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CHAPTER47 Burn care drug formulary
Sedatives
• The following drugs should only be used in the patients with a protected
airway, ie. intubated patients in a critical care setting
• Sedative doses should generally be titrated to eect against regular
(daily) sedation breaks where appropriate or a sedation scoring
system such as the Ramsey scale or the Richmond Agitation Sedation
Scale (RASS)
Propofol
• Used commonly as a rst line sedative on critical care
throughout the UK
• Intravenous anaesthetic. Mode of action unclear, potentiates glycine
and GABA
Advantages
• Short duration of action (starts and stops quickly); half- life
approximately 10– 70 minutes with less accumulation than other
sedative drugs
• Good for assessing the patient, eg. head injury
• Anti- tussive/ reduces bronchospasm
Disadvantages
• Only licensed for 3days
• More expensive than some other agents
• Tolerance may develop
• High lipid load (1% preparation contains 1 kcal/ mL; monitor
triglycerides)
• Contraindicated in children
• Causes hypotension:reduces blood pressure by 15– 25% without a
compensatory rise in cardiac output
• No analgesic eects
• Peanut allergy
• Propofol infusion syndrome
Benzodiazepines
• Benzodiazepine, acts at benzodiazepine receptors linked to GABA
receptors
• Midazolam is commonly the drug of choice in UK critical care units
Advantages
• Short acting:half life approximately 2 hours
• Respiratory depression
• Anterograde amnesia
• Cheaper?
Disadvantages
• Respiratory depression.
• Anterograde amnesia.
• Accumulation (especially in renal impairment)
• Hypotension?
• No analgesic eects
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Selective α2 receptor agonists, eg. clonidine or
dexmedetomidine
• Have their analgesic eects predominantly centrally, eg. at the dorsal
horn of the spinal cord
• Act as analgesic and sedation/ analgesic- sparing eects
• May cause less sedation- induced delirium than other agents such as
benzodiazepines
• Dexmedetomidine is newly licensed in the UK and as yet there is very
limited experience with its use in the burns population; it is more potent
sedative than clonidine but it has less analgesic properties (and less
eects on blood pressure)
Sedatives and their suggested dosage ranges
Table47.4 highlights the standard dose ranges used for intubated patient
in the intensive care setting. These drugs are usually titrated to a sedation
score (see example in Table 47.5).
Monitoring sedation
Table47.5 describes a sedation score used on Whiston hospital intensive
care unit to monitor the patient’s responsiveness while sedated. The target
generally is 1 (aware but calm) but there are instances in the management
of the burns patient, eg. dressings changes or passive limb movements
during physiotherapy where a lower score may be more appropriate to
reduce patient distress.
Table47.4 Standard dosage ranges forcommon sedatives
inintensive care
Drug Dose
Propofol 1– 4mg/ kg/ h; maximum dose 4mg/ kg/ h
Midazolam 10– 50µg/ kg/ min
Clonidine Initially start at 1µg/ kg/ h
Dexmedetomidine Initially 0.7µg/ kg/ h; usual range 0.2– 1.4µg/ kg/ h. Make
Increase by increments of 0.5 mL/ h every 3 hours if BP stable
max dose 4µg/ kg/ h
When discontinuing, wean gradually over a number of hours
(eg. reduce by 50% every 2 hours). If hypertension occurs
reduce rate more slowly
adjustments in rate hourly until required sedation level is
achieved
SEDATIVES
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CHAPTER47 Burn care drug formulary
Table47.5 Whiston hospitals sedation score
3 Agitated and restless
2 Awake and uncomfortable
1 Aware but calm
0 Roused by voice, calm
– 1 Roused by movement
– 2 Roused by pain
– 3 Unrousable
A Natural sleep
P Paralysed
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SEDATIVES
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CHAPTER47 Burn care drug formulary
Fluids
• Fluids play an important role starting immediately post- burn injury right
through the patients hospital stay
• Initial uid resuscitation is achieved with following a set protocol such as
Parkland’s (using Hartmann’s/ Ringers lactate solution) or Muir Barkley
(using albumin)
• To avoid overhydration the resuscitation uid rate can be modied
targeting a specic urine output. For example0.5– 1mL/ pre- burn kg/ h
• It may be necessary to prescribe a regimen of background uid on top
of the resuscitation uid, eg. an extra 2– 3 L of Hartmanns/ Ringers
lactate or 4% glucose/ 0.18% sodium chloride
• Additional uid boluses may be required to maintain blood pressure, it
is as yet unclear as to whether these uid boluses should be crystalloid
(Hartmanns/ Ringers lactate) or colloid (such as gelatine or starch). If
uid boluses alone are not enough or appropriate consider starting a
vasopressor such as noradrenaline (noradrenaline (norepinephrine))
• It may be appropriate to use hypertonic albumin solutions to replace
low serum albumin levels targeting for example a level of 20 g/ L or
greater
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Vasopressors
• Before starting vasopressors make sure the patient is adequately lled
with uid (see Parklands Formulary, Muir Barkley Formulary).
Noradrenaline
• Acts predominantly on α1 receptors (agonist) although has some
β1 action
• An extremely potent vasopressor
• Cardiovascular eects
• i BP (and SVR) via arterial and venous vasoconstriction
• Cardiac output may i or d depending on clinical circumstances
• Cautions. Acts by increasing afterload; not appropriate for use
in patients with cardiogenic shock (blood supply to kidneys and
peripheries may be decreased)
Vasopressin
• Synthetic copy of a naturally occurring peptide hormone
• Vasopressin agonist
• Vasoconstrictor (via AVP receptor 1A).
• Used as an adjunct to therapy (usually combined with NA) (Table 47.6)
Table47.6 Standard starting doses forvasopressors
Drug Dose
Noradrenaline Start infusion at 0.05µg/ kg/ min but can be titrated
Vasopressin Start at 0.03 units/ minute, reduce cautiously once target
quickly to achieve target blood pressure
blood pressure has been achieved
VASOPRESSORS
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CHAPTER47 Burn care drug formulary
Stress ulcer prophylaxis
Stress ulceration has historically been a common complication in the major
burns patient but improved nursing care, early enteral feeding and changes
in practice such as 30° head of the bed elevation have helped greatly reduce
its incidence. Drugs interventions are however still regularly prescribed.
Sucralfate
• Acomplex of aluminium hydroxide and sulphated sucrose
• May act to prevent stress ulceration by protecting the stomach mucosa
from acid pepsin attack
• There have been reports of bezoar formation lead to some text
advising caution in its use in the critically ill especially those being
enteraly feed or with delayed gastric emptying
• May cause less nosocomial pneumonias and Clostridium dicile
diarrhoeas than H2 antagonist and proton pump inhibitors but evidence
of this is debatable
• Likely to cause constipation and may impede absorption of some drugs,
eg. digoxin if given at the same time
• Falling out of favour
H2 antagonists
• Eg. Ranitidine
• Inhibit secretion of gastric acid by antagonism of histamine h2 receptors
• Given intravenously or oral/ enterally
Proton pump inhibitors
• Eg. omeprazole (IV or ng/ oral), pantoprazole (IV or ng/ oral) or
lansoprazole (ng/ oral)
• Inhibit gastric acid secretion by inhibiting H+K+- atpase
• May carry an increased risk of ventilator associated pneumonia and
Clostridium dicile infection compared to the other agents but evidence
in inconclusive
• Can be given enterally or intravenously
• Lansoprazole orodispersible tablets can potentially block ne bore
feeding tubes so other preparations may be more suitable to be
administered by the nasogastric route
Common doses
Table47.7 Common drugs and dosages prescribed forstress ulcer
prophylaxis
Drug Dose
Sucralfate Oral/ enteral 1 g 4– 6 hourl y
Ranitidine IV 50mg tds
Proton pump inhibitors Oral/ enteral lansoprazole 30mg od
Oral/ enteral 150mg bd
IV pantoprazole/ omeprazole 40mg od
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VITAMINS, AMINO ACIDS, AND TRACE ELEMENTS
Vitamins, amino acids, and trace
elements
Replacement of deciencies of certain vitamins and trace elements may be
benecial in aiding wound healing. The following all have some evidence to
suggest supplementation may be of benet to the patient but exact targets
and doses are as yet unclear (Table 47.8).
• Ascorbic acid
• Zinc
• Selenium
• Glutamine
• Copper
Table47.8 Suggested dosing regimens (enterally)
Dose Example dosing regimen
Ascorbic acid 100mg tds up to 1 g daily
Zinc sulfate 125mg tds
Copper 2mg daily
Selenium 200µg daily
Glutamine 0.3 g/ kg/ day intravenously for 5– 10days
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CHAPTER47 Burn care drug formulary
Antibiotics
• Generic or prophylactic antibiotics are generally not indicated
• Body temperature often rises as high as 40°C in the rst day or two in
major burns, and may persist for a week or so. This is not necessarily
indicative of a secondary infection
• Antibiotic therapy should be guided by a combination of clinically
suspected infection site, serum inammatory markers (eg. white cell
count, C- reactive protein) and ideally cultures and sensitivities if available
• Although the burn area is a highly susceptible to infection, regular
dressings, topical antiseptics, baths, and good nursing care reduce the
likelihood of this
• The respiratory system is a likely source, especially in the ventilated patient
who may have an undiagnosed/ unmeasurable airway burn; even without
an airway injury intubated patients are also at risk of ventilator- associated
pneumonia. Systemic digestive tract decontamination (SDD) should
be considered, this consists of a combination of oral +/ – intravenous
antibiotics used prophylactically to eradicate potentially harmful normal
gut oral. It is generally an infection control strategy applied to the whole
Intensive Care Unit but may still work where burns patients are nursed in
isolation/ cubicles. See Box 47.1 for an example regimen
• Antibiotic dosing is very important in the major burn injury as the
pharmacokinetics can be very dierent from the standard patient
• During the initial acute phase diuse increases in capillary permeability
throughout the body lead to the loss of protein rich uid, this in turn
can lead to a drop in cardiac output causing end organ hypoperfusion.
For example reduction in blood ow to the kidneys will transpire as
a reduction in glomerular ltration rate and potentially a reduction in
removal of renally cleared drugs
• After approximately 48 hours the patient enters a catabolic phase
assuming they have been adequately volume resuscitated and so have
an increased cardiac output with a corresponding increase in renal and
hepatic blood ows
• During both of these phases antibiotic pharmacokinetics will be altered
and dierent dosing strategies should be considered such as doses
above the normal licensed dose or extended infusion administration
practices (eg. each dose of piperacillin/ tazobactam or meropenem
infused over 3 or 4 hours or vancomycin given as a continuous infusion).
Where possible therapeutic drug monitoring should be used for all
antibiotics to target dosing/ administration eectively.
Box 47.1 Example ofsystemic digestive tract
decontamination (SDD) protocol
• SDD paste/ gel (topically to the gums and lips of intubated and
additionally the tracheostomy site in tracheotomized patients)
• Colistimethate sodium 50mg/ mL; 2mL qds ng
• Amphotericin 100mg/ mL; 5mL qds ng
• Tobramycin 27mg/ mL; 2mL qds ng
• +/ – intravenous broad- spectrum antibiotic such as a cephalosporin
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FLUID-SPARING DRUGS
Fluid- sparing drugs
Some drugs, eg. ascorbic acid, if started soon after burn injury, are thought
to reduce the amount of uid required in the resuscitation stage after a
burn injury. However, their incorporation into standard practice has so far
been limited by lack of evidence and practical aspects such as availability of
a suitable intravenous preparation
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