What are the recommendations for adjuvant management in burn patients?

Adjuvant Management in Burn Patients

The most effective adjuvant management for burn patients includes multimodal analgesia, appropriate wound care, early nutritional support, and targeted pharmacological interventions like oxandrolone for severe burns, while avoiding prophylactic antibiotics unless clinically indicated. 1, 2

Pain Management

• Multimodal analgesia approach:
  • Titrate all analgesic medications based on validated comfort and analgesia assessment scales 1
  • Use a combination of acetaminophen, NSAIDs, and opioids as needed 2
  • Consider ketamine as an adjunct for severe burn-induced pain 1
  • Employ non-pharmacological techniques (virtual reality, hypnosis) when appropriate for dressings in stable patients 1, 2
  • Use a patient-appropriate validated pain tool at least once daily 1

Wound Care Management

• Conservative approach:

  • Cleanse wounds by gently irrigating with warmed sterile water, saline, or dilute chlorhexidine (1/5000) 1, 2
  • Decompress blisters by piercing and leaving the roof intact as a biological dressing 2
  • Apply greasy emollient (50% white soft paraffin with 50% liquid paraffin) over the epidermis 1, 2
  • Use non-adherent dressings for denuded areas (e.g., Mepitel™ or Telfa™) 1
  • Consider silver-containing products for sloughy areas only 1, 2

• For extensive burns:

  • Consider transfer to a burn center for patients with >30% BSA epidermal loss 1
  • Surgical debridement may be necessary to remove necrotic tissue 1

Infection Prevention and Management

• Key principles:
  • Take swabs for bacterial and candidal culture from lesional skin on alternate days 1
  • Do not administer systemic antibiotics prophylactically 1, 2
  • Only use antibiotics when there are clinical signs of infection 1, 2
  • Employ strict barrier nursing to reduce nosocomial infections 1
  • Monitor for signs of infection (increasing pain, redness, swelling, discharge, fever) 2

Nutritional Support

• Nutritional guidelines:
  • Provide continuous enteral nutrition throughout the acute phase 1
  • Deliver 20-25 kcal/kg daily during the early catabolic phase 1, 2
  • Increase to 25-30 kcal/kg daily during the anabolic recovery phase 1, 2
  • Start nutritional support within 12 hours after burn injury 2
  • Prefer oral or enteral routes over parenteral nutrition 2

Fluid Resuscitation

• For extensive burns:
  • Administer crystalloids as first-line treatment 2
  • Use 20 ml/kg of balanced crystalloid solution in the first hour for adults with ≥20% BSA burns and children with ≥10% 2
  • Prefer balanced solutions like Ringer's lactate 2
  • Monitor fluid balance carefully and catheterize if necessary 1

Pharmacological Adjuncts

• Oxandrolone:

  • Consider for severe burns (typically >20% TBSA) 3, 4
  • Typical dosing is 20 mg/day 5
  • Benefits include:
    • Reduced hospital length of stay 3, 4
    • Improved wound healing time for donor sites 4, 6
    • Decreased weight loss and nitrogen loss 4, 6
    • Increased lean body mass and bone mineral density 3, 4
  • Monitor liver enzymes, though significant dysfunction is rare 4, 5

• Hyperbaric Oxygen Therapy (HBOT):

  • Not recommended for burn wound healing 1
  • Only indicated for carbon monoxide poisoning after smoke inhalation 1

Environmental Considerations

• Temperature control:
  • Maintain ambient temperature between 25°C and 28°C 1
  • Use a pressure-relieving mattress 1

Rehabilitation

• Early intervention:
  • Begin range of motion exercises early to prevent contractures 2
  • Consider massage therapy to soften scar tissue and improve circulation 2

Burn Severity Assessment and Referral

• Consider referral to a burn specialist for:
  • Burns involving face, hands, feet, genitalia, or perineum
  • Full-thickness burns

  • 10% TBSA in children or >20% TBSA in adults 2

By implementing this comprehensive adjuvant management approach, clinicians can optimize outcomes for burn patients while minimizing complications and promoting functional recovery.