How to manage a patient with 50% burns, leukocytosis, hypoalbuminemia, and massive pleural effusion?

Management of 50% Burns with Leukopenia, Hypoalbuminemia, and Massive Pleural Effusion

This patient requires immediate transfer to a specialized burn center with ICU capabilities, aggressive fluid resuscitation guided by urine output (not standard formulas given the pleural effusion), albumin supplementation to maintain levels >30 g/L, and urgent evaluation for the source of the pleural effusion which may represent infection, fluid overload, or inhalation injury complications. 1

Immediate Priorities

Critical Care Setting and Team Assembly

• Transfer immediately to a burn center or ICU experienced in managing severe burns with >10% TBSA involvement, as this 50% TBSA burn far exceeds the threshold requiring specialized care 2, 1
• Assemble a multidisciplinary team including burn surgery/plastic surgery, intensive care, and nursing with burn expertise 2
• Barrier-nurse in a side room with controlled humidity (25-28°C ambient temperature) on a pressure-relieving mattress 2

Airway Assessment

• Evaluate immediately for intubation criteria given the extensive 50% TBSA burn (well above the 40% threshold), even without facial involvement 2
• Intubate without delay if any signs of respiratory distress, severe hypoxia, hypercapnia, or altered mental status are present 2
• The massive left pleural effusion significantly increases respiratory compromise risk and may necessitate intubation for airway protection 2

Fluid Resuscitation Strategy

Modified Approach Due to Pleural Effusion

• Do NOT use standard Parkland formula (4 mL/kg/%TBSA) given the massive pleural effusion, as this indicates either fluid overload ("fluid creep") or another complicating process 1
• Start with conservative crystalloid resuscitation using Ringer's Lactate at 20 mL/kg bolus initially 1
• Titrate fluids strictly to urine output (target 0.5-1 mL/kg/hour) rather than calculated volumes to avoid worsening pulmonary edema 1, 3
• Insert urinary catheter for precise monitoring 2

Albumin Supplementation

• Initiate 5% albumin infusion immediately (8-12 hours post-burn if within that window) at 1-2 g/kg/day to maintain serum albumin >30 g/L 1
• This addresses the hypoalbuminemia (1.28 g/dL) and reduces crystalloid requirements, potentially preventing further fluid accumulation 1
• Albumin administration reduces organ failure incidence and mortality in severe burns 1

Management of Pleural Effusion

Diagnostic Evaluation

• Obtain urgent chest CT if patient stable enough to characterize the effusion and rule out empyema, hemothorax, or underlying pulmonary pathology 3
• Perform diagnostic thoracentesis to analyze fluid for infection (culture, cell count, pH, LDH, protein) versus transudative process 3
• Consider inhalation injury as a cause—assess for circumoral burns, oropharyngeal burns, carbonaceous sputum, and history of enclosed space fire 2, 4

Therapeutic Intervention

• Perform therapeutic thoracentesis or chest tube placement if the effusion is causing respiratory compromise, which is likely given its "massive" size 3
• If empyema is identified, initiate broad-spectrum antibiotics covering Staphylococcus aureus and Gram-negative organisms including Pseudomonas 2

Infection Surveillance and Management

Leukopenia Concerns

• The WBC of 3,850 is concerning for either bone marrow suppression or overwhelming sepsis in the context of severe burns 2
• Take swabs from three areas of burn wounds for bacterial and fungal cultures immediately and on alternate days 2
• Monitor closely for clinical signs of sepsis: confusion, hypotension, reduced urine output, decreased oxygen saturation, increased skin pain 2
• Do NOT give prophylactic systemic antibiotics—reserve for documented infection to avoid promoting resistant organisms and Candida colonization 2

Infection Monitoring

• Monitor C-reactive protein and serial WBC counts 2
• Watch for monoculture on repeat swabs indicating predominant organism and increased invasive infection risk 2
• If systemic infection develops, initiate antibiotics targeting both Gram-positive (including MRSA) and Gram-negative organisms based on local resistance patterns 2

Wound Care Protocol

Conservative Approach

• Cleanse wounds gently with warmed sterile water, saline, or chlorhexidine (1:5000) solution 2
• Apply 50% white soft paraffin with 50% liquid paraffin over all burn areas including denuded zones 2
• Apply topical antimicrobial (silver sulfadiazine 1% cream or silver-containing dressings) to sloughy areas only, not prophylactically 2, 5
• Decompress blisters by piercing and aspirating fluid; leave detached epidermis as biological dressing 2
• Apply non-adherent dressings (Mepitel or Telfa) with secondary foam dressing for exudate collection 2

Surgical Considerations

• Evaluate daily for need to escalate to surgical debridement if clinical deterioration, extension of detachment, subepidermal pus, local sepsis, or delayed healing occurs 2
• Consider early excision and grafting once patient stabilized, as this improves outcomes 3, 6

Nutritional Support

• Insert nasogastric tube and initiate continuous enteral nutrition immediately if oral intake inadequate 2
• Provide 20-25 kcal/kg/day during acute catabolic phase, increasing to 25-30 kcal/kg/day during recovery 2
• Early enteral nutrition is critical for the hypermetabolic response to burns 3, 6

Monitoring Parameters

Daily Assessments

• Urine output hourly (target 0.5-1 mL/kg/hour) 1
• Fluid balance with daily weights 2
• Serum albumin levels (maintain >30 g/L) 1
• Complete blood count, electrolytes, renal function, liver function 2
• Respiratory status and oxygen requirements 2
• Pain assessment using validated tools 2

Compartment Syndrome Surveillance

• Monitor for compartment syndrome in any circumferential burns, particularly on extremities 1, 7
• Assess distal perfusion, capillary refill, pulses, and neurologic function every 2-4 hours 7
• Perform escharotomy urgently if signs of vascular compromise develop 1, 7

Critical Pitfalls to Avoid

• Avoid "fluid creep"—the massive pleural effusion suggests this may already be occurring; aggressive fluid restriction with albumin supplementation is essential 1
• Do not delay thoracentesis if respiratory compromise present—the effusion must be addressed urgently 3
• Never give prophylactic antibiotics in the absence of documented infection 2
• Do not use hydroxyethyl starch (HES) or gelatin colloids—these are contraindicated in burns 1
• Avoid normal saline as primary resuscitation fluid due to hyperchloremic acidosis and AKI risk 1