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CHAPTER47 Burn care drug formulary
Muscle- sparing drugs (anticatabolic measures)
Used in the phase of increased metabolic rate and hyperdynamic circula­tion post burn injury to prevent accelerated muscle wasting that may delay mobilization and therefore impede recovery and even increasing mortality.
Propranolol
• Abeta- blocker that acts by competitive antagonism of both beta 1 and
beta 2 adrenoceptors. Reduces heart rate (tachycardia), thermogenesis and resting energy expenditure. It also increases lean body mass and reduces skeletal muscle wasting
• In practice start at a low dose for example10mg bd and then titrate
rapidly to attain a heart rate of between 60 and 100 beats per minute, usual dosage range 10– 40mg bd– tds
• Therapy with propranolol is often interrupted or contraindicated as
hypotension in septic or otherwise haemodynamically unstable patients results in the use of vasopressors (such as noradrenaline), which limits it role
Anabolic steroids
• Used primarily to prevent muscle wasting
Oxandrolone
• 1/ 20th the potency of testosterone, indicated for use in both male and
female patients
• Key trial suggests 10mg bd enterally starting on day 5 after burn injury
and continuing until hospital discharge
• There is no specic target or monitoring of eectiveness, can be
used while patient is on vasopressors. Liver function tests (specically transaminases) should be monitored and oxandralone discontinued if signicant anomaly occurs
• No preparation is readily available in the UK; a licensed preparation is
available in the USA
Nandrolone
• Used as an alternative to oxandrolone because it is more easily available
in the UK
• Insulin, metformin, and other agents that reduce post- burn
hyperglycaemia may be of benet
• Consider also non- pharmacological interventions such as adequate
enteral feeding (at 35kcal/ kg/ day during the catabolic phase with a high protein feed such as Jevity® Plus HP) and a high ambient room temperature (28– 30°C)
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Itch
• During healing of partial thickness burns or donor sites itch can be a problematic complication
• Acombination of antihistamines and topical cooling agents may be most eective
• Calamine lotion is alcohol based and so can cause drying of the skin and irritation in itself so is best avoided
• In general sedating antihistamines are more eective than non- sedating but may not be practical during the day therefore a regimen of non- sedating antihistamines such a fexofenadine during the day supplemented with a sedating agent such as hydroxyzine at night may work
• 1% menthol in aqueous cream applied liberally when required is a suitable and eective topical agent (Tables 47.9 and 47.10)
Table47.9 Examples ofantihistamine oral dosing regimens
Drug Dose
Chlorphenamine 4mg 4 hourly, maximum 24mg/ 24 h
Hydroxyzine 10mg bd and 25mg nocte
Fexofenadine and hydroxyzine combination
120mg fexofenadine in a morning and 25mg hydroxyzine nocte
ITCH
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CHAPTER47 Burn care drug formulary
Suggested drug concentrations
Table47.10 Suggested standard drug concentrations inthe UK assupported bythe United Kingdom Clinical Pharmacy Association (UKCPA) and Intensive Care Society (ICS)
Medication Infusion composition Concentration
Morphine 50mg in 50mL 1mg/ mL
100mg in 50 mL 2mg/ mL
Fentanyl 2.5mg in 50mL 50µg/ mL
Alfentanil 25mg in 50mL 500µg/ mL
Remifentanil 2mg in 40mL 50µg/ mL
5mg in 50mL 100µg/ mL
Midazolam 50mg in 50 mL 1mg/ mL
100mg in 50 mL 2mg/ mL
Clonidine 750µg in 50mL 15µg/ mL
Dexmedetomidine 200µg in 50mL 4µg/ mL
400µg in 50mL 8µg/ mL
Adrenaline 4mg in 50mL 80µg/ mL
8mg in 50mL 160µg/ mL
16mg in 50mL 320µg/ mL
8mg in 100mL 80µg/ mL
16mg in 100mL 160µg/ mL
32mg in 100mL 320µg/ mL
Noradrenaline 4mg in 50 mL 80µg/ mL
8mg in 50mL 160µg/ mL
16mg in 50mL 320µg/ mL
8mg in 100mL 80µg/ mL
16mg in 100mL 160µg/ mL
32mg in 100 mL 320µg/ mL
Dobutamine 250mg in 50 mL 5mg/ mL
500mg in 100 mL 5mg/ mL
Dopamine 200mg in 50 mL 4mg/ mL
400mg in 50 mL 8mg/ mL
Vasopressin (Argipressin) 20 units in 50 mL 0.4 units/ mL
Amiodarone (load) 300mg in 50 mL 6mg/ mL
300mg in 100mL 3mg/ mL
(Continued)
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SUGGESTED DRUG CONCENTRATIONS
Table47.10 (Contd.)
Medication Infusion composition Concentration
Amiodarone (continuation. . .)
Heparin 20,000 units in 20 mL 1,000 units/ mL
Magnesium sulfate 20mmol in 50 mL 0.4mmol/ mL
Phosphate 20mmol in 50mL 0.4mmol/ mL
Insulin 50 units in 50 mL 1 unit/ mL
Epoprostenol The formulation of Flolan® has changed. Dierent
Reproduced with the kind permission of the Intensi ve Care Society and the Faculty of Intensive Care Medicine.
300mg in 50mL 6mg/ mL
600mg in 50 mL 12mg/ mL
900mg in 50 mL 18mg/ mL
300mg in 500 mL 0.6mg/ mL
600mg in 500 mL 1.2mg/ mL
900mg in 500 mL 1.8mg/ mL
25,000 units in 25 mL 1,000 units/ mL
20mmol in 100 mL 0.2mmol/ mL
20mmol in 250mL 0.08mmol/ mL
40mmol in 100mL 0.4mmol/ mL
50mmol in 500mL 0.1mmol/ mL
formulations in circulation. Consult package insert.
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CHAPTER47 Burn care drug formulary
Further reading
Ali A, Herndon DN, Mamachen A, etal. Propranolol attenuates hemorrhage and accelerates wound
healing in severely burned adults. Critical Care 2015;19:217. Bull JP, Squire JR. A study of mor tality in a burns unit. Annals of Surgery, 1949;160– 73. Demling RH, DeSanti L. The rate of restoration of body weight after burn injury, using the anabolic
agent oxandrolone, is not age dependent. Burns 2001;27:46– 51. Demling RH, Orgill DP. The anticatabolic and wound healing eects of the testosterone analog
oxandrolone after severe burn injury. Journal of Critical Care 2000;15:12– 17. Demling RH, DeSanti L. Oxandrolone induced lean mass gain during recovery from severe burns is
maintained after discontinuation of the anabolic steroid. Burns 2003;29:793– 7. Jeschke MG, Herndon DN. Burns in children:standard and new treatments. Lancet 2014;383:1168– 78. Lundy JB, Chung KK, Pamplin JC, etal. Update on severe burn management for the intensivist. Journal
of Intensi ve Care Medicine 2016;31:499– 510. Navickis RJ, Greenhalgh DG, Wilkes MM. Albumin in burn shock resuscitation:a meta- analysis of
controlled clinical studies. Journal of Burn Care & Research 2016;37:e268– 78. Nordlund MJ, Pham TN, Gibran NS. Micronutrients after burn injury:a review. Journal of Burn Care
& Research 2014;35:121– 33. Richardson P, Mustard L. The management of pain in the burns unit. Burns 2009;35:921– 36. Rousseau A- F, Losser M- R, Ichai C, Berger MM. ESPEN endorsed recommendations: nutritional
therapy in major burns. Clinical Nutrition 2013;32, 497– 502. Rowan MP, Cancio LC, Elster EA, etal. Burn wound healing and treatment: review and advance-
ments. Critical Care 2015;19:243. Sánchez- Sánchez M, Garcia- de- Lorenzo A, Herrero E, etal. Evaluation of a protocol for resuscitation
in burn patients. Critical Care 2014;18:430. Sánchez M, García- de- Lorenzo A, Herrero E, etal. A protocol for resuscitation of severe burn pa-
tients guided by transpulmonary thermodilution and lactate levels:a 3- year prospective cohort
study. Critical Care 2013;17:R176. Sen S, Greenhalgh D, Palmieri T. Re view of bur n injury research for the year 2009. Journal of Bur n
Care & Research 2010;31:836– 48. Sen S, Palmieri T, Greenhalgh D. Review of burn research for the year 2013. Journal of Burn Care
& Research 2014;35:362– 8. Summer GJ, Puntillo KA, Miaskowski C, etal. Burn injury pain: the continuing challenge. Journal of
Pain 2007;8:533– 48. Tran NK, Godwin ZR, Bockhold JC, etal. Clinical impact of sample interference on intensive insulin
therapy in severely burned patients:a pilot study. Journal of Burn Care & Research 2009;35:72– 9. Walker PF, Buehner MF, Wood LA, etal. Diagnosis and management of inhalation injur y:an updated
review. Critical Care 2015;19:351. Weinbren MJ. Pharmacokinetics of antibiotics in burn patients. Journal of Antimicrobial
Chemotherapy 1999;44:319– 27.
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Appendix 1
Transfer proforma
Transfer proforma:part1 418 Transfer proforma:part2 422
417
APPENDIX 1
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Transfer proforma:part1
Patient name DoB and age Weight (kg)
Date and time of burn History of injury
Date and time arrived to primary unit
Referring unit:
Referrer name:
Grade:
Direct line:
Fax number:
Details of rst aid
Other injuries
Allergies tetanus status
Past medical history (including medications, smoking, alcohol, occupation, psychiatric history)
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TRANSFER PROFORMA:PART1
BURN TBSA% CHART
Ignore simple erythema
Draw what is described
Estimated Burn TBSA
= %
Area Age 0 1 5 10 15 Adult
A= ½ of head 9½ 8½ 6½ 5½ 4½ 3½
B= ½ of one
thigh
C= ½ of one lower leg
2¾ 3¼ 4 4½ 4½ 4¾
2½ 2½ 2¾ 3 3¼ 3½
419
Body region Partial thickness (%) Full thickness (%)
Head
Neck
Anterior trunk
Posterior trunk
Right arm
Left arm
Buttocks
Genitalia
Right leg
Left leg
Total Burn
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APPENDIX 1
420
Wound management advice
Language:
Is an interpreter needed:Yes/ No
Next of kin (name, relationship, and contact details)
Referral accepted/ declined for transfer (N.B.check if ITU bed avail­able, if required)
If accepted for transfer and TBSA >15%, tick when transfer proforma– part2 faxed to referring unit for completion
Form completed by (sign and print)
Designation
Contact details
□
© Susie Zhi- Jie Yao with kind permission
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TRANSFER PROFORMA:PART1
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