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Hi, everybody. Welcome to the November edition of the SI CS Evening education Updates. Um I'm just gonna give it a couple of minutes um for a few more people to join and then we'll get started. Ok, so welcome to everybody who's just joined. Um This is our November education evening update and we've got a fantastic talk for you tonight. Um Just before we start, I just wanted to mention that the registration for SSS 24 has opened. Um So that meeting is the 7th and 8th of March 2024. Um And you can register through the sixth website. Um So our speaker tonight is Doctor Leah Payton. Um We're very lucky to have her tonight. She's the lead for burns critical Care at the Scottish National Burn Center at the Glasgow Royal Infirmary. Um She also works with the care of Burns in Scotland Managed Clinical Network as a steering group member and data group chair and she coauthored the ESI M Academy Modules in burns injury. Um Doctor Bason is here tonight to talk to us about, uh give us an update in the management of burns. So thank you so much. Um for being here tonight and I will hand you over. Are you muted? Sorry. Uh start again. Uh So thank you very much Helen for that lovely introduction and for inviting me to speak about burns critical care to this esteemed audience. So this is a picture of heather burning over the So Wafer, this is not only a source of injury for previous patients, but also something of a metaphor for burns care in Scotland as the landscapes change somewhat over recent years. And it's probably important that we as intensivist and anesthetists have some control over that process. So over the next 45 minutes or so, I'm going to talk about aspects of burns critical care, focusing primarily on the front end of the patient's admission because I think that's likely to be of most interest to people in the audience. I'll start with a brief summary of aspects of burns pathophysiology that are relevant to us as those leading resuscitation. Then I'll sidestep into the reorganization of burns services in Scotland over recent years and what this means for referrals. Then we'll come to clinical matters, prioritizing the phases of care, outwit the burn center and laterally touching on the problems that we encounter further down the line at this point. It's probably appropriate that I provide something out of a disclaimer because the evidence base for much of what I'm about to say is limited largely as a consequence of the small numbers of burns that we now see in developed countries. So we end up making reasoned judgments in the absence of true high quality evidence. I think that evidence is coming because international collaborative networks are evolving. And within the last year, we've had the reenergized trial. A multicenter randomized controlled trial of sufficient quality that made its way into the New England journal. This was a negative trial, but at least it shows what's possible when we collaborate between burn centers. So let's start with some pathophysiology. The immediate changes that occur with cutaneous burns are conceptualized within Jackson's burn wound model. This describes three concentric three dimensional zones with differing pathological features and increasing capacity for recovery. There's an inner zone of coagulative necrosis where maximal and irreversible tissue damage occurs due to coagulation of proteins. This is surrounded by an intermediate zone of stasis where impaired blood flow renders the tissue vulnerable but potentially salvageable. There's an outer zone of hyperemia which is characterized by inflammation and vasodilatation with burns that exceed more than 25% total body surface area. This zone of hyperemia is sufficient to induce a systemic inflammatory response. And our challenge is in trying to ensure that the process that occurs within this zone. Three, doesn't jeopardize the survivability of zone two as the largest organ in the body. The skin is vitally important to maintaining homeostasis. So it's unsurprising that sizable cutaneous deficits lead to systemic sequelae that evolve over time. There's an initial release of proinflammatory and myocardial depressant factors coupled with hypovolemia that arises from evaporative losses and capillary leak. And this gives rise to an ebb phase that lasts for around 48 to 72 hours after burn injury. This is followed by a subsequent flow phase that can last weeks, months and potentially years. It's characterized by a hyperdynamic hypermetabolic physiological state during which immune dysfunction further predisposes to sepsis. Some understanding of burn depth is also important because this will dictate the requirement for surgical intervention. Burn depth usually depends on the temperature to which the skin's been exposed. And the duration of that exposure, superficial or epidermal burns are characterized by extensive erythema but no blisters, they're painful but will heal without surgery or sequelae. And the classic example of this would be sunburn. Most of us having experienced that partial thickness, burns are evidenced by breakdown of the dermis, sorry, breakdown of the epidermis. With exposure of the dermis and blisters, they can be subdivided into superficial dermal and deep dermal burns. Superficial dermal burns are characterized by a moist pink appearance. They may be associated with blisters and are painful but will heal without surgery usually within a period of about three weeks and without significant scarring. Deep dermal burns. On the other hand, extend further through the dermis. They have a dry cherry or brick red appearance, they're less painful and because more of the dermal regenerative structures are obliterated, they're less likely to heal up their own record. So we'll most often need surgery both in the acute phase and for reconstructive purposes, full thickness burns are those which extend through the dermis into the subcutaneous tissues. They have a waxy appearance and may in actual fact be painless because the dermal regenerative structures are obliterated. There's no capacity for spontaneous healing out with contracture from the wound edges. So these will always require excision and grafting in the acute phase and will potentially require quite considerable reconstructive surgery. The consequences of a burn injury also depend on the surface area of the body involved. This is usually expressed as a percentage of total body surface area and doesn't include areas of epidermal burns. It's generally recorded on the London writer chart as shown here and will dictate the systemic sequelae critical care interventions and prognosis of a patient. Recent decades have seen a marked decrease in high income countries. The frequency of burn injuries and this has largely occurred as the consequences of accident prevention measures both at home and in the workplace. There have also been marked improvements in the survival of patients with burn injury over recent decades and this means that the original prognostic estimates are now overly pessimistic. So for example, patients with burn injuries that were previously deemed to be 100% fatal are now actually more likely to survive and die than die. And this means as with most of intensive care, there's no increasing focus on reducing morbidity and restoring function. But for patients with burn injury, that's genuinely a very prolonged process that requires truly multidisciplinary care. So that means that I get to work consistently with patients, er, and a group of variably talented, er, and equally genuinely committed people, not the least of which I have to say is our surgical colleagues. Um now I'm not going to touch much on burns surgery. Uh other than to tip my hat to the burns surgeons because really their interventions will determine the success of our own Escher debridement and grafting really are key to addressing the ischemia, infection, fluid and electrolyte homeostasis and hypermetabolism in these patients as such. Even with the difficulties in generating evidence that I alluded to earlier surgical intervention has been shown to reduce mortality, shorten hospital length of stay and facilitate rehabilitation, but that's enough time spent on the surgical ego. Let's instead turn to what's happened with Scottish burn ses over recent years. In 2016, a national review identified a need for centralization of care of patients with major burns. This was planned to bring the Scottish service in line with the hub and spoke models that are employed elsewhere in the UK and across Europe, North America and Australasia. It was also felt to be advantageous as clinical expertise in managing major burn injuries has contracted as the number of cases has fallen. The National Services Division, the salt buds bids even for a Burns hub and GG and C were the sole applicants for this burns hub. Their bid was initially rejected on the grounds of cost and had to be resubmitted with their federal thresholds increased. Eventually, the Scottish National Burn Service was commissioned with pediatric service at Royal Hospital for Children operational fully from December 2021 and phased implementation of the adult service at Glasgow Royal Infirmary over 2021 and 2022. And during this period, this phased period, patients in NHS Lothian and other Southeast health boards were managed within the Southeast region for a temporary period. This was envisaged as a means of permitting the capital work necessary within Glasgow Royal Infirmary to correct uh to develop appropriate and additional critical care capacity. Now, unfortunately, this hasn't happened because of wider infrastructure issues. Uh sometimes happens at Glasgow Royal Infirmary when you scratch the surface, you identify deeper issues. But I'm pleased to say that this actually hasn't impacted our ability to admit appropriate patients at UK level. There are three tiers of burn care that are recognized each with specific referral thresholds that are documented in this guidance. From 2012 burns centers deal with the highest complexity of injury and have dedicated resource both at critical care and ward level as well as immediate operating theater access and theory. Burns units deal with moderately complex injury and have a separately staffed discrete burns ward. Whereas burns facilities manage non complex injury within the setting of a standard plastic surgical ward. So with this pa shift, we now have the burns center with pediatric provision at the Royal Hospital for Children and adult provision at gri supported by facilities in nine wells in Aberdeen Royal Infirmary. And split between Saint John's Hospital and the Royal Infirmary of Edinburgh in Southeast Scotland. And there's some degree of oversight that's provided by the care of burns in Scotland to manage with the shift in referral thresholds that were made necessary by the revised bid. Patients being managed in the burn center are those requiring level three care and also significant early excision and grafting. Importantly, this doesn't include patients with inhalational injury alone. We're unfortunately not funded for those patients and we don't really have a credible route of step down available for them. Other referral criteria include burns exceeding 25% TB sa in adults or 15% in Children. Extensive deep burns or burns that occur in frail elderly patients, babies or as a consequence of high voltage electrical injuries. Again because of the revisions to the burns, but these criteria are slightly out of keeping with UK guidance. But there's the catch all of referring any patient whose needs exceed the capacity available in regional units in preparing this talk. I thought I'd take a look at our activity since phased implementation of the adult burn service at Glasgow Royal Infirmary. Since 2021 we've admitted 44 patients over that time period with around a quarter that have been brought directly to gri by a pre hospital service. This makes us similar to other UK burn centers in that the majority of our patients are undergoing secondary transfers. However, I think it's important to be aware that there are key differences here in Scotland in terms of the time frames and distances that might be involved with those secondary transfers and also the logistics when we don't have the same infrastructure or specialized critical care teams mediating interhospital transfers for adults in Scotland. And this gives us some pause for thought around about how we move these patients in the future for patients. Not in receipt of prehospital critical care. Around 1/5 came directly to gri with the ambulance service. Another fifth went to other hospitals in Greater Glasgow and Clyde a further fifth to hospitals in other west of Scotland boards and the remaining 2/5 to hospitals in the North East and Southeast regions. It's important to mention that all mainland health boards are represented here. So although these patients won't come often to your departments, they will come which brings so nicely to clinical aspects and management of the critically injured burn patient. So imagine you get a call saying that a badly burned patient is en route to your emergency department. What's your immediate response? Well, I guarantee you that most clinicians will be at least a little uncomfortable in this scenario. Patients with big burns aren't that common and they do need key decisions made relatively quickly all while trying to control a natural emotional response to what can actually be quite severe disfigurement. And then we say blithe things like keep coming. Just remember ATL S Well, maybe we don't do that, try and remember umpteen things in an unfamiliar situation when emotions are high. Maybe we should think about using an aid memoir like this one handily available on the Kobus website and covering a to e principles priorities even within the first hour of intervention, such a need more and more would lead us initially to consideration of intubation. Sometimes it's obvious. Er and the decision is straightforward for the patient with deep burns to the face and neck burns that cover more than 30% body surface area or evidence of upper airway compromise in the form of stridor intubation should obviously be prioritized. Likewise, intubation is intubated, sorry intubation is indicated as a matter of course for patients with respiratory failure or coma. But it's somewhat less clear whether intubation is appropriate for the patient who presents with flash burns to the face or speech or swallowing disturbance in these patients. It's perhaps worth thinking about examining the larynx with a fiber optic scope or undertaking a period of close observation as this may avoid intubation. But I'm aware that's easy for us to say and do, but it's less easy if you're about to put them in the back of an ambulance. So when and out just intubate, you're never going to get these decisions right? 100% of my time of the time. So one of my colleagues talks about choosing the mistake that you're going to make. Er and definitely the mistake to make in this situation is to intubate a patient unnecessarily rather than have to rescue a compromised airway. So airway management in burns patients can be difficult. So it's appropriate that the most experienced intubator available carries out this task. We'd always advocate using an uncut and atrial tube so that there's less risk of proximal displacement as the face swells forward, often by as many as several centimeters. Ideally, a size eight or larger range of tracheal tube permits airway toilet. And it's probably worth saying that in the past burns would have been one of those scenarios where inhalational induction might have been held up as the technique of choice. However, there's emerging evidence that this doesn't provide the margin of safety, one's thought in terms of sustained ventilation. So personally speaking, I'd preoxygenate the patient as best I could and then look to secure the airway through a rapid sequence induction post intubation. It's important to keep the F IO two high until the carboxy hemoglobin level is known to be less than 3% or brought down to that level. If the patient has significant toxicity, airway edema generally peaks at around 24 to 48 hours and resolves within 3 to 6 days. Over that period, it's important to keep the head of the bed elevated to 30 degrees where possible to try and retard that edema formation. During this period, there's a clear risk of the endo heal tube becoming dislodged and of significant harm occurring if the tube does become dislodged. So it would be usual for most of our burns patients to be more sedated than our other patients during that initial phase of their admission. The next priority should be to address the circulation, intravenous fluid resuscitation is indicated for patients with more than 15% burns in adults and upwards of 10% total body surface area burns in Children at our center. We still use the Parkland formula as our initial estimate for fluid input. This was first described more than 50 years ago by Doctor Charles Baxter who worked at Parkland Memorial Hospital. Shown here by way of trivia. Both he and the hospital are also known for receiving the fatally wounded President Kennedy. But his long lasting contribution to burns critical care has been to suggest that patients receive four mils of the ringer lactate per kilogram. Actual body weight per percent body surface area burned over the 24 hours from the time of the burn with half given in the first eight hours and the subsequent 16 hours accounting for the remainder of the volume. However, I think it's really important to be aware this is very much a starting point for fluid resuscitation and should not be continued without further review. Another issue that's important to consider alongside fluid resuscitation is that of cyanide toxicity. Cyanide is inhaled as a component of smoke and plastics and other synthetic polymers burn. It binds to the cytochrome oxidase within cells causing histotoxic hypoxia and generating anaerobic metabolism. It's also been shown to exert a direct neurotoxic effect through an MDA release unless we present with seizures and coma on initial testing. Cyano toxicity may manifest as a lactic acidosis, particularly one that doesn't respond as you might expect to fluid resuscitation with an associated high venous oxygen tension where concern exists. Cyanide toxicity should be treated empirically with hydroxycobalamin at a dose of 5 g. So that's 1000 times the dose that you normally use in the context of vitamin deficiency given over 15 to 30 minutes and repeated once if necessary. It's a relatively benign drug, but it will cause orange red discoloration of body fluids for at least 4 to 8 hours. And this can interfere with laboratory measurements, particularly coagulation screens and biochemistry. And it's also been reported to interfere with dialysis. Although we haven't any particular experience of that in our own unit and the final early priority in the emergency department is that of temperature control. It's long been thought that hypothermia was associated with worse outcomes in burns patients. But it's been difficult to tease that out as an effect that was distinct from that of burn size. So patients with big burns are often hypothermic and it was difficult to discern whether it was the big burn or the hypothermia that was driving the poor outcomes in these groups. But in the summer, we had a large data registry analysis published which showed that for every one degree fall in temperature in the emergency department, there was a 5% increased odds of mortality on logistic regression analysis. So this creates an opportunity for us to improve outcomes in our burns patients. Because temperature is potentially modifiable. There is significant potential for burns patients to lose heat both at presentation and when undergoing operative procedures. But there are simple things that we can do to try and mitigate this including removing wet clothes and bed linen, minimizing exposure. For example, making sure that the patient is only examined by those clinicians who are going to make fundamental differences to their management, not by all and sundry and that we apply for their warmers and then reapply them. And when we've done the things that need done for those patients by raising the temperature in our emergency department, resuscitation rooms in theater and in critical care and by ensuring that all the fluids that we're going to be giving these patients, many, many liters are warmed appropriately. Further down the line burns, patients are at significant risk of developing significant core temperature elevation and that occurs as a resulting as a result of changes in the hypothalamic set point. This creates a scenario whereby super added infection can cause profound hyperpyrexia that adversely affects enzyme and hence organ function, proactive temperature management is therefore required. And one strategy that we've chosen to employ is the thermo the intravascular temperature management device shown here. This consists of a catheter that sits within the femoral vein around this catheter are three balloons through which saline is circulated and the temperature of the saline will be manipulated depending on the disparity of the measured temperature of the patient and the temperature. The set temperature of the machine we've shown through our trial period that this device is good at delivering the temperature that we're seeking to achieve. But it's not without risks. And we've seen quite significant issues with cloturin with this device. So once we've ticked off these various facets of resuscitation, one of our next concerns will be where to send the patient for a subset of patients. It'll be obvious that their circumferential burns need omy either to facilitate ventilation as shown in the top picture or to restore a limb perfusion. Thereafter, we can think about any interhospital transfer that may be required. Occasionally, transfer of patients with the most severe burns might be inappropriate. And we appreciate that this uh is a relatively rare scenario in that we're considering early palliation of patients with prior good baseline function. This is Serge B who gave his name to the initial prognostic score used in burns injury, which has subsequently been revised to account for the adverse prognostic impact of inhalational injury. It can be calculated as age plus total body surface area burned plus 17. If inhalation injury is present, nomograms have been constructed from this to aid prognostication and this enables clinicians, relatives and where possible patients to participate in decisions about treatment limitation, possibly even before transfer away from loved ones for elderly patients with big burns. But again, we appreciate that this is out with the norms of intensive care practice when we're talking about patients with good line, good baseline functional status. So national guidelines would suggest that a consultant burn specialist is involved in decision making a roundabout palliation. So once the patient's been stabilized in the emergency departments er and undergo any enterotomies that were required, they're potentially being brought to a non burns icu overnight pending transfer in the morning. And what are we going to consider in that stage? Well, as if by magic, we have another aid memoir. Uh this time covering treatment optimization over that 1st 12 hours again, in a at e fashion, one of the key priorities in this phase is attention to fluid management, not infrequently estimates of the size of the burn will change when it's reviewed by more experienced personnel. So this needs to be factored in. However, as ever optimal filling is a really a ch really a challenging balancing act, particularly in these patients, there's definitely a risk of organ failure with under resuscitation. However, patients with big burns are at risk of fluid creep where the volumes administered exceed those predicted. So for 100 kg man, not uncommon in the west of Scotland with a 50% burn, there's potential for more than 20 L of fluid to be administered within the 1st 24 hours. Unsurprisingly, this can lead to adverse consequences including pulmonary edema ileus in patients with clear need for enteral nutrition, compartment syndromes and generalized peripheral edema that might hinder graf take. So this phase very much tallies with the optimization part of the rule strategy that's advocated by mal brain that you'll have come across in other areas of critical care. But how do we do that in practice particularly when patients might have complicated matters by imbibing their own diuretic ahead of their burn injury. Um I should pause here and credit my colleague, Doctor Cowan with this photograph, the photographer I should say of a modern art installation with Glasgow Royal Infirmary in the background. So it's oh really? So this is our protocol whereby fluid input is reduced on hour, on hour in the presence of an adequate urine output. Occasionally the buck fast can distort things. So it's also worth considering standard indices of perfusion and evidence of hebe concentration in the form of a rising hematocrit for osmolality. It's also worth thinking about measuring intraabdominal pressure if oliguria starts to occur as you as you move further into that 1st 24 hours and doesn't really respond to fluid challenges. Another strategy that we'll use in the context of patients requiring high volumes of fluid is out of colloid rescue with albumin. This has been shown in a meta analysis to reduce both the fluid input and the incidence of abdominal compartment syndrome. Practically speaking, we'll use 4.5% albumin at 12 hours post burn. If the projected fluid input over that 1st 24 hours exceeds six mils per kilo actual body weight per percent body surface area burned. And we'll give it as one third of the hourly fluid requirement until 40 hours post burn. Ok. So let's switch systems and think about inhalational injury in my mind. At least this isn't a particularly useful as her, not a particularly useful diagnosis because it's very much an umbrella term for a spectrum of pathologies with different causes effects and treatments. And I think it's fair to say that this heterogeneity in terms of what we understand by inhalational injury is hampering much needed research in this area. The incidence of inhalational injury appears to increase with both age and TBSA burned and where it is useful is in pre predicting those patients who require up to 50% more resuscitation fluid and those patients likely to feel worse. So what do I mean by a spectrum of pathology? Well, people variously use the term inhalation injury to refer to both respiratory tract injury and systemic effects of inhaled toxins. And even just the respiratory tract injury might be happening at the level of the upper airway due to heat within the tracheal bronchial tree as a consequence of chemical insult or d in down in the lung, parenchyma as a result of inflammation or infection. So, I'd like you to be clear in what you mean by inhalational injury. I'm going to take this opportunity to focus mainly on tracheal bronchial injury, which as I've said is a chemical insult caused by substances in inhaled smoke or steam that irritate the mucosa. It may be suspected on the basis of a history of fire in an enclosed space or prolonged extrication and it may present with dyspnea, wheeze and cough that is associated with carbonaceous sputum. However, for some patients, it can remain occult until diagnosed at bronchoscopy. Diagnostic bronchoscopy is moderately sensitive and highly specific for inhalation injury when compared with histologic sampling. And it's probably important to make the diagnosis of tracheal bronchial injury. Since this correlates with mortality, ventilator days and length of stay, it's generally graded on a scale of 0 to 4 on the abbreviated injury score with zero indicating no injury. One if minor erythema is present two when erythema is more moderate or accompanied by carbonaceous deposits or bronchorrhea. Three, if there is severe inflammation with the viability and grade four manifesting as mucosal sloughing or necrosis with endoluminal obliteration. So, what do we do about tracheobronchial injury? Well, again, it's coming back to the simple things, regular suctioning, chest physio and early immobilization, bronchoscopic toilet and BA L have also been suggested, but there's no convincing evidence of benefit and some concern that removal of surfactant could predispose to harm. So we generally confine this to patients who have proximal bronchial obstruction and result in consolidation and collapse and shunt nebulized. Heparin is often quoted as a therapeutic intervention in the context of this tracheobronchial injury. And it does have a theoretical advantage in terms of opposing the formation of fibrin casts that are often seen as part of the pathological process. There's also some evidence to support this practice in the form of this meta analysis by Lan et al from a couple of years ago, looking at the diamonds at the bottom of this forest plot here, you can see that it lies to the left of the line of no effect suggesting that nebulized heparin confers a survival advantage when compared with placebo. So, are you sold? Well, I guess any meta analysis is only really as good as this study that it includes. And when you go looking at this meta analysis, it's based on nine case control studies involving just over 600 patients. There's one prospective study but again, neither randomized nor blinded when it demonstrates a survival benefit. And the remaining eight studies are single center retrospective studies with historical controls. Now at a time when burn outcomes are improving over the course of time, this is dubious as a valid competitor. So actually where the meta analysis is perhaps most accurate is in concluding that a large high quality Multicenter RCT is required, which takes us to the fabulously named Hepburn. This was an international Multicenter double blind Placebo controlled trial that aimed to randomize 116 ventilated burn patients, bronchoscopically confirmed inhalation or injury to nebulizations of heparin or saline every four hours for 14 days or until extubation. And the primary outcome measure was envisaged as the number of ventilator free days within the 1st 28 days, many of us in the burns community were eagerly anticipating this trial only really to end up chastened. Published in 2020 by this stage minus, it's a catchy acronym and badge. The trial ultimately recruited only 13 patients over a period of 11 months in 2014 and 15. Their pickup rate for inhalational injury actually wasn't too bad with nearly two thirds of those suspected of inhalational injury on clinical grounds having evidence of this at bronchoscopy. However, more than 60% of potential participants were excluded and most of those because of lack of consent, they also alluded to high costs that were associated with the purchase and blinding of trial medication because of the low recruitment, no analysis of effectiveness were undertaken what they did identify. However, were several instances of serious ventilatory problems due to saturation of the expiratory filter, sufficiently bad to cause temporary discontinuation of the surgery. For those of us who ventilated patients on anesthetic machines during the pandemic. This issue is both familiar and potentially quite feared more. Over over 30% of nebulizations in the treatment group were withheld mainly because of concerns with regard to bleeding. And again, this points to significant potential safety issues. So th I think the jury on inhaled therapeutics, particularly nebulized heparin uh and it remains to be determined the role of these agents in tracheal bronchial injury. But I think it would be fair to say that our unit probably has equipoise as regards these interventions and it's been identified at UK level as a priority for research. So it's likely that over the next few years, we may start to see more high quality research being done in this area that we and potentially other centers in Scotland who are managing isolated injury, inhalational injury and might be asked to participate in. So, what do we do in the meantime? Well, our approach at the moment is one of masterful inactivity which appears reasonable in the context of these images of the same patient taken one week apart, showing a grade three injury at the top here and almost complete resolution at the bottom. So I've already taken up a fair amount of your evening and I'm only a couple of days into an ICU admission that is likely to last weeks, if not months. So I've just got one slide each on a couple of the key priorities as we move further into the patients stay, nutrition is vitally important for these patients because energy expenditure increases with basal metabolic rate, doubling in burns exceeding 40% T BSE. Without appropriate nutritional support. There's significant potential for loss of lean body, mass, immune compromise and impaired wound healing. It's been shown that starting enteral nutrition within 24 hours, as opposed to waiting beyond 48 hours reduces complications in terms of bleeding and sepsis and confer a mortality benefit for those patients who struggle with caloric delivery because of gastric stasis. Then we may need to think about post pyloric feeding. The early involvement of a specialist dietitian is vital to make sure that we're delivering appropriate nutrients for these patients and then hot off the press on the back of our New England journal trial. There is no role for glutamine supplementation. As part of our nutritional approach to the burns patient, the increase in basal metabolic rates is one component of the hyper metabolic response seen in burns patients. This is a severe sustained hyperdynamic circulatory metabolic and immune response. Seeing critically ill burns patients from around day five, it's analogous to the surge response seen in many critically ill patients, but it's more dramatic and more persistent, potentially lasting for up to three years following the injury. It's driven by stress hormones and the coagulation, complement and cytokine cascades as well as damage associated molecular patterns from burned tissue. It has effects on multiple organs as shown in the diagram here and it can lead to profound catabolism. There's a potential role as a therapeutic agent in this process. A potential role for propranolol exerting sympathetic blockades. Although the evidence available thus far is primarily in pediatric practice, sympathetic stimulation is also reduced by providing effective analgesia for burns patients, which is clearly important for other reasons. This is our protocol again, courtesy of Doctor Cowan and it consists of differentiating between background breakthrough and procedural pain. It's important that any analgesic approach is multimodal tailored to the individual patient and then tapered appropriately. Because opioids form the mainstay of our analgesic strategy. It's also imperative that we're attending to bowel management in these patients. And lastly, I couldn't talk about burns in critical care without mentioning sepsis because this is the most common mode of death in patients with burns who survived a hospital. It's unsurprising in the context of the bacterial multiplication that these patients see and also the relative immunosuppression that these patients experience. However, it can actually be quite challenging to identify sepsis in the context of ongoing hypermetabolism or systemic inflammation. As patients sit with elevated body temperature and arresting tachycardia degree of tachypnea. Also, we don't want to use antimicrobials without due cause because these patients are very much at risk of antimicrobial resistance developing during the course of their admission. And I think the role of fungal pathogens in particular uh in burns is increasingly recognized and actually associated with quite a poor prognosis as we've seen recently with some of our patients. So, in trying to bring things to a sensible conclusion, um I hope I've been able to illustrate that the management of a patient with severe burns is a long term process that addresses both the burn wound itself. And also it's profound systemic sequelae which can be quite longlasting. You'll be aware that the surgical management of the burn wound varies with the depth. And that alongside that initial critical care interventions will encompass intubation, appropriate fluid resuscitation, temperature control, getting enteral nutrition on board and ensuring that analgesia is tailored to the individual patient. As we progress through the admission, we start to encounter inhalation, injury, sepsis, and hypermetabolism as pathological processes that need our attention as intensivist or anesthetists. And we're very much aware that these patients are infrequently encountered. Um And it's challenging to remember what needs to be done for them in the heat of the moment. Nobody really wants to have to go and find an obscure page on a website. So we're trying to put together an app er, the rudiments of which you can see on the right hand side of the scheme here. Uh that might be of use to people dealing with these patients on an infrequent basis in terms of priorities of care and how we might approach these patients. So once it's ready we'll hopefully disseminate that. Thanks very much. I'll happily take any questions. Thank you so much, Doctor Payton. That was a really practically useful and very interesting talk. Um, if anyone wants to ask any questions, um, if you just type them into the chat, um, I've got a couple of questions if that's ok. Um, so, er, you talked about, um, some of the Burns networks we've got in Scotland and about Cobi and also about the kind of lack of evidence and trials and things. Do you think with the centralization of burn services, it's gonna become easier to get that evidence and to, to get networks within the UK um, for burns management or is there anything already that exists? Um, yeah, so when we were sort of doing some of the preparatory work for the Burns Center, we sort of put out some feelers to try and ascertain what, what was already available in terms of burns critical care for us, er, that we could potentially join. And I think maybe that hadn't been a priority for the critical care community, but I think increasingly that's recognized as something that will move forward. There's now a critical care specialist interest group, um, as part of the British Burn Association. Uh, and some of the audience uh may have joined us fairly recently at the Burns Critical Care Meeting in Mar Hall, which was designed not only to mark the sort of inauguration or development of the Scottish Burn Center, but actually probably to allow us an opportunity to network with other centers and perhaps put the initial path in place for trying to do more collaborative work because it's only really by doing collaborative work across centers and across countries that we're going to find the answers to the questions that we've talked about. And thank you. Um I also just wanted to ask you a little bit about, um what about uh talked about intubation and um maybe intubating a lower threshold for a transfer? Um Once you'd received a patient that was intubated for a transfer, would you kind of how, how would you go about assessing whether when they would be extubated, how long would you leave it? Um to kind of see if things progressed? Um It depends a little bit on the nature of the burn injury. Um So, ii guess uh for the sort of borderline patient that we were talking about with flash burns to the face where you've had a high intensity heat, but only for a short period of time, they are going to become more significantly swollen. And as we've talked about that edema, we'll probably peak at around 24 to 48 hours. So, if they've already been intubated, we would probably look to reassess beyond that 24 48 hour period to see whether there's a cuff leak. Um And whether we can sensibly extubate them in the context of them, not potentially needing further surgery for their burns. Yes, thank you. Um We've got a question in from Emerin. Um, do you use beta blockers, anabolic steroids or specific nutritional additives or supplements in your center? Uh, ok. Um, so yes. Uh, we do have a protocol for beta blockers and for an anabolic steroid by the name of oxandrolone, uh beta blockers, as I said, have a reasonable evidence base in pediatric practice. Uh, but at the moment, we're kind of extrapolating that to adult burns critical care. We'll start uh beta blockers when the vasopressors at a level that allows us to do that without expectation of compromise. Er, and we'll continue them up until the point where the wounds have healed because the benefit is felt to be in terms of reducing the time taken for grafts to take and for donor sites to heal and thereby shortening length of stay within the hospital. So we'll start it when the physiology allows and we'll keep it going until the wounds have healed, but we're awaiting better quality evidence in adults. Um, we have used Oxandrolone in the past. The problem with oxandrolone is that it's lost its FDA license. Uh So it will likely cease to become available. Uh, and we have had um, one patient certainly who was diabetic in the context of being on Oxandrolone that then resolved in the context of coming off that steroid treatment. So it's not without risks. Er, and I think the evidence is, remains questionable but I think over the coming months we won't actually be able to access it. So I think it will be less of a concern. Uh, in terms of nutritional supplements, the, our dietician um, is quite keen that we use protein supplements and vitamin supplements. They're recommended in the ESPN guidelines. But again, the evidence for using those is pretty poor. Thank you. Um And Barbara Miles has asked, do you think we should adopt the three mil per kilo as the starting calculation in Scotland? Uh So Barbara's asking this question because there was a consensus meeting at the British Burn Association meeting in Dublin er where it was decided that the 2 to 4 mils per kilo should actually be three mils per kilo. Um as a starting point. Now, I think we will probably end up being an outlier if we don't adopt that three mils per kilo per percent. Um So we probably will, but I think all of this is probably aside from the main focus, er and the main focus should be that this is always just the starting point. Some patients need more fluid, some patients need less and you do need to spend time at the bedside and looking at the biochemistry and looking at the physiology to ascertain. Am I giving too much, am I giving too little and for burns patients? But that that's a particular challenge. It definitely sounds like it. Um, and Alastair hurry is asking, uh, do you offer routine antimicrobial cover of major burns or target to specific sites as usual practice? Um, so we, we tried to use as little antibiotics as possible early on in the admission. Um, so if they've been started on antibiotics at the point of presentation, we'll generally try and stop those because the burns are sterile for the 1st 4 to 8 hours. Er, once they've had their initial debridement and grafting, they'll generally be on antimicrobial cover until the first graft check, which happens around day two and then we'll try and get the antibiotics off as quickly as possible. Uh Because what we tend to see happen is the patients initially come in with gram positive organisms and then acquire gram negative organisms that become increasingly resistance and then we're getting fungal pathogens added into the mix. So we try and use antibiotics as little as possible. Certainly no role for prophylaxis and keeping the perioperative courses as short as possible. There's actually some work being done in France around about whether that perioperative prophylaxis is needed at all. Yeah, thank you. Um That might be all the questions um for you tonight. Thanks to everyone who's come and everyone um asking a question as well. Uh I will just put my slides back on. Um So yes, thank you so much um for that talk and we really, really appreciate um you coming to do that. Uh I just thank you for asking. Um I wanted to mention next month um which is actually not that far away. It's brought a couple of weeks earlier er to Dec December our festive edition. It's going to be top trials of 2023 Dr Robert do. Um So without further ado um that's us for our November education update. Thank you so much for presenting Doctor Payton and thanks everyone for coming. Um Hopefully see you all in December by everyone.