Hypotension with adequate UOP - Adult Burn Guideline

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The optimal minimum blood pressure for burn patients must be individualized. Some patients will maintain adequate organ perfusion (and thus have adequate urine output) at mean arterial blood pressures (MAP) lower than 70. True hypotension must be correlated with urine output. If a MAP (generally less than 55mmHg) is not adequate to maintain the urine output goal of at least 30ml/hr, the following steps are recommended:

1. Start with Vasopressin 0.04 units/min IV (do not titrate)
2. Monitor CVP (goal 8-10)
3. If the CVP is not at goal, increase fluid rate by 33%
4. If the CVP is at goal, then add norepinephrine IV 0.1 mcg/kg/min, titrate by 0.01-0.05 mcg/kg/min every 5 minutes to a SBP or MAP goal. Max dose is 1mcg/kg/min.
5. If additional vasopressors are needed, consider the placement of an invasive hemodynamic monitor. These patients may be volume depleted but a missed injury should be suspected.
   1. If hypotension persists, assess for missed injury.
   2. Consider adding epinephrine or neosynephrine as a last resort.
6. If the patient is exhibiting catecholamine-resistant shock, consider the following diagnoses:
   1. Missed injury and ongoing blood loss.
   2. Acidemia. If pH is less than 7.2, then adjust ventilator settings to optimize ventilation (target PCO2 30-35.) If, despite optimal ventilation, patient still has a pH less than 7.2, consider bicarbonate administration.
   3. Adrenal insufficiency. Check a random cortisol level and start hydrocortisone 100mg every 8 hours.
   4. Hypocalcemia. Maintain ionized calcium greater than1.1

Note: use vasopressor agents with caution in patients with history of cardiac dysfunction, dysrhythmias, or recent (within in the last 6 months) MI.