Vascular access in burn patients
Key Points
- Peripheral IVs through burned skin are acceptable when unburned sites are unavailable; two large-bore IVs are adequate for initial resuscitation VERIFY
- CVCs are frequently required in large burns; CRBSI rates are 2-3 times those in other ICU populations, with Acinetobacter baumannii and gram-negative organisms predominating [1][4]
- Bundle-based CLABSI prevention programs can dramatically reduce infection rates in burn ICUs [3]
- PICCs offer intermediate-duration access with acceptable complication rates, though burn-specific guidelines are lacking [2]
- Daily review of line necessity and early removal of unnecessary catheters are the most effective single interventions for CLABSI prevention [3]
Overview
Establishing and maintaining vascular access in burn patients presents unique challenges. Extensive burns reduce the available area of unburned skin for peripheral intravenous (IV) catheter placement. Massive edema from resuscitation can make peripheral veins difficult to cannulate. The need for large-volume fluid resuscitation, vasoactive medications, blood products, and parenteral nutrition often mandates central venous catheter (CVC) placement. Burn patients frequently require multiple simultaneous access points and prolonged catheter dwell times, both of which increase infection risk. Catheter-related bloodstream infection (CRBSI) rates in burn patients are 2-3 times those of other ICU populations [3].
Peripheral Venous Access
Peripheral IV catheters are the first-line access for initial resuscitation. Two large-bore (16-gauge or larger) peripheral IVs provide adequate flow rates for acute burn resuscitation. When unburned extremities are unavailable, peripheral IVs may be placed through burned skin. This practice is widely accepted in burn care despite the theoretically increased infection risk, because the alternative of delaying resuscitation carries greater immediate harm VERIFY.
Peripheral access becomes increasingly difficult as resuscitation edema progresses. Ultrasound-guided peripheral IV placement can extend the utility of peripheral access in edematous patients VERIFY.
Central Venous Access
CVCs are frequently required in patients with large burns for volume resuscitation, vasoactive infusions, parenteral nutrition, and hemodynamic monitoring. Preferred sites include the subclavian, internal jugular, and femoral veins. Site selection depends on the pattern of burn injury, available unburned skin, and operator experience.
Jiang et al. reported catheter-related complications in 19 severely burned patients with 174 venous accesses (108 CVCs) following a mass casualty bus fire [1]. CVC tip culture positivity was 25%, and CRBSI rate was 11.1%. Acinetobacter baumannii was the most common pathogen in both catheter colonization and bloodstream infection. TBSA burned, number of catheters, and days of indwelling were independently associated with catheter tip colonization [1].
Jeon et al. studied CVC colonization in 214 severely burned patients undergoing routine catheter changes at 7-day intervals [4]. The colonization rate was 20%, with 59% of colonized catheters associated with bloodstream infection caused by the same organism. Femoral catheterization, TBSA burn of 30% or greater, non-flame burns, CVC changes during pre-existing bacteremia, and renal replacement therapy were independent risk factors for catheter-related BSI [4].
Peripherally Inserted Central Catheters
Younghwan et al. retrospectively analyzed 106 burn patients who received PICCs placed by a clinical nurse specialist [2]. The average dwell time was 18.5 days. Complication rates were relatively low at 16%, including mechanical phlebitis (11%), occlusion (2%), and one infection. No standardized guidelines for PICC use in burn patients currently exist [2].
Intraosseous Access
Intraosseous (IO) access is an established emergency alternative when peripheral and central venous access cannot be rapidly obtained. IO access is appropriate in the prehospital setting and emergency department for initiating resuscitation in patients with extensive burns and no accessible veins VERIFY. IO access is a temporary bridge and should be converted to conventional IV access as soon as feasible.
Infection Prevention
CLABSI prevention in burn patients follows the same bundle approach used in other ICU settings (hand hygiene, maximal barrier precautions, chlorhexidine skin preparation, optimal site selection, daily review of line necessity) but adherence is more challenging given the disrupted skin barrier and need for frequent dressing changes.
Effendi et al. described a quality improvement initiative that reduced CLABSI rates in a burn ICU from 7.39 to 2.29 infections per 1000 line days, subsequently achieving over 635 days without a CLABSI [3]. Key interventions included daily review of line indications, physician oversight of blood culture ordering, nurse peer observation for hub disinfection, and improved nursing competency for peripheral IV placement to reduce CVC dependence [3].
Aryan et al. analyzed 175,538 trauma patients with central lines from the TQIP database and found that CLABSI occurred in fewer than 0.1% but significantly increased length of stay and mortality [5]. Risk factors included other hospital-acquired infections (CAUTI, VAP), small intestine injury, chronic kidney disease, and cirrhosis [5].
Controversies and Evidence Gaps
The optimal CVC change interval in burn patients is unknown. Routine scheduled changes may not reduce infection rates compared with clinically indicated changes, but evidence is limited to retrospective data [4]. The safety and infection risk of peripheral IV access through burned skin has not been prospectively studied. No standardized protocols exist for PICC placement and management in burn patients [2]. The role of antimicrobial-impregnated catheters and antibiotic lock solutions specific to the burn population has not been adequately investigated.
References
[1] Jiang H et al. "Retrospective data about the catheter-related complications and management in massive bus burn casualties." J Vasc Access 2016;17(4):353-9. PMID: 27056030 [2] Younghwan C et al. "Use of blind placements of peripherally inserted central catheters in burn patients: a retrospective analysis." Burns 2015;41(6):1281-5. PMID: 25665735 [3] Effendi M et al. "Reducing Central Line-Associated Bloodstream Infections in a Burn Intensive Care Unit: Using a Business Framework for Quality Improvement." J Burn Care Res 2023;44(5):1073-1082. PMID: 37463324 [4] Jeon K et al. "Central venous catheter tip colonization and associated bloodstream infection in patients with severe burns under routine catheter changing." Am J Infect Control 2024;52(7):813-818. PMID: 38355049 [5] Aryan N et al. "Incidence, Risk Factors, and Outcomes of Central Line-Associated Bloodstream Infections in Trauma Patients." Surg Infect (Larchmt) 2024;25(5):370-375. PMID: 38752327