Patients with burn wounds are at risk of various complications, such as delirium, renal failure and sepsis. It is important to consider these risks throughout treatment and care.

Delirium

Delirium is a serious complication in burn patients, characterized by psychological and/or motoric unrest. Treatment is difficult and specialized and can involve anxiolytic drugs, such as haloperidol and quietapine, together with psychiatric and psychological support.

Pain, anxiety and delirium all improve markedly with wound healing. Therefore wound treatment remains the priority in caring for burn patients.

Burn wound infection

Infection is a common complication for burn patients. Infection is mainly spread via healthcare workers’ hands, so it is vital to teach, implement and monitor hand hygiene guidelines. Healthcare workers should use alcohol hand rub between patients and must wash their hands when soiled.

Always maintain a clean hospital environment to avoid infection in burn patients.

Risk factors for infection:

• Delayed presentation
• >20% TBSA burned
• Delayed burn wound excision
• Extremes of age (very old, very young)
• Patients with impaired immunity

Diagnosing burn wound infection

Burn wound infection begins with bacterial colonization and develops into full infection.

Bacterial colonization of the burn wound

Most burn wounds will be colonized by bacteria as early as 3 days post-injury. Wound colonization is defined as the presence of multiplying microorganisms on the surface of a wound, with no immune response from the host and with no associated clinical signs and symptoms.

Wound colonization can impair wound healing, so when there is an unexpected delay in wound healing, take a wound swab.

At the same time, change the topical agent used for local therapy until you get results from the wound swab. Usually, the topical agent chosen would be an anti-Staphylococcal therapy, such as Fucidin®, Bactroban®, honey or Furacin®.

Burn wound infection

Signs and symptoms of burn wound infection can include:

• Purulent discharge
• Erythema
• Tenderness
• Warmth
• Edema
• Surrounding cellulitis
• Increased pain
• A rapid change in the clinical condition of the patient, e.g.:
  • Tachycardia
  • Tachypnea
  • Oliguria
  • Fever
  • Hyperthermia

If you suspect a burn wound is infected, you must take wound swabs and look at the wound and dressings for an indication of infection. Two common bacterial infections may be identifiable:

Administer systemic antibiotics if there is septicemia or a hemolytic streptococcal wound infection.

However, avoid using prophylactic systemic antibiotics for acute burns.

If the burn wound is infected, clean it with handheld showering, irrigation and wiping to remove dirt, dressings and topical ointment. Then apply a suitable topical agent, depending on the type of infection:

• Pseudomonas – SSD (Silver Sulfa Diazine, Flammazin®), 0.5% acetic acid or 0.5% silver nitrate (AgNO3) solution
• Staphylococcus – fusidic acid (Fucidin®) or mupirocin (Bactroban®)

Burn treatment during infection

A burn wound infection does not prevent you from performing excision and skin grafting. However, if there is a generalized or systemic infection, such as septicemia, only excise the infected eschar. This may also be a suitable option for patients with low hemoglobin in low-resource settings. You can then perform a skin graft later when the patient’s condition has improved.

Be aware that there may be infection under the eschar. Shortly after the burn injury, the eschar provides a natural barrier to infection. During the process of wound healing, the eschar separates, providing a portal of entry for bacteria. The blood flow deep to the eschar is poor and infection may follow. When the eschar is infected, remove it surgically.

Sepsis

Systemic microbial infection (sepsis) is the major cause of multi-organ failure (MOF) and death in burn patients who survive more than 48 hours. It is therefore most important to prevent sepsis, for example, through:

• Meticulous hygiene
• Optimal wound therapy
• Patient isolation
• Maintenance of homeostasis

Avoid using prophylactic systemic antibiotics for acute burns. In communities where streptococcal carriers or infection is widespread, administer simple prophylaxis for 24 hours only.

When a patient has septicemia or a hemolytic streptococcal wound infection, administer systemic antibiotics.

Signs and symptoms

Sepsis can present catastrophically or insidiously.

Steps to diagnose and treat sepsis

1. Take blood cultures immediately if you suspect sepsis.
2. Administer high dosage intravenous antibiotics, preferably chosen based on microbiological data.
3. Administer extra oxygen.
4. The patient may need extra fluids for hypotension and to combat oliguria. Note: this can increase the risk of provoking lung edema.
5. Established multi-organ failure may require mechanical ventilation, inotropic support and renal dialysis. The condition is potentially reversible, but mortality is high.

Acute renal failure (ARF)

The main causes of acute renal failure (ARF) are hypovolemia, abdominal compartment syndrome (ACS) and septic complications. Following sepsis, renal failure is a frequent component of multi-organ failure.

ARF is uncommon in patients who have been carefully resuscitated with fluids in the first 48 hours. Early renal failure is associated with inadequate fluid resuscitation, or ACS resulting from excessive fluid resuscitation.

Urine volume alone is an unreliable indicator of renal function. Instead, better indicators are progressive increases in serum creatinine and ureum levels. The RIFLE criteria (classification for acute kidney injury) have been validated in burns. [Can we include the RIFLE list or a link to a reliable source here?] Treatment comprises the identification and reversal of the cause of renal failure.

Continuous Renal Replacement Therapy (CRRT)

Provide renal replacement therapy if renal failure is progressive despite optimal measures. Continuous veno-venous hemofiltration (CVVH) is the simplest and safest technique, but it requires equipment and expertise. CRRT provides control of fluids and electrolytes and may be beneficial by filtering out reactive short-chain peptides.