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Optimal resuscitation of
severe burns with PiCCO
• Improved volume management with GEDI (Global End Diastolic Volume Index) in severely burned patients(1)
• Significantly lower MODS (Multiple Organ Dysfunction Score) in burn patients using PiCCO(1)
• Instant bedside quantification of pulmonary edema with ELWI (Extra Vascular Lung Water Index)
Individualize your burn
resuscitation with PiCCO
Currently the most common practice for volume management in burn patients is based on the Parkland or Brooks formulas
which estimate the amount of fluid based on burn size and body weight. The result is monitored only by Hourly Urine Output
(HUO) and Mean Arterial Pressure (MAP).
Numerous studies have shown that this treatment strategy is far from perfect:
Outcome of study
Sánchez-Sánchez M. et al. A protocol for resuscitation
of severe burn patients guided by transpulmonary
thermodilution and lactate levels: a 3-year prospective
cohort study(2)
The surveyed data support previous studies showing that urine output and vital
signs, such as blood pressure and heart rate, are insufficient to guide resuscitation of critically burned patients. PiCCO derived GEDI* should be used as the
parameter to guide fluid management.
Csontos C. et al. Arterial thermodilution in burn
patients suggests a more rapid fluid administration
during early resuscitation(1)
A number of studies have proved that the Parkland Formula frequently underestimates the water and electrolyte loss of burned patients. The surveyed data
suggest that the PiCCO derived GEDI* is a better target parameter than HUO
in the fluid resuscitation of severely burned patients in the first 3 days post-injury.
Holm C. et al.Intrathoracic blood volume as an end
point in resuscitation of the severely burned: an
observation study of 24 patients(3)
Resuscitation guided by PiCCO-Technology should become the standard in
the treatment of large burns, as only invasive multi-parametric monitoring may
reflect the true hemodynamic status of these patients.
• About 24 hours post burn injury HUO and MAP may
provide inadequate and unreliable information on the
patient’s actual volume status due to renal insufficiency /
acute renal failure(1)
• Furthermore, static formulas may mislead therapeutic
decisions because they do not consider the individual
patient’s conditions during the course of treatment
• The Parkland or Brooks formulas often underestimate
the water and electrolyte losses(2)
PiCCO measurements enable patient individualized fluid resuscitation protocols as used by Csontos et al.(1)
Initial fluid resuscitation based on the Parkland formula during the
first 24 hours post-injury (4ml/kg/% of burned total body surface area)
< 600 ml/m2
600-640 ml/m2
640-680 ml/m2
> 680 ml/m2
500 ml crystalloid
solution bolus
Inf. rate
increase by 10%
No intervention
Inf. rate
reduction by 10%
*Instead of GEDI the study measured the ITBVI
(ITBVI = 1.25*GEDI)
Wait for 2 hours
Burns of more than 20% of body surface area may be complicated by shock, lung injury and sepsis.
Advanced hemodynamic monitoring with the PiCCO-Technology facilitates the management of these
life-threatening disorders.
Pathophysiology of severely burned patients
Capillary leak syndrome
(loss of plasma, fluids and
electrolytes) causes:
• Hypovolemia
• Risk of hypoperfusion
• Risk of burn shock
High level of endogenous
catecholamines affects:
Necrotic tissue results in:
• Release of toxic
• Cardiovascular system
• Impaired immune response
• Risk of Systemic
Inflammatory Response
Syndrome (SIRS)
• Tissue perfusion
• Metabolic rate
Fluid management: too little,
too much, or even ... too late?
What is the optimal amount of fluid
for burn resuscitation?
• What is the cardiac output?
• Is the patient fluid responsive?
• Is the patient at risk of volume
overload/pulmonary edema?
• Does the patient have increased pulmonary permeability?
Benefits of PiCCO-Technology for monitoring of burn patients
Several studies have confirmed the benefits of PiCCO-Technology for monitoring of burn
patients. The bedside measurement of continuous cardiac output allows an early detection of
unpredictable changes in the hemodynamic status. The multi-parametric PiCCO-Technology
enables the institution of personalized goal-directed burn resuscitation, which helps prevent fluid
overload or fluid under-resuscitation and adjust inotropes and vasopressors.
Extravascular Lung Water Index (ELWI):
• PiCCO derived ELWI gives information on interstitial lung
water and helps in tracking pulmonary edema
Global End Diastolic Volume Index (GEDI):
• PiCCO derived GEDI provides reliable information about
cardiac preload(2)
Example of a GEDI guided fluid resuscitation protocol to treat
severely burned patients with a permissive hypovolemic
approach as used in the study by Sánchez-Sánchez et al.(2):
• Enables quantification of fluid shifts from intra - to extravascular compartments(2)
480 ml/m2
Continuous lactate measurement is
provided by EIRUS
480-800 ml/m2
> 800 ml/m2
Lactate (mmol/L)
> 2.0
< 2.0
• Lactate levels act as a warning signal in patients at risk
EVLWI (ml/kg)
< 10
> 10
Pressure (mmHg)
< 15
> 15
• Changes in lactate levels over time can be used in the
assessment of the patient’s overall condition and response
to therapy. Continuous monitoring with EIRUS tracks this
important parameter at a glance with no trend gaps
• EIRUS instantly alerts nursing staff when out-of-range
• Can be an early warning sign of developing sepsis(4)
• The continuous elevation of ELWI can predict poor
outcome in burns(4)
• Helpful in guiding and monitoring fluid resuscitation and
optimization of the cardiac output(2)
• ELWI together with the Pulmonary Vascular Permeability
Index (PVPI) helps to differentiale between hydrostatic- and
permeability pulmonary edema
EVLWI (ml/kg)
< 10
> 10
Pulmonary edema is not easily detected by chest X-ray as
demonstrated in the pictures below. ELWI is much more
sensitive and allows bedside quantification of pulmonary
edema. Protocols using ELWI as a monitor to guide volume
resuscitation and other cardiovascular support have been
shown to decrease length of ICU stay and mortality.(5,6)
If lactate ↑
Severe lung edema
ELWI 21 ml/kg BW
values are detected
Moderate lung edema
ELWI 11 ml/kg BW
• Ensures the ability for prompt treatment for timely
management of glucose and lactate levels
↑ fluid
= fluid
↓ fluid
↓ fluid
if Cardiac Index (CI) < 2.5 (l/min/m2) give inotrope or vasopressor
*Instead of GEDI the study measured the ITBVI (ITBVI = 1.25*GEDI)
No lung edema
ELWI 5 ml/kg BW
Get equipped for all eventualities:
What if…
…the location of the patient’s burn injury prohibits the insertion of the PiCCO catheter into
the femoral artery?
PULSION offers PiCCO catheters in different sizes which can be applied at other
insertion points (brachial, axillary or radial).
…you want to use the PiCCO-Technology in severely burned pediatric patients?
Specially developed pediatric 3 French catheter is available.
…the location of the patient’s burnt tissue is prohibiting the application of
a standard jugular CVC to perform a thermodilution?
The transpulmonary thermodilution also works with a femoral CVC. GEDI values will be
corrected automatically by the software.
In less severe cases there is the possibility to use the ProAQT-Technology which provides
cardiac output trend monitoring, but does not require a CVC.
…you want to measure lactate values continuously to optimize your burn resuscitation protocol
and improve patient outcome?
EIRUS is a unique continuous monitoring platform for both lactate and glucose. EIRUS
eliminates the risk of trend gaps and reduces the workload of the nursing staff. This new
technology is developed by Maquet and distributed by PULSION.
Csontos C. et al. Arterial thermodilution in burn patients suggests a more rapid fluid
administration during early resuscitation. Acta Anaesthesiol Scand 2008; 52(6): 742749.
Sánchez-Sánchez M. et al. A protocol for resuscitation of severe burn patients guided
by transpulmonary thermodilution and lactate levels: a 3-year prospective cohort
study. Critical Care 2013; 17(4): R176.
Holm C. et al. Intrathoracic blood volume as an end point in resuscitation of the severely burned: an observation study of 24 patients. J Trauma 2000; 48(4): 728-34.
PULSION Medical Systems SE
Hans-Riedl-Straße 17
85622 Feldkirchen
Phone: +49 (0)89 45 99 14-0
[email protected]
Bognar Z. et al. Extravascular lung water index as a sign of developing sepsis in
burns. Burns 2010; 36(8): 1263-1270.
Mitchell J.P. et al. Improved outcome based on fluid management in critically
ill patients requiring pulmonary artery catheterization. Am Rev Respi Dis 1992;
145(5): 990-998.
Eisenberg P.R. et al. A prospective study of lung water measurements during
patient management in an intensive care unit. Am Rev Respi Dis 1987; 136(3):
PULSION Medical UK, Ltd.
Unit C4, Heathrow Corporate Park,
Green Lane • Hounslow
Middlesex, TW4 6ER,
Tel. +44 (208) 81 47 97 4
[email protected]
PulsioFlex & PiCCO Module (Manufacturer:
PULSION Medical Systems SE)
EIRUS (Manufacturer:
Maquet Critical Care AB)
MPI4113EN_R00 1.
© 2014-09 PULSION Medical Systems SE
Literature references