Sepsis management in Burns

Rathivika. S. Sundar

Consultant Physician – Infectious Diseases, Kauvery Hospital, Alwarpet, Chennai

Background

This is the paper, which discuss the factors lead to sepsis in the burn patients and their managements.

Why is person with burns injury prone to sepsis?

  • Loss of protective barrier
  • Subcutaneous blood vessels thrombosis
  • Avascular bed
  • Alteration in innate and adaptive immunity
  • Hypermetabolism

Risk factors of Sepsis in Burns

  • Age >50 years
  • Inhalational injury
  • Increased TBSA >25%
  • Full thickness burns
  • Pre-existing immunosuppressed state

Pathophysiology

  1. Pro inflammatory Phase
  2. Release of IL-1, IL- 4, IL-6, TNF α
  3. Vitals : RR, Temperature, heart rate ↑ Hypermetabolic state
  4. Persistent SIRS
  5. Compensatory anti-inflammatory Phase CARS
  6. Anti-inflammatory cytokines ↑ Pro-inflammatory cytokines ↓
  7. IL-10 and TGF-β (peak level 1 week after injury) Decrease in NK activity and IFN γ

Jeschke MG et al, NRDP 2020

Sepsis markers and scores

SOFA score – 1994

ABA recommendation

  • Hepatic – Hyperglycemia
  • GCS – only in non-sedated patients
  • Add tolerance to Enteral feeding
  • Only Nor-Epinephrine used (Dopamine is excluded in view of ↑HR )

Burns SOFA score

Boehm D et al, .Medicina 2021

3 H’s – Beginning of Organ Failure

Boehm D et al, Medicina 2021

Common sources of sepsis in Burns

  • Pneumonia ± respiratory failure (20–56%)
  • Septicaemia due to wound infection
  • Central venous access, other vascular lines (arterial/venous)
  • Indwelling urinary catheters

Management

  • Initiate Antibiotic within 45 min
  • Presumed pathogen and Empiric Antimicrobial
  • Betalactam antibiotics – bolus dose
  • Therapeutic drug level monitoring
  • Blood cultures – confirm diagnosis and guide de-escalation
  • Source control

Wound cultures

Weekly until signs of infection subside

Admission cultures: transfers from other facilities

Quantitative analysis: identifying “invasive infection” • Invasive infection >=105 colonies/gram of tissue

Summary

  • Burns – Immunosuppressed state
  • Persistent SIRS – Different criteria for sepsis
  • Serial Procalcitonin and IL-6
  • “Presumed pathogen” with Empiric antimicrobial
  • Knowledge of “Antibiogram and HAI” of the facility
  • Remove central lines, urinary catheters at the earliest
  • Strict HIC practices
  • Differentiate between colonization, contamination and invasive infection.

Dr.Rathivika S Sundar

Dr. Rathivika S Sundar
Consultant Physician – Infectious Diseases

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