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Burn resuscitation.

ABSTRACT: Fluid resuscitation following burn injury must support organ perfusion with the least amount of fluid necessary and the least physiological cost. Under resuscitation may lead to organ failure and death. With adoption of weight and injury size-based formulas for resuscitation, multiple organ dysfunction and inadequate resuscitation have become uncommon. Instead, administration of fluid volumes well in excess of historic guidelines has been reported. A number of strategies including greater use of colloids and vasoactive drugs are now under investigation to optimize preservation of end organ function while avoiding complications which can include respiratory failure and compartment syndromes. Adjuncts to resuscitation, such as antioxidants, are also being investigated along with parameters beyond urine output and vital signs to identify endpoints of therapy. Here we briefly review the state-of-the-art and provide a sample of protocols now under investigation in North American burn centers.

SUBMITTER: Endorf FW

PROVIDER: S-EPMC3226577 | biostudies-literature | 2011 Nov

REPOSITORIES: biostudies-literature

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Burn resuscitation.

Endorf Frederick W FW Dries David J DJ

Scandinavian journal of trauma, resuscitation and emergency medicine 20111111

Fluid resuscitation following burn injury must support organ perfusion with the least amount of fluid necessary and the least physiological cost. Under resuscitation may lead to organ failure and death. With adoption of weight and injury size-based formulas for resuscitation, multiple organ dysfunction and inadequate resuscitation have become uncommon. Instead, administration of fluid volumes well in excess of historic guidelines has been reported. A number of strategies including greater use of ...[more]

PMID: 22078326

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Project description:IntroductionBurn injury and its subsequent multisystem effects are commonly encountered by acute care practitioners. Resuscitation is the major component of initial burn care and must be managed to restore and preserve remote organ function. Later complications of burn injury are dominated by infection. Burn centers are often called to manage soft tissue problems outside thermal injury including soft tissue infection and Toxic Epidermal Necrolysis.MethodsA selected review of recent reports published by the American Burn Association is provided.ResultsThe burn-injured patient is easily and frequently over resuscitated with complications including delayed wound healing and respiratory compromise. A feedback protocol is designed to limit the occurrence of excessive resuscitation has been proposed but no new "gold standard" for resuscitation has replaced the Parkland formula. Significant additional work has been included in recent guidelines identifying specific infectious complications and criteria for these diagnoses in the burn-injured patient. While new medical therapies have been proposed for patients sustaining inhalation injury, a new standard of medical therapy has not emerged. Renal failure as a contributor to adverse outcome in burns has been reinforced by recent data generated in Scandinavia. Of special problems addressed in burn centers, soft tissue infections and Toxic Epidermal Necrolysis have been reviewed but new treatment strategies have not been identified. The value of burn centers in management of burns and other soft tissue problems is supported in several recent reports.ConclusionRecent reports emphasize the dangers of over resuscitation in the setting of burn injury. No new medical therapy for inhalation injury exists but new standards for description of burn-related infections have been presented. The value of the burn center in care of soft tissue problems including Toxic Epidermal Necrolysis and soft tissue infections is supported in recent papers.

Project description:Intravenous (IV) resuscitation of burn patients has greatly improved outcomes and become a cornerstone of modern burn care. However, the heavy fluids and vascular access required may not be feasible in austere environments, mass casualty, or delayed transport scenarios. Enteral resuscitation has been proposed for these situations; we sought to examine the effectiveness of this strategy on improving burn-induced kidney injury. Anesthetized Yorkshire swine sustaining 40% TBSA full-thickness contact burns were randomized to three groups (n = 6/group): fluid deprivation, ad libitum water access, or 70 mL/kg/d Oral Rehydration Salt solution (ORS). Urine and blood were collected at baseline (BL), 6, 12, 24, 32, and 48h post-burn, at which point tissue was harvested and CT angiography performed. Although fluid consumption by ad libitum and ORS groups were matched (132±54mL/kg versus 120±24mL/kg, respectively), ORS intake increased urine output compared with water and no water (47.3±9.0 mL/kg versus 16.1±2.5 mL/kg, and 24.5±1.7 mL/kg respectively). Plasma creatinine peaked 6h following burn (1.67±0.07mg/dL) in all animals, but at 48h was comparable to BL in animals receiving water (1.23±0.06mg/dL) and ORS (1.30±0.09mg/dL), but not fluid deprived animals (1.56±0.05mg/dL) (P<0.05). Circulating levels of blood urea nitrogen steadily increased, but also decreased by 48h in animals receiving enteral fluids (P<0.05). Water deprivation reduced renal artery diameter (-1.4±0.17mm), whereas resuscitation with water (-0.44±0.14 mm) or ORS maintained it (-0.63±0.20 mm;P< 0.02). Circulating cytokines IL-1?, IL-6, IFN?, and GM-CSF were moderately elevated in the fluid-deprived group. Taken together, the data suggest that enteral resuscitation with ORS rescues kidney function following burn injury. Incorporating enteral fluids may improve outcomes in resource-poor environments and possibly reduce IV fluid requirements to prevent co-morbidities associated with over-resuscitation. Studies into different volumes/types of enteral fluids are warranted. While ORS has saved many lives in cholera-associated dehydration, it should be investigated further for use in burn patients.

Project description:There are limited data on the efficacy of early fluid resuscitation with third-generation hydroxyethyl starch (HES 130) in burn injury. Adverse effects of HES on survival and organ function have been reported.In this randomized, controlled, double-blind trial, 48 patients with severe burn injury were assigned to receive either lactated Ringer's solution plus 6% HES 130/0.4 in a ratio of 2:1 or lactated Ringer's solution with no colloid supplement for the first 72 hours. Primary outcome parameter was the group difference of administered total fluid from intensive care unit (ICU) admission up to day 3. Secondary outcomes included kidney and lung injury and failure, length of stay, and mortality.Three-day totals of administered resuscitation fluid (medians) were 21,190 mL in the lactated Ringer's group and 19,535 mL in the HES group (HES: -1,213 mL; P?=?0.39). Creatinine levels from day 1 to 3 (HES: +0.4 ?mol/L; 95% confidence interval (CI) -18.7 to 19.5; P?=?0.97) and urinary outputs from day 1 to 3 (HES: -58 mL; 95% CI -400 to 283; P?=?0.90) were not different. Six patients in each group developed acute respiratory distress syndrome (ARDS) (risk ratio 0.96; 95% CI 0.35 to 2.64; P?=?0.95). Length of ICU stay (HES vs. lactated Ringer's: 28 vs. 24 days; P?=?0.80) and length of hospital stay (31 vs. 29 days; P?=?0.57) were similar. Twenty-eight-day mortality was 4 patients in each group (risk ratio 0.96; 95% CI 0.27 to 4.45; P?=?0.95), and in-hospital mortality was 8 in the HES group vs. 5 patients in the lactated Ringer's group (hazard ratio 1.86; 95% CI 0.56 to 6.19; P?=?0.31).There was no evidence that early fluid resuscitation with balanced HES 130/0.4 (6%) in addition to lactated Ringer's solution would lead to a volume-sparing effect in severe burn injury. Together with the findings that early renal function, incidence of ARDS, length of stay, and mortality were not negatively influenced by HES in this setting, balanced HES 130/0.4 (6%) plus lactated Ringer's solution could not be considered superior to lactated Ringer's solution alone.ClinicalTrials.gov NCT01012648.

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Burn resuscitation.

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Burn resuscitation.

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