Avoid the Pitfalls of Vascular Access in Burn Patients
Myron S. Powell MD
James H. Holmes IV MD
A burn patient with less than 50% total body surface area (TBSA) involved can usually begin resuscitation via two large-bore peripheral lines. With burns of greater than 50% TBSA or in patients with severe premorbid diseases, central venous access is typically needed. Vascular access should ideally be established early in the course of injury before the formation of significant edema. If resuscitation is inadequate, burn shock may lead to multiorgan dysfunction/failure syndrome, which almost invariably results in a fatal outcome.
What to Do
When obtaining vascular access on a burn patient, there are numerous options with their individual benefits, risks, and complications. Placement through unburned tissue, all things being equal, is preferable to placement through burned tissue; that is, an intravenous line should be placed through the right antecubital space in the setting of a left antecubital burn. Peripheral lines in the upper extremities are optimal; however, cut-downs are contraindicated, given the inordinate infection rate associated with them. Any line may be placed through burned tissue, if necessary, but lines through eschar should be removed within 72 hours, given the high colonization and infection rates beyond that time period. Central venous catheters are beneficial for those requiring prolonged treatments with large volumes of fluids (i.e., large burns or inhalation injury), invasive hemodynamic monitoring, total parenteral nutrition, or certain medications. Theoretically, peripherally inserted central catheters avoid some of the disadvantages of classical central lines, but their efficacy and place in the management of the severely burned patient have yet to be clinically defined.