6.3.1Central Nervous System

Anoxic brain injury used to be the leading cause of death in burn patients, which has been replaced by sepsis and MOF [7]. Adequate resuscitation and early intubation improved mortality in burn patient [12, 14]. However, neurological disturbances are commonly observed in burned patients. The possibility of cerebral edema and raised intracranial pressure must be considered during the early ßuid resuscitation phase, especially in the case of associated brain injury or high-voltage electrical injury. Inhalation of neurotoxic chemicals, of carbon monoxide, or of hypoxic encephalopathy may adversely affect the central nervous system as well as arterial hypertension [14, 21, 22, 24]. Other factors include hypo-/hypernatremia, hypovolemic shock, sepsis, antibiotic overdosage (e.g., penicillin), and possible oversedation or withdrawal effects of sedative drugs. If increased intracranial pressure is suspected, neurosurgery needs to consulted and most likely bolt are place and therapy initiated to decreased intracranial pressure.

In general, severe burn injury is associated with nonspeciÞc atrophy of the brain that normally resolves over time. No intervention is needed.

Pain and anxiety will generally require rather large doses of opioids and sedatives (benzodiazepines mainly). Continuous infusion regimens will generally be successful in maintaining pain within acceptable ranges. Sedatives and analgesics should be targeted to appropriate sedation and pain scales (SAS or VAS scores four appear optimal), thus preventing the sequelae associated with oversedation and opioid creep, namely, ßuid creep and effects on the central and peripheral cardiovascular system [18]. Therefore, consideration should be given to the use of NMDA receptor antagonist, such as ketamine or gabapentin, who have important opioid-sparing effects to decrease the need for opioids and benzodiazepines [2, 4]. We Þnd multimodal pain management combining a long-acting opioid for background pain, a short-acting opioid for procedures, an anxiolytic, an NSAID, acetaminophen, and gabapentin for neuropathic pain control [2, 4] used at our institution targeted to SAS (sedation score) and VAS (visual analog scale) scores provides adequate analgesia and sedation.

6.3.1.1 Intensive Care Unit-Acquired Weakness

Survival and organ function have been the main outcome measures for burn patients; however, recently long-term outcomes move into the focus of burn care providers. A signiÞcant component of long-term outcomes include the peripheral nervous system and muscular system which manifest as neuromyopathy. The importance of positioning and prevention of peripheral nerve compression is well known and ingrained in the daily practices of most critical care units. The main risk factors for neuropathy include multiple organ failure, muscular inactivity, hyperglycemia, use of corticosteroids, and neuromuscular blockers. In a recent publication by de Jonghe and Bos [29], early identiÞcation and treatment of conditions leading to multiple organ failure, especially sepsis and septic shock, avoiding unnecessary deep sedation and excessive hyperglycemia, promoting early mobilization, and weighing the risk and beneÞts of corticosteroids might reduce the incidence and severity of ICUacquired weakness.