell
asimproveappearanceandfunction.
ResearchshowsthatE&Gsurgicalinterventionnotonlyimprovessurvivalrates,it
decreases the length of hospital stay and decreases the total cost associated with
burns.1Additionally,ithasbeenshownthatmortalitydecreaseseveninthepresence
of inhalational injuries. Early surgical removal of the burn wound and covering of
thesurgicalsitewithautograftorallograftbecamethestandardofpracticein1976.1
The presence of a burn wound, partial- or full-thickness, is a constant drain on the
patient’s reserves; surgical intervention and closure of the burn wound significantly
limitthisdrain.
The main objective in burn care is closure of the wound with the patient’s own
epidermis. Sometimes closure is spontaneous, but often surgery is required to
Theopinionsorassertionscontainedhereinaretheprivateviewsoftheauthorandarenottobe
construedasofficialorasreflectingtheviewsoftheDepartmentoftheArmyortheDepartment
ofDefense.
UnitedStatesArmyInstituteofSurgicalResearch,FortSam,Houston,TX78234,USA
E-mailaddress:[email protected]
PerioperativeNursingClinics7(2012)71–75
doi:10.1016/j.cpen.2011.12.005 periopnursing.theclinics.com
1556-7931/12/$–seefrontmatterPublishedbyElsevierInc.
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4. TITLE AND SUBTITLE 5a. CONTRACT NUMBER
A Burn Intensive Care Unit Nurse’s Perspective
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Wallace Jr. A.,
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Standard Form 298 (Rev. 8-98)
Prescribed by ANSI Std Z39-18
72 Wallace
remove the eschar and cover the wound with autologous skin graft or autograft
(harvestedfromthepatient).Whenthereisnotenoughautografttocoverthewound,
thegoldstandardisuseofallograft,orcadaverskin,tocoverthewound.1Iffreshskin
isavailable,itmaytakeasaskintransplantuntilthebodyrejectsit,whichmaytake
weekstomonths.Thistemporarycoveringallowsdonorsitestohealbeforetheyare
reharvested.
The burn patient is transported to the operating room (OR) in a manner different
fromthewayotherpatientsgoin.Thepatientisbroughtinonthespecialtybed(Kin
AirbedorFluidAirbed,KCI,SanAntonio,TX,USA)thatheorshewasonintheBICU.
Athermoreflectiveblanketcoversthepatienttomaintainandhelppreventanyheat
losswhilemovingfromthewarmenvironmentoftheBICUoutintothecoolerhallway.
Hemodynamic monitoring continues throughout the transport process until the
patientisconnectedtothemonitorsintheOR.Allpumpsaretransportedalongwith
his or her vasoactive drugs, and intravenous (IV) fluids are kept running during the
transport to the OR and during the procedure. Up to three IV poles with two
three-chamber pumps each are transported with the patient. Additional staff are
requiredtohelpmaneuverthebed,themonitors,andtheIVpolesforasafeandquick
triptotheOR.
Respiratory therapists are part of the transport team because the volumetric
diffusiverespiratorventilatorisoftenusedintheOR.Therespiratorytherapistwears
a backpack harness containing a green fiberglass oxygen tank that is connected to
theventilator,whichremainsconnectedtothepatientduringthetransport.
TheentireORstaffwaits,wearingprotectivegowns,masks,eyewear,andgloves,
as the patient is rolled into the room. Once lines are secured the team is ready to
movethepatientovertotheORtabletoposition,prep,anddrapeappropriatelyfor
thebeginningoftheE&Gprocedure.
Positioningtheburnpatientproneforanypartofthesurgicalprocedurehasitsown
setofissues.Wheneverthepatientisturnedontoapronepositionforharvestingof
graftsordebridementofburns,thepotentialexistsforinvasivelinestobedislodged,
Foley catheter, trauma, and, most critical, unintentional extubation, which would
cause decompensation and require emergent return to the BICU. Additionally,
pronating a patient often results in facial and scleral edema, even with the use of
specialfacepaddingandgoggles.
Burn wounds have been classified into three categories: first-, second- and
third-degree. The burn community prefers to use the terms superficial or partial-
thicknessandfull-thicknesstodescribeburninjuries.Typically,afirst-degreeburnis
not considered part of the burn wound because it involves only the epidermis and
heals quickly with the growth of new keratinocytes.1 The second-degree, or partial-
thickness,burndestroysalloftheepidermisaswellasportionsofthedermis.Some
partial-thicknessburnshealwithoutsurgicalinterventionifthefollicularbulgeareais
uninjured.Itisthoughtthatstemcellsoriginatingfromthebulgeareaproducethenew
keratinocytes that repopulate the epidermal basal cell layer including sebaceous
glands and hair follicles within the new epidermis.1 This burn wound is extremely
painful, making cleaning and debridement a horrific procedure for the patient and a
stressfuldailyactivityfortheburnnurse.Partial-thicknessburnsthatcanbeleftalone
aretreatedwithtopicalantimicrobialagents.
Atangentialexcisionisusedonapartialthicknessburnbyremovingthinlayersof
burned skin until the surgeon reaches viable dermis or the subcutaneous fat is
exposed.Severalinstrumentsmaybeusedtoexcisetheburnwoundincludingknives
with adjustable guards that allow the surgeon to vary the depth of penetration or
dermatomes.TheRosenbergknife,Goulianknife,Watsonknife,and,VersaJetwater
BurnICUPerspective 73
dissector are some examples of tangential excision instruments used in burn
procedures.Withatangentialexcision,healthytissueisdeterminedbythepresence
of dermal or subcutaneous bleeding.2 The burn is debrided to a shiny white dermal
surfacewithfinecopiousbloodflow.
Deep-,orfull-thickness,burnsinvolvetheentirethicknessofthedermisandextend
intothesubcutaneousfat.Ifsmallenough,afull-thicknessburnwoundwillhealasthe
eschar separates and granulation occurs, but this process leads to hypertrophic
scars. Surgical intervention is most likely the only choice in any full-thickness burn
injury.Thisleather-likeinjuryisrelativitypainlessandnonblanching.Allotherburned
areashavepainassociatedinandaroundtheburnwound.EarlyE&Gdecreasesthe
painassociatedwiththeburnwoundovertime.2
Current practice is to excise as much of the burn wound as possible during the
initialsurgicalprocedure,takingintoaccountthestabilityofthepatient.1Theexcision
of the burn wound can be a tangential excision that removes the burned tissue,
leavingasmuchoftheunderlyingviabletissueaspossible.Withthistypeofexcision
body contours are better preserved, hospital stay is decreased, reconstructive
surgicalproceduresarefewer,andpatientsreportlessassociatedpain.1
The fascial excision is a formal integumentectomy excision that removes the
subcutaneous fat including the lymphatic tissue down to the fascia. Although less
bloodlossisexpected,thisprocedurecreateswhatisknownas“step-offs.”During
afascialexcision,thesurroundingviabletissueandunderlyingfatresultinanuneven
surfacethatcreatesthestep-off.Typically,electriccauterycanbeusedtoexcisethe
burnwound,decreasingbleedingasthetissueisremoved.
Meshedsplit-thicknessautograftgivesalessdesirablecosmeticappearancebutis
required when available donor sites are limited or the patient has suffered an
extensiveburn.Themeshedskinisachievedbyrunningthesheetgraftthroughthe
surgicalmesheratadeterminedratioofexpansion(1:1through4:1).Theparallelslits
created in the sheet graft allow the skin to be expanded when being placed on the
excisedwoundbed.Thenewlyplacedmeshedautograftwillbegintoreepithelialize
acrosstheintersticesconnectingthemeshedskintoprovidewoundclosure.Timeto
closure is dependent on the patient and ratio of expansion. When healed, the graft
retains the wafflelike meshed appearance, texture, and color. Meshed graft is
protectedbythesurgicaldressingfor3to5days,allowingthegrafttoadheretothe
woundbed.Leavingthedressingsonforsuchanextendedtimeallowsthefibrinseal
thatinitiallyholdstheautograftinplacetoadvancewithcapillarygrowthandcollagen
production.2 Allograft may be placed over the larger expanded autograft to protect
against shearing. The use of negative-pressure dressings or Wound Vacs (KCI, San
Antonio,TX,USA)mayalsobeusedtocoverandprotectthenewlyplacedautograft,
keepingthedressinginplaceforthesame3to5dayspostoperatively.
Eachtypeofgraftplacedonthepatienthasspecificimplicationsinthepostoper-
ative period for the BICU staff. Split-thickness sheet autograft, or sheet graft, is a
continuouslayerofdonorskinthatisharvestedfromthedonorsiteandsecuredtothe
patientwithstaples,sutures,oradhesivestrips.Thistypeofgraftisusuallyreserved
forcosmeticareasliketheface,neck,hands,andfingers.Thethicknessofthegraft
harvested typically is 0.009 to 0.020 inches as determined by the burn surgeon to
maximizeoutcomefortheindividualpatient.Thethickergraftstendtoshrinklessand
provide a better cosmetic appearance.2 With sheet grafts, typically 12 to 24 hours
postgraftplacementthenurseandsurgeonevaluatethegraftandremoveanyblood
clots and accumulated serum. The sheet graft must be assessed and evaluated
frequently to remove any subgraft hematoma or seroma by needle aspiration or by
placing a small incision to roll out fluid or clots. Rolling out the seroma toward the
74 Wallace
edgeofthegraftwithacotton-tipapplicatorduringthefirstseveraldayscanbecome
anhourlytask.
Burn patients typically become hypothermic while in the OR despite increased
roomtemperature(85°–95°F)anddrapingwhileontheORtable.Itisnotuncommon
for the BICU room temperature to be increased to between 85° and 100° F. Most
nurseschoosetohavetheroomaswarmaspossiblebecausetheyunderstandthat
postoperativehypothermiaincreasestheriskofvasoconstriction,hypoperfusion,and
metabolic acidosis. Heat lamps and space blankets along with increased room
temperature are efficient ways to warm the patient and provide an optimal environ-
ment for graft take. Another piece of equipment that should be available is a rapid
infuserwithheatingcapabilities.ThisdeviceallowsforafastdeliveryofIVfluidsfor
hypovolemic shock and gives the staff another option to reverse the hypothermic
statethepatientmayreturnin.
Forpostoperativepatientsdeemedatriskforhemodynamicinsufficiency,theUS
ArmyBurnCenterpreparesvasopressin,norepinephrine,anddobutaminepriortothe
patient’s return from surgery. The first drug of choice is vasopressin. In the Army
BICU,vasopressinishungasafirstlinedruginhemorrhagicshockassociatedwith
excessivebloodloserelatedtoextensiveE&G.Vasopressinactsontherenalsystem
by increasing the water permeability of the distal tubules and collecting ducts,
allowingwaterreabsorption.Italsoactsonthecardiovascularsystembyincreasing
peripheral vascular resistance and in turn increasing the arterial blood pressure.
Vasopressin is an on/off drug; there is no need to titrate up or down. The standard
doseis0.04U/minor2.4U/h.
If the patient continues to require cardiovascular support, norepinephrine is the
next choice in the bedside arsenal. Norepinephrine acts on both (cid:1)-and (cid:1)-
1 2
adrenergic receptors, causing vasoconstriction and increased peripheral vascular
resistance. At increased doses and when combined with other vasopressors it can
leadtolimbischemia.Incausingvasoconstrictionandlimbischemia,norepinephrine
is basically starving the newly placed graft of blood flow and increasing the risk of
poorornografttakeandultimatelyriskinganothersurgicalprocedureforthepatient
toundergo.Forthisreasonnorepinephrineisnotconsideredasafirstlinevasopres-
sor in the Burn ICU. Norepinephrine is hung and titrated up, down, and off very
quickly,ifpossible.
SinceDobutamineisadirect-actingagentwhoseprimaryactivityresultsfromthe
stimulation of the (cid:2)-adrenoceptors of the heart which increases contractility and
1
cardiacoutput,itisoflittleuseimmediatelypostoperativelybecausethepatientoften
has hypovolemic shock. Once fluid and blood products have restored intravascular
volume,dobutaminemaybeused.
AttheArmyBurnCenter,havingtwo“bricks”atthebedsideisapracticeusedfor
a large-burn patient returning from the OR. The brick is a consolidation of elements
usedduringamassivetransfusionintoonebagandisonlyusedinthefaceofongoing
bleeding and severe hypotension while waiting for blood products. The brick is
composed of 100 mL of 25% albumin and 1 A ofsodium bicarbonate in 1 L Ringer
lactate. If the mean arterial pressure is low ((cid:1)50), the physician may transfuse the
patientpostoperativelywithpackedredbloodcells,plasma,and/orplatelets.
The hypovolemic state brought on by massive blood loss in the OR and possible
continued blood loss from open wounds and donor sites continues to assault the
patient’s hemodynamic stability. At this time, BICU nurses hang the brick while
waitingforadditionalbloodproductstoarrive.
Totalfluidsinfusedincludecolloids,crystalloids,bloodproducts,andhypodermal
clysis (subcutaneous fluid instillation). Colloids (albumin and plasma proteins) are
BurnICUPerspective 75
usedtoincreaseintravascularvolume;crystalloids(lactatedRingerandnormalsaline)
help in the vascular volume but also replace the extracellular fluid. The amount of
packedredbloodcellsgivenintheburnORisagoodindicatorofbloodlossand
allows the BICU nurse to anticipate the need for more products to have on hand
in the BICU.
In the burn OR, hypodermal clysis is a subcutaneous injection of saline into the
dermisthatallowsforeasierharvestingoverirregularsurfacesliketheribsorback.At
the Army Burn Center, a solution of 1 L ofRinger lactate with 1 cc of epinephrine
1:100,000 U infused with an 18-gauge spinal needle and a pressure pump is used.
Thisderma-infusedsolutioniseventuallyabsorbedintothepatient’svasculatureover
the course of several hours. Physicians and BICU staff must be made aware of this
volume to adjust the IV volume being administered and reduce the risk of fluid
overload.
It is impossible to accurately estimate blood loss during burn surgery. During the
procedure,bloodisnotcollectedincanisterswhereitcanbemeasuredbutisunder
the patient, in surgical drapes, absorbed in sponges and towels, on the floor, and
evenwasheddowndrains.Theestimatedbloodlossisanartformestablishedover
countlesssurgicalproceduresandisawell-educatedguessbytheexperiencedburn
anesthesiologist. Urine output is also a component of fluid loss and should be
includedintheORtoBICUreport.
Donor site care is different from burn wound care; each burn facility has its own
wayofdressingandmanagingdonorsites.OneisXeroformgauzestapledoverthe
wound, Telfa and epi-laps (sterile burn sponges soaked in a solution of 10 cc
epinephrine1:100,000Uin1Lsterilenormalsalineirrigation)thencompressedwith
an elastic bandage. The dressing is removed 24 hours postoperatively. Heat lamps
areappliedifadditionaldryingisrequired.Lampsareplaced18to24inabovethesite
for 20 minutes each hour to facilitate drying. A positioning device that elevates the
limb and allows air flow around the donor site to aid in drying is effective. Some
biologicaldressingsareused,butiffluidaccumulatesunderthedressingitcanlead
toinfectionandpossibleconversiontoafull-thicknesswound.Infectionandpossible
conversionoccurswhenadonorsitehasdecreasedperfusionandthewoundfluidis
lefttocreateanoverlymoistwoundbed.
AtriptotheburnORincreasestheworkloadoftheBICU,butawell-preparednurse
can receive the patient from the OR in any condition and lead the nursing team
throughapotentiallychaotic,intense,andemergentpostoperativeperiod.
Burncarerequiresconstantcommunicationandattentiontodetail;itisaphysical
form of nursing that requires mental and physical toughness. From the warm
environment and long hours at the bedside caring for the patient to the interaction
with the families, burn nurses are at the front of patient care. With the proper
education and training, those who choose the rewarding title of burn nurse make a
differenceeverydayinthelivesoftheirpatientsandtheirpatients’families.
REFERENCES
1. HerndonDN.Totalburncare.3rdedition.Philadelphia:Elsevier;2007.Chapters11,
13,14,15.
2. CarrougherGJ.Burncareandtherapy.StLouis(MO):Mosby;1998.Chapter10.