Pediatric Difficult to Resuscitate Protocol - Burns

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In patients <30kg with persistent oliguria and estimated fluid resuscitation >6ml/kg/%TBSA, switch from Lactated Ringers (LR) infusion to 5% albumin (isotonic premixed 5% albumin or 200ml of 25% albumin in 800ml LR at the previous resuscitation fluid rate.

Note: For patients greater than 30kg, use ADULT DIFFICULT TO RESUSCITATE PROTOCOL.

1. Contact burn attending
2. Initiate 5% albumin infusion at current resuscitation fluid rate. DO NOT titrate maintenance fluids
3. Initiate CVP and SvO2 monitoring via central access. Monitor bladder pressure every 4
   1. Contact burn attending for bladder pressures ≥20mmHg
4. Targets
   1. Urine output: 1-2 ml/kg/hr
   2. SvO2: ≥60%
   3. CVP: 8-10mmgHg
   4. Bladder pressure: <20mmHg
5. If urine output is 1-2ml/kg/hr after 1 hour and the patient is normotensive, continue difficult to resuscitate protocol. Every attempt should be made in minimize fluid administration while maintaining organ
6. If urine output >2ml/kg/hr after 1 hour, decrease the albumin infusion rate by 20%.
7. After 48 hours of albumin infusion, IVF type and rate to be determined by burn attending
8. If urine output is less than 1ml/kg/hr and the patient is hypotensive after 1 hour, follow hypotension guidelines and notify burn attending
9. If urine output is less than 1ml/kg/hr and the patient is normotensive after 1 hour
   1. CVP = <8mmHg
      • Increase albumin infusion rate by 33%
      • Check hemoglobin & hematocrit
      • Consider albumin bolus of 10-20ml/kg
      • Check urine output every 30 minutes
        1. If urine output = <1ml/kg/hr at q30 min assessments, increase albumin infusion rate by 33%
      • If CVP remains <8 for 2 consecutive hours, contact burn attending & consider transfusion
   2. CVP = ≥8mmHg
      • Add milrinone 0.25 mcg/kg/min. Titrate to a max of 0.75 mcg/kg/min for UOP 1- 2ml/kg/hr
      • DO NOT increase albumin infusion rate
      • If urine output remains <1ml/kg/hr after 1 additional hour, add epinephrine 0.1mcg/kg/min and contact burn attending. Titrate to a maximum dose of 0.25mcg/kg/min
      • Consider ECHO, CRRT
      • Consider hypotension protocol
10. If CVP, SvO2, and urine output reach goal, stop increasing fluids and contact burn attending
11. If the patient becomes hypotensive along with urine output <1ml/kg/hr, follow the pediatric burn hypotension guidelines, and notify burn attending
12. After 48 hours, infusion of albumin should be titrated down. IV fluid type and rate will be determined and ordered by burn attending