Antishock Therapy for Systemic Treatment with BRT with MEBT/MEBO

Dr. Xu considers that in the antishock therapy postburn, it is more important to protect and recover the functions and structures of internal organs than to supplement blood volume only. 

The principles of the treatment are as follows:

1. Protection and Enhancement of Cardiac Function

We propose that a lot of protein degradation products released from burned skin tissue could be absorbed into the blood circulation, and could further inhibit and decrease cardiac function, thus inducing cardiogenic shock. 

Therefore, severely burned patients (TBSA 150% and/or third-degree 110%) should be routinely injected intravenously with cedilanid (lanatoside C) 0.2 mg in 25–50% GS 50 ml q.d. after injury or admission. 

Then, the amount and frequency of cedilanid should be regulated according to the changes in heart rate and peripheral circulation. 48 h postinjury, the administration of cedilanid should be stopped unless the patient is still suffering from abnormal cardiac function, in which case cedilanid should be applied until the symptoms disappear. 

If symptoms of heart failure arise during the course of treatment, the patient should be treated with 0.2–0.4 mg cedilanid immediately. One treatment is frequently sufficient.

2. Protection of Renal Function

After massive burns, one of the main complications in the shock stage is renal dysfunction that is caused firstly by microvascular spasm of the renal parenchyma and renal ischemia. 

It is also the major etiology of renal failure. Therefore, treatment of renal function is the crux of antishock and comprehensive treatment to relieve the microvessels in the renal parenchyma. This needs to be addressed as early as possible. 

The principles of renal treatment are follows: After injury or immediately upon admission, severely burned patients routinely require an intravenous drip with 1% procaine 100 ml, caffeine sodiobenzoate 0.5 g, vitamin C 1.0 g, 25% GS 100– 200 ml, q.d. or b.i.d.–t.i.d. depending upon the degree of shock and the amount that urine production is reduced. 

This intravenous drip should be continued in patients with anuria until urination is recovered. The routine treatment plan may be maintained until wound healing.

3. Supplement Blood Volume

After massive burns, a great deal of intravascular fluid exudes toward the wound surface and tissue space, which leads to the reduction in effective blood volume resulting in hypovolumic shock. 

Therefore, during the above treatment course, the blood volume should be monitored and replenished as needed. 

In particular, attention must be paid to avoid massive intravenous infusion blindly without precise attention being paid to cardiac and renal functions, as well as other excretory functions. The principle is as follows:

4. Compositions of Fluid Infusion. 

The ratio of crystalloid solution (normal saline or 5% GNS) to colloid solution should be 1:1. The colloid solution should be composed of 3/4 parts of plasma and 1/4 part of whole blood when the condition allows, otherwise 1/2 part of plasma and 1/2 part of plasma substitute can be used.

5. Amount of Fluid Infusion. 

According to the basic principles of surgery, the amount of fluid infusion should be equal to the amount of body deficiency. In the shock stage of massive burns patients (during 48–72 h after injury), we offer a more detailed formula:

formula fluid infusion

6. Speed of Fluid Infusion.

After extensive burns, the trauma stresses the heart, kidney and brain tissue, making their functions vulnerable. 

During the first 24 h postburn, 1/2 of total fluid amount should be infused in the first 8 h, another 1/2 should be infused over the next 16 h evenly again, with regard to cardiac and renal functions. 

During the second 24 h postburn, all of the fluid should be infused at a uniform speed. During the third 24 h after injury, the amount and speed of fluid infusion must be determined strictly in the light of the symptoms of shock and the amount of urine. 

When the symptoms of shock are improved markedly or disappeared and the amount of urine is 11 ml/h W kg, the speed of fluid infusion should be decreased and the fluid amount should be reduced by 1/3.

7. Nursing Care in Shock Stage

After severe burns, the onset of shock would be related to thermal injury as well as adequate nursing care. The burns patient can hardly withstand any further stress due to the already severely compromised condition of all internal organs. Thus, nursing care constitutes a critical service in supporting as stress-free a recovery period as possible. 

Nurses should:
a. Directly apply MEBO on the wound surface immediately, isolate the wound from contacting with air, relieve wound pain, protect the wound from any irritative damage, resist the tendency to debride the wound.

b. Apply air conditioner or bedstead and sheeting to maintain room temperature at 30–34°C, and prevent fluctuation in room temperature.

c. Smooth out the bed sheet and dressing, protect the wound from any compression, change dressing and MEBO every 12 h gently, while keeping the patient in the horizontal supine position. Again, turning the patient over is contraindicated.

d. Control the speed of fluid infusion such that it flows at a constant rate remembering that rapid fluctuation of infusion speed is forbidden.