Which finding indicates that fluid resuscitation has been successful for a patient with a burn injury?

P. Guilabert,

1

Anesthesia and Critical Care Department

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Published:

19 August 2016

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  P. Guilabert, G. Usúa, N. Martín, L. Abarca, J. P. Barret, M. J. Colomina, Fluid resuscitation management in patients with burns: update, BJA: British Journal of Anaesthesia, Volume 117, Issue 3, September 2016, Pages 284–296, https://doi.org/10.1093/bja/aew266

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Abstract

Fluid and electrolyte treatment for burn resuscitation began in 1921 when Underhill1 studied the victims of the Rialto Theatre fire in New Haven and found that blister fluid has a composition similar to plasma. In 1942, Cope and Moore2 developed the burn oedema concept and introduced the body-weight burn budget formula. Other charts were then developed: the Wallace rule of nines,3 the rule of the hand, and the one currently considered the most exact, the Lund and Browder Chart.4 Finally, in 1968, Baxter and Shires5,6 developed the Parkland formula, the one most widely used today for initial fluid resuscitation in burn patients.7 In accordance with the indications of the Advanced Burn Life Support programme of the American Burn Association, this formula now stipulates 2–4 ml of Ringer's lactate (RL) solution per kilogram of weight per percentage of burned body surface area in adults. It is intended to be adapted to vascular permeability changes to avoid fluid excess (the phenomenon known as ‘fluid creep’),8–10 and the amount has to be corrected according to the urinary output,5,8,11 which ultimately leads to substantial variability in the quantity of fluids administered. Sometimes this process is imprecise because the body surface area calculations are not always reliable (e.g. in obese patients).

After all these years of studying burn patient pathophysiology and outcomes, it is now clear that prompt fluid resuscitation is essential for survival in these patients.12 Since the implementation of efficient, dynamic fluid replacement, fewer patients die in the first 24–48 h.13 It is a priority to maintain intravascular volume and organ perfusion despite the oedema caused by intense fluid resuscitation.13,14 When resuscitation is suboptimal, burn depth increases and the shock period is longer, leading to greater mortality.12 However, can we be sure that resuscitation is done properly?

We found it surprising that despite advances in haemodynamic monitoring and establishment of the ‘goal-directed fluid therapy’ concept, many burn units still base their resuscitation practice on a formula created 40 yr ago.7,15 In 1991, Dries and Waxman16 had already suggested that resuscitation based only on the urinary output and vital signs might be suboptimal. It is also surprising that after the recent emergence of studies on hydroxyethyl starches (HES), burn patients have been included alongside septic patients as those in whom starch administration should be avoided, even though none of the studies on which these recommendations were based included patients with major burns. These considerations prompted us to undertake the present review.

The aim of this review concerning initial fluid resuscitation in burn patients was to provide an overview of the current data regarding two key questions: what is the best way to determine the amount of fluids a burn patient needs, and what are the optimal fluids to use in this patient population? The reasons why burn patients require large amounts of fluids in the initial resuscitation is not a subject of this review, because the pathophysiological changes occurring are extensive and would require a review in themselves.

Methods

To provide answers to the proposed questions, we carried out a two-phase bibliographic search of articles published since 2000, the time when the scientific community focused renewed interest on fluid therapy, new concepts such as goal-directed therapy appeared, some products such as the previous generation starches were no longer available, and the Boldt retraction occurred.17,18

First, we identified related clinical practice guidelines, systematic reviews, and other critical syntheses of documents in the scientific literature, such as health technology evaluation reports. In this first phase, we consulted the electronic database MEDLINE, using PubMed and the Cochrane Database of Systematic Reviews. The search strategy included the following terms: burn, burn resuscitation, fluid therapy, colloids, gelatins, crystalloids, hydroxyethyl starch, albumin, isotonic and hypertonic solutions, saline, Ringer's solution, Ringer's lactate, Ringer's acetate (RA), monitoring, haemodynamic monitoring, goal-directed therapy, lactate, base deficit, burn metabolic parameters, lactate clearance, systematic, review, randomized controlled trial, controlled clinical trial, and meta-analysis.

In the second phase, we specifically searched individual studies, prioritizing randomized controlled trials, but also including observational studies, retrieved from MEDLINE. Only studies carried out in adults and reported in articles written in English, French, or Spanish were selected. The research was carried out in November 2014, and articles retracted up to that date were excluded. The GRADE criteria19 were used to evaluate the scientific quality of the studies selected.

During the period reviewed, 13 studies were published on goal-directed therapy in burn patients, and 11 of them are included in this review.15,20–29 One study performed in paediatric patients and another written in a language other than the three specified above were excluded.

Regarding crystalloids, we reviewed 42 articles, two of which were included.30,31 The remaining articles were excluded for the following reasons: 17 did not meet the search criteria, four were reviews, eight were written in other languages, five were protocols, guidelines, descriptions of daily clinical practice, or surveys, two were carried out in paediatric patients, and four were experimental animal studies.

In relation to hydroxyethyl starches, we first analysed the studies carried out with last-generation starches that later prompted the recommendations not to use these substances in burn patients,32–35 and then performed a search on HES use for burn resuscitation. Two articles investigating HES in burn patients were included,36,37 whereas seven non-systematic reviews, nine articles that did not meet the search criteria, three that included critically ill patients, and four in other languages were excluded.

Eighteen articles were found on albumin use in burn patients, and four were included in the present review.38–41 We excluded three non-systematic reviews, two articles focusing on hypoalbuminaemia that did not deal with initial replacement therapy, one in paediatric patients, one in animals, one experimental study, four that were protocols, guidelines, or descriptions of daily clinical practice, and one deemed to have a high risk of bias. This last study42 was based on information from a database in which albumin administration was recorded as a ‘special procedure’. The study assumed that patients who were not given albumin had received only crystalloids; the potential use of other colloids was not considered. Furthermore, fluid therapy did not seem to follow an established protocol; hence, it is likely that the more severely ill patients who did not respond to crystalloids were those given albumin treatment.

Fluid therapy for burns

Determining the initial amount of fluid therapy a burn patient needs

Burn patients receive a larger amount of fluids in the first 24 h than any other trauma patients because of the pathophysiological mechanisms occurring in the injury. Burn shock is a combination of hypovolaemic shock and cell shock, characterized by specific microvascular and haemodynamic changes. In addition to the local lesion, the burn stimulates the release of inflammatory mediators that induce an intense systemic inflammatory response, producing an increase in vascular permeability in both the healthy and the affected tissue. The increased permeability provokes an outpouring of fluids from the intravascular space to the interstitial space, giving rise to oedema, hypovolaemia, and haemoconcentration. These changes, together with increased vascular resistance and the decreased cardiac contractility produced by tumour necrosis factor and interleukin-1 release, can trigger a state of shock, depending on the magnitude of the lesions. The amount of inhalation injury also has an effect on the clinical course, fluid requirements, and the patient's prognosis (Fig. 1). The main objective of fluid administration in thermal trauma is to preserve and restore tissue perfusion and prevent ischaemia, but resuscitation is complicated by the oedema and transvascular displacement of fluids characteristic of this condition.12–14

Fig 1

Burn shock pathophysiology.

Given that the amount of fluids to be administered is directly proportional to the severity of the injuries, patients with major burns are the most difficult to manage. There are several published definitions of major burn based on the burn surface area (BSA), the amount of smoke inhalation, the patient's age and co-morbidities, and whether or not it is an electrical injury. It was Baxter43 who first showed that patients with >30% BSA experience a systemic transmembrane potential decline in both burned and unburned cells. In our unit, major burns are considered to be those involving a BSA of at least 20%, because strict i.v. resuscitation is needed in such patients.44 The correct choice of fluid therapy is extremely important in major burns because incorrect replacement can lead to a series of deleterious effects, as discussed below.

Initial resuscitation is based on crystalloids.5,6Although it has been shown that these solutions have a smaller volume expansion effect than colloids,45 because of the increased capillary permeability occurring during the first 24 h, colloids will pass to the extravascular space, exert an oncotic effect, and cause a paradoxical augmentation of what is commonly called the third space.46 Although recent studies claim that the increased permeability starts at 2 h postburn and lasts for 5 h,47 the use of colloids in burn patients remains controversial.

Goal-directed fluid therapy

Goal-directed fluid therapy has been an important concept in initial fluid resuscitation for major burns since publication of the retrospective study by Dries and Waxman16 in 1991. These authors observed that the vital signs and urinary output showed little variation after fluid replacement, whereas significant changes were seen in the parameters measured by pulmonary artery catheterization (PAC). These findings led to the conclusion that fluid resuscitation guided by the vital signs may be inadequate.16

Since that time, cardiac output has been considered one of the most important measures to guide volume therapy, but only 8% of burn units base their initial resuscitation plan on this parameter because PAC is needed for its measurement.15 However, during the last 15 yr, several articles have reported on a new volume monitoring and replacement approach for goal-directed fluid resuscitation based on transpulmonary thermodilution (TTD) and arterial pressure wave analysis, which are less invasive than PAC (Table 1).

Table 1

Goal-directed therapy studies in major burns. BP, blood pressure; BSA, burned surface area; CI, cardiac index; CO, cardiac output; EVLW, extravascular lung water; GEDVI, global end-diastolic volume index; HOU, hourly urinary output; HR, heart rate; ITBV, intrathoracic blood volume index; LiDCO, lithium dilution cardiac output; LVED, left ventricular end-diastolic; LVES, left ventricular end-systolic; MAP, mean arterial pressure; MODS, multiple organ dysfunction score; PAC, pulmonary artery catheter; ScvO2⁠, central venous oxygen saturation; SVI, stroke volume index; SVRI, systemic vascular resistance index; TEE, transoesophageal echocardiography; TTD, transpulmonary thermodilution; UO, urinary output

Table 1

Goal-directed therapy studies in major burns. BP, blood pressure; BSA, burned surface area; CI, cardiac index; CO, cardiac output; EVLW, extravascular lung water; GEDVI, global end-diastolic volume index; HOU, hourly urinary output; HR, heart rate; ITBV, intrathoracic blood volume index; LiDCO, lithium dilution cardiac output; LVED, left ventricular end-diastolic; LVES, left ventricular end-systolic; MAP, mean arterial pressure; MODS, multiple organ dysfunction score; PAC, pulmonary artery catheter; ScvO2⁠, central venous oxygen saturation; SVI, stroke volume index; SVRI, systemic vascular resistance index; TEE, transoesophageal echocardiography; TTD, transpulmonary thermodilution; UO, urinary output

But, are these new techniques applicable to burn resuscitation? Have they been validated in burn patients? Which parameters should we use as end points? And do they improve the outcomes?

As a result of the huge temperature changes and associated hypothermia burn patients experience, the applicability of thermodilution methods remained uncertain in this population until a publication in 2005 provided results supporting their use. In a prospective study including 50 patients with more than 25% BSA burns and receiving mechanical ventilation, 750 measurements were carried out. The study concluded that variability was <10% for the cardiac output, intrathoracic blood volume (ITBV), and total blood volume, and between 9.5 and 12.9% for the extravascular lung water (EVLW). In addition, there was no correlation between body temperature and the reproducibility of the measurements.20

Two observational studies have compared the measures obtained by PAC and TTD,15,21 and another has compared transoesophageal echocardiography (TEE), TTD, and PAC.22 The first, carried out in 23 burn patients, compared the cardiac output values and concluded that although output measured by TTD was slightly higher, the difference was not important for clinical practice.15 The second study, performed in 14 patients, validated the parameters stroke volume index and systemic vascular resistance index for normal and low cardiac output using TTD, and reported a good correlation with measures obtained by conventional PAC.21

In 2009, Bak and colleagues22 published a study evaluating haemodynamic variables measured by TEE, TTD, and PAC during initial resuscitation according to the Parkland formula. The authors reported no significant differences between the various methods. They also found that the left ventricular end-systolic, left ventricular end-diastolic, and global end-diastolic volume indexes are suboptimal 12 h after burn injury and normalize at 24 h. Furthermore, both the EVLW and the ITBV are increased 23 h after burn injury.

With regard to TEE, only two additional studies were published in burn patients during the period of the present review, one describing the results of the measurements and their relationship with cardiac output48 and the other using TEE as a diagnostic technique in burn patients with bacteraemia or hypotension.49 Although TEE seemed to be a safe and minimally invasive technique in these reports, further studies are needed to validate its use for initial resuscitation in these patients.

Several authors have focused on determining which parameters should be used for guiding major burn resuscitation. In an observational study carried out in 2000, Holm and colleagues23 reported that the cardiac index and oxygen delivery evaluated during the first hours were useful for this purpose in major burn survivors. Nonetheless, the findings did not suffice to indicate that these parameters should be the end points used.

During the same year, Holm and colleagues24 published another observational study, including 24 patients in whom the ITBV was evaluated as a resuscitation end point. The authors concluded that patients received more fluids based on this parameter than would be estimated by the Parkland formula, with no differences in the EVLW. The ITBV increase improved the oxygen delivery and showed a good relationship with oxygen delivery and the cardiac index.

Küntscher and colleagues25 undertook an observational study, in which ITBV and EVLW measurements obtained using single- and double-indicator dilution techniques were compared. The authors concluded that the single-indicator dilution technique was not accurate enough to assess ITBV and EVLW in burn shock.

Four prospective randomized studies, three using TTD26–28 and one using LiDCO® haemodynamic monitoring,29 have compared the results of initial resuscitation performed according to the Parkland/Baxter formula with those of goal-directed therapy based on preload parameters.

The first of these, by Holm and colleagues26 and including 50 patients, found that initial fluid administration was higher in the TTD group with resuscitation based on the ITBV. Urinary output was also higher, but there were no significant differences between the groups regarding renal failure. No relationship was found between the EVLW and the volume infused, and there were no significant differences in preload, cardiac output, morbidity, or mortality.

Csontos and colleagues27 compared the multiple organ dysfunction score (MODS) and central venous oxygen saturation (⁠S cvO2⁠) values during the first 3 days postburn between patients treated according to the Parkland formula and those whose treatment was based on the ITBV measured by TTD. Fluid infusion was greater in the ITBV group during the first day, and the ScvO2 was found to be higher. In the Parkland group, the MODS score was higher at 48 and 72 h, and the usual haemodynamic parameters (urinary output and central venous pressure) showed no correlation with Scv O2 or any other haemodynamic parameter.

In 2013, Aboelatta and Abdelsalam28 conducted a clinical trial with 30 patients and compared initial resuscitation using the Parkland formula vs TTD-guided resuscitation. The goals were ITBV >800 ml m−2 and cardiac index >3.5 litre min m−2, with limited fluid administration in patients with EVLW >10 ml kg−1. The TTD group received a larger amount of fluids during the first 72 h, and urinary output was higher, but the mean arterial pressure and heart rate were lower in this group. There were no differences in central venous pressure, hospital stay, or mortality. Of note, the authors highlighted the difficulty or even impossibility of achieving normovolaemia parameters in the first 24 h postburn and suggested the possibility of redefining them for this type of patient.

Curiously, also in 2013, Tokarik and colleagues29 published the only study whose results were incongruent with those reported previously. It was a clinical trial including 21 patients that compared initial resuscitation according to the Parkland formula with resuscitation guided by preload dynamic parameters measured by the LiDCO® system. This is the only study in which the amount of crystalloid infusion during the first 24 h was lower in the goal-directed therapy group, but there were no significant differences between the groups in the total volume of resuscitation solution used or in the remaining study parameters. Of note, the monitoring device was different from that used in the previous studies, and it has not been validated in burn patients.

After reviewing these results, it seems reasonable to say that TTD has a role in burn resuscitation, while keeping in mind that the available studies included small samples, and the results were obtained in a short time and were based on haemodynamic parameters. Until now, the true effect of this approach on patient survival has not been reported. Multicentre studies with large samples and strict methodology are needed to achieve a good level of evidence for TTD use in these patients.

The studies described suggest that burn patients are likely to require more intensive resuscitation than the amount they receive based on the modified Parkland formula, particularly in the first 24 h, in order to improve the preload parameters, cardiac index, ScvO2⁠, and oxygen delivery. Normovolaemia may not be the main goal to achieve, although it seems that the EVLW is not affected by greater fluid administration in the first hours.

It is a fact that most centres providing initial care to burn patients are not equipped with the resources needed to guide resuscitation by goal-directed therapy techniques, and to date, these methods have not shown survival benefits relative to use of the Parkland formula. But it is also true that rigorous studies with large patient samples will further elucidate the initial pathophysiology of burn patients and enable development of formulas that are better adapted to their real needs.

Certain metabolic variables have been specifically investigated in burn patients. Lactate concentrations, the lactate/pyruvate ratio, the base deficit, and even microalbuminuria have shown prognostic value, and some of these parameters may be of use to guide the quality of initial resuscitation. Nonetheless, although these variables show value for this purpose, the results using current measurement methods are not immediately available; hence, they are not considered as useful as the real-time markers obtained by monitoring.50–52

What fluids should be used in initial resuscitation?

Crystalloids

During the last few years, several studies have been published on crystalloid-based fluid therapy in various types of patients. Balanced solutions have been shown to be superior to unbalanced crystalloids (evidence level 1B).53

Multiple adverse effects have been described with the use of saline solution, and several studies have reported problems associated with RL use in critically ill patients and others without burn injuries.31,54–59 But can these results be extrapolated to burn patients?

The literature is limited regarding what type of crystalloid is most appropriate for burns. By definition, the Parkland formula is performed with RL, which is why this has been the fluid of choice in burns.7 Only two observational studies were found comparing different types of crystalloids in burn patients, and only one of them compared two balanced isotonic solutions (Table 2).

Table 2

Crystalloid studies in major burns. ACS, abdominal compartment syndrome; BSA, burn surface area; HLS, hypertonic lactated serum; HUO, hourly urinary output; IAP, intra-abdominal pressure; RA, Ringer's acetate; RL, Ringer's lactate; SOFA, sequential organ failure assessment

Table 2

Crystalloid studies in major burns. ACS, abdominal compartment syndrome; BSA, burn surface area; HLS, hypertonic lactated serum; HUO, hourly urinary output; IAP, intra-abdominal pressure; RA, Ringer's acetate; RL, Ringer's lactate; SOFA, sequential organ failure assessment

In 2006, Oda and colleagues30 studied a cohort of 36 burn patients with >40% BSA burns and no severe smoke inhalation injury. The authors' objective was to analyse the development of abdominal compartment syndrome and its relationship with initial fluid administration. Based on the fact that hypertonic serum reduces fluid requirements, the authors designed a study comparing initial resuscitation with RL vs hypertonic lactated saline, with urinary output at 0.5 ml kg−1 h−1. Patients given lactated saline received a significantly smaller amount of fluids than those given RL. Furthermore, peak abdominal pressure and peak inspiratory pressure at 24 h were lower in the saline group. Only 14% of patients receiving lactated saline developed abdominal compartment syndrome as opposed to 50% in the RL group.

A study by Gille and colleagues31 in 2013 provides interesting results, but it has a retrospective–prospective observational design, and the quality of the evidence is low. The authors compared initial resuscitation with RL (retrospective n=40) or RA (prospective n=40). Patients receiving RA had an initial trend to lower Sequential Organ Failure Assessment (SOFA) scores, which were significantly lower on days 3–6. There were no differences in the amount of crystalloids infused, but the RA group required a smaller amount of colloids, packed red blood cells, and plasma infusion. Lactate concentrations were increased in the RL group on days 1–3. Ringer's acetate was associated with a higher incidence of thrombocytosis, but no thrombotic events were described. The duration of hospital stay and days on mechanical ventilation were lower in the RA group. There were no significant differences in mortality.

Taking into account that balanced solutions have already proved superior for fluid replacement, RA would seem to be the most suitable option for large replacements. Nonetheless, although this solution has shown a favourable profile in trauma patients, the related evidence in burn patients is limited. Further studies comparing RL with RA for initial resuscitation are needed. Hypertonic solutions may also have a place in burn resuscitation. The Cochrane systematic reviews,60 guidelines from the USA,44 and other reviews11,61,62 have evaluated their efficacy in burn patients, but up to now there is no clear evidence in favour or against them, and additional studies are required to define the correct doses and timing.

Colloids

Colloids are controversial in burn management, even more so after the recent warning issued by various drug control agencies contraindicating the use of HES in burn patients.63 Colloids are fluids that contain macromolecules, and they have a greater expansion effect than crystalloids.45 They can have natural (plasma and albumin) or synthetic (HES and gelatine) components.

Gelatins are now the synthetic colloid used in burns, being the only available option after the HES warning,63 but their expansion capacity is inferior to that of HES, and their effect ceases 1 h after administration.64 Two meta-analyses65,66 published in 2012 concluded that gelatins have no advantages over crystalloids,66 and as of today, their safety cannot be confirmed.65 There are no studies ensuring their safety in burn patients.

Several reviews have concluded that HES use is associated with a higher risk of mortality and kidney injury compared with other resuscitation solutions in septic patients, and burn patients have been included within this group.67,68 Some of the studies leading to the HES alert have been reviewed and criticized for being methodologically questionable.69–72 Others were carried out with first- and second-generation starches, which are no longer used for this purpose.73,74 Their adverse effects are well recognized, and they are not included in the present review.

We analysed the 6S,32 CRYSTMAS,33 CHEST,34 and CRISTAL35 studies, which were the basis for the alert that HES should not be used in burn resuscitation. Surprisingly, patients with major burns were excluded from three of these studies,32,34,35 and in one study no information was provided in this respect.33 The analysis of these studies is summarized in Table 3.

Table 3

Colloid studies upon which the recommendations were based. AKI, acute kidney injury; BSA, burn surface area; HES, hydroxyethyl starch; ICU, intensive care unit; RRT, renal replacement therapy; RIFLE, risk injury failure loss or end stage kidney disease

Table 3

Colloid studies upon which the recommendations were based. AKI, acute kidney injury; BSA, burn surface area; HES, hydroxyethyl starch; ICU, intensive care unit; RRT, renal replacement therapy; RIFLE, risk injury failure loss or end stage kidney disease

A systematic review and meta-analysis conducted by Zarychanski and colleagues67 included 38 clinical trials in critically ill patients published up to October 2012, comparing the use of HES vs crystalloids, albumin, or gelatine and assessing the relationships with acute kidney injury and mortality. Most trials were classified as having a high or unclear risk of bias. After excluding the retracted studies, HES was associated with higher mortality rates, more prevalent renal failure, and higher requirements for renal replacement therapy. Two of the studies were carried out in burn patients, but one was written in Chinese75 and the other used HES 200/0.6,76 a previous-generation starch. Hence, both were excluded from the present review.

The Cochrane review68 of 2010, updated in 2013, included 42 studies with good methodological quality, in which HES was compared with any other fluid therapy for hypovolaemia treatment. A significant increase in renal failure and renal replacement therapy was observed in the HES group. Burn patients were not excluded, but a separate analysis in this population was not provided.

The only study investigating third-generation HES in major burns was a randomized clinical trial including 48 patients, carried out by Béchir and colleagues36 in 2013. Mixed resuscitation therapy (HES plus RL) was compared with crystalloids alone (RL). The aim was to calculate the total volume infused within the first 72 h and determine the safety profile. No differences were found in the mortality rate, volume administered, or renal damage between the groups (Table 4).

Table 4

Colloid studies in major burns. ACS, abdominal compartment syndrome; AKI, acute kidney injury; BSA, burn surface area; FFP, fresh frozen plasma; HES, hydroxyethyl starch; IAP, intra-abdominal pressure; MODS, multiple organ dysfunction score; RL, Ringer's lactate; VAP, ventilator-associated pneumonia

Table 4

Colloid studies in major burns. ACS, abdominal compartment syndrome; AKI, acute kidney injury; BSA, burn surface area; FFP, fresh frozen plasma; HES, hydroxyethyl starch; IAP, intra-abdominal pressure; MODS, multiple organ dysfunction score; RL, Ringer's lactate; VAP, ventilator-associated pneumonia

Concerning natural colloids, fresh frozen plasma has classically been used as a plasma expander, but the high associated cost and risk of disease transmission have limited its use mainly to coagulation disorders77 (Table 4).

In 2005, O′Mara and colleagues37 reported a prospective randomized study in 31 burn patients, comparing RL resuscitation with RL plus fresh frozen plasma. A larger volume was needed in the crystalloid alone group, and there was a greater increase in intra-abdominal pressure. In addition, a correlation was found between the amount of liquid infused and intra-abdominal pressure. These findings are consistent with those reported by Ivy and colleagues,78 who described intra-abdominal hypertension and abdominal compartment syndrome in major burns. Nonetheless, the sample size was small; hence, larger studies are needed to evaluate the efficacy of fresh frozen plasma in preventing compartment syndrome.

The use of albumin for fluid resuscitation in critically ill patients has been questioned since 1998, when the Cochrane79 review concluded that albumin may be associated with higher mortality. Since then, several studies, such as SAFE,80–82 ALBIOS,83 and the review by Hartog and colleagues,84 have shown favourable results, except in traumatic brain injury. The Surviving Sepsis Campaign,85 published in 2013, recommends albumin in patients unresponsive to crystalloid resuscitation, with a 2C level of evidence. However, burn patients are generally excluded from these studies or are not analysed as a subgroup. We retrieved four relatively recent studies specific to these patients.

In 2006, Cooper and colleagues38 carried out a multicentre randomized clinical trial with 42 burn patients comparing fluid resuscitation with RL vs RL plus albumin. The BSA and inhalation injuries were more severe in the albumin group. Although the differences between arms were not significant in themselves, the expected mortality was 18.6% in the albumin group and 9.4% in the controls (P=0.06), and no adjustment was made for this imbalance. In the intention-to-treat analysis, there were no significant differences between the groups for the primary outcome, lowest MODS from day 0 to day 14, or mortality at day 28, but the authors mentioned that their study was underpowered for both these outcomes.

In 2007, Cochran and colleagues39 conducted a study in patients with ≥20% BSA burns, comparing those who received albumin because of increased fluid requirements with a cohort comparable for age and burn injury who did not require albumin administration. On multivariate analysis, albumin administration was found to be a protective factor for mortality.

In 2010, Lawrence and colleagues40 performed a retrospective observational study in burn patients with ≥20% BSA and reported that albumin use in patients receiving a volume of crystalloids above the amount estimated by the Parkland formula resulted in reductions in the mean resuscitation ratio and the hourly fluid requirements.

An observational retrospective–prospective study published by Park and colleagues41 in 2012 compared burn patients treated with RL and a synthetic colloid vs those treated with albumin. Mortality, days on mechanical ventilation, mechanical ventilation-associated pneumonia, and laparotomy for abdominal compartment syndrome were significantly lower in the albumin group. The study was limited partly by its prospective–retrospective design. No randomization or blinding was specified, implying a high risk of bias.

The latest study published on albumin in burn resuscitation was a meta-analysis carried out by Navickis and colleagues86 in 2014, including randomized and non-randomized clinical trials. After exclusion of two studies with a high risk of bias, albumin was found to be associated with a lower incidence of compartment syndrome and lower mortality.

After concluding this review and in agreement with the opinions of others,70,87 we believe it is reasonable to say that the studies motivating the HES alert, which did not include burn patients, may not have been an entirely appropriate basis for the warning in this population. The small number of studies investigating colloids in burn patients do not reflect an increase in acute kidney injury or mortality. Furthermore, none of the HES studies prompting the alert was done with balanced HES, and chloride is known to be associated with renal injury.58 Gelatins have not shown superiority over crystalloids, and their safety is uncertain. Both albumin and plasma could be a good option for burn patients, although the available data on plasma use are limited. Multicentre studies focused on colloid use should be carried out in this specific population.

Conclusions

Suboptimal fluid resuscitation in burn patients leads to greater burn depth and extension of the shock period, which usually takes place in the first 24–48 h. According to the results of goal-directed therapy studies, the amount of fluid given in the first 24 h should be somewhat higher that that estimated by the Parkland formula.

Major burn resuscitation should ideally be performed according to goal-directed therapy with thermodilution methods because they are less invasive than PAC and have been well validated in burns. Some studies have shown an improvement in the cardiac index, Scv O2⁠, oxygen delivery, and MODS when resuscitation is based on TTD and taking the ITBV and EVLW as end points; nonetheless, the optimal parameters remain to be defined.

The initial resuscitation fluid should be a balanced crystalloid. Colloids seem inappropriate during the first hours because of the patient's increased capillary permeability. Ringer's acetate seems to protect the electrolytic balance in large replacements, and it may be the crystalloid of choice for initial resuscitation in burn patients.

Although there are reports of poorer outcomes in septic patients with the use of HES, the current scientific evidence does not suffice to support a specific contraindication for HES use in burn patients. As was the practice in many burn units, we formerly used HES after the first 24 h when it was needed and we did not have the impression that outcomes were worse in our patients, but this is a subjective evaluation.

Gelatins have not shown superiority over crystalloids in their expansion capacity, and their safety is still uncertain.

Hypertonic solutions, albumin, and plasma have been associated with lower volume requirements for initial resuscitation, lower intra-abdominal pressure, and a lower incidence of compartment syndrome; hence, these solutions could have a place in burn resuscitation, but additional evidence is needed to support their use.

Multicentre randomized controlled trials on fluid resuscitation in major burns are still needed to define the best fluid therapy in this population. Data are lacking on the optimal end points for TTD, the difference between initial resuscitation with Ringer's lactate or Ringer's acetate, the proper timing to initiate colloids, and the comparative performance of the different natural and synthetic colloids in burn patients.

Authors' contributions

Study design: P.G., G.U., N.M., L.A., M.J.C.

Study conduct: P.G., M.J.C.

Data analysis: P.G., G.U., N.M., L.A.

Final approval of the contents: J.P.B.

Wrote the manuscript and approved the final manuscript: P.G., G.U., N.M., L.A., M.J.C.

Reviewed the final version: P.G., M.J.C.

Declaration of interest

None declared.

References

1

Underhill

F

The significance of anhydremia in extensive surface burn

.

JAMA

1930

;

95

:

852

–

7

2

Moore

FD

The body-weight burn budget. Basic fluid therapy for the early burn

.

Surg Clin North Am

1970

;

50

:

1249

–

65

3

Evans

EI

Fluid and electrolyte requirements in severe burns

.

Ann Surg

1952

;

135

:

804

–

17

4

Lund

C

The estimate of areas of burns

.

Surg Gynecol Obs

1944

;

79

:

352

–

8

5

Baxter

CR

Physiological response to crystalloid resuscitation of severe burns

.

Ann N Y Acad Sci

1968

;

150

:

874

–

94

6

Baxter

C

Fluid resuscitation, burn percentage, and physiologic age

.

J Trauma

1979

;

19

:

864

–

5

7

Greenhalgh

DG

Burn resuscitation: the results of the ISBI/ABA survey

.

Burns

2010

;

36

:

176

–

82

8

Schwartz

SI

Supportive therapy in burn care. Consensus summary on fluid resuscitation

.

J Trauma

1979

;

19

:

876

–

7

9

Shires

G

Proceedings of the Second NHI Workshop on Burn Management

.

J Trauma

1979

;

19

(11 Suppl)

:

862

–

3

10

Saffle

JIL

The phenomenon of ‘fluid creep’ in acute burn resuscitation

.

J Burn Care Res

2007

;

28

:

382

–

95

11

Azzopardi

EA

Fluid resuscitation in adults with severe burns at risk of secondary abdominal compartment syndrome—an evidence based systematic review

.

Burns

2009

;

35

:

911

–

20

12

Barrow

RE

Early fluid resuscitation improves outcomes in severely burned children

.

Resuscitation

2000

;

45

:

91

–

6

13

Artz

CP

The burn problem

. In:

Artz

CP

The treatment of burns

.

Philadelphia

:

W.B. Saunders

,

1969

;

1

–

22

14

Rose

JK

Advances in the treatment of burn patients

.

Burns

1997

;

23

(Suppl 1)

:

S19

–

26

15

Holm

C

Arterial thermodilution: an alternative to pulmonary artery catheter for cardiac output assessment in burn patients

.

Burns

2001

;

27

:

161

–

6

16

Dries

DJ

Adequate resuscitation of burn patients may not be measured by urine output and vital signs

.

Crit Care Med

1991

;

19

:

327

–

9

17

Shafer

SL

Notice of retraction

.

Anesth Analg

2010

;

111

:

1567

18

Wise

J

Boldt: the great pretender

.

Br Med J

2013

;

346

:

f1738

19

Sanabria

AJ

GRADE: methodology for formulating and grading recommendations in clinical practice

.

Aten Primaria

2015

;

47

:

48

–

55

20

Holm

C

Reproducibility of transpulmonary thermodilution measurements in patients with burn shock and hypothermia

.

J Burn Care Rehabil

2005

;

26

:

260

–

5

21

Küntscher

MV

Transcardiopulmonary vs pulmonary arterial thermodilution methods for hemodynamic monitoring of burned patients

.

J Burn Care Rehabil

2002

;

23

:

21

–

6

22

Bak

Z

Hemodynamic changes during resuscitation after burns using the Parkland formula

.

J Trauma

2009

;

66

:

329

–

36

23

Holm

C

Haemodynamic and oxygen transport responses in survivors and non-survivors following thermal injury

.

Burns

2000

;

26

:

25

–

33

24

Holm

C

Intrathoracic blood volume as an end point in resuscitation of the severely burned: an observational study of 24 patients

.

J Trauma

2000

;

48

:

728

–

34

25

Küntscher

MV

Transcardiopulmonary thermal dye versus single thermodilution methods for assessment of intrathoracic blood volume and extravascular lung water in major burn resuscitation

.

J Burn Care Rehabil

2003

;

24

:

142

–

7

26

Holm

C

A clinical randomized study on the effects of invasive monitoring on burn shock resuscitation

.

Burns

2004

;

30

:

798

–

807

27

Csontos

C

Arterial thermodilution in burn patients suggests a more rapid fluid administration during early resuscitation

.

Acta Anaesthesiol Scand

2008

;

52

:

742

–

9

28

Aboelatta

Y

Volume overload of fluid resuscitation in acutely burned patients using transpulmonary thermodilution technique

.

J Burn Care Res

2013

;

34

:

349

–

54

29

Tokarik

M

Fluid therapy LiDCO controlled trial—optimization of volume resuscitation of extensively burned patients through noninvasive continuous real-time hemodynamic monitoring LiDCO

.

J Burn Care Res

2013

;

34

:

537

–

42

30

Oda

J

Hypertonic lactated saline resuscitation reduces the risk of abdominal compartment syndrome in severely burned patients

.

J Trauma

2006

;

60

:

64

–

71

31

Gille

J

Safety of resuscitation with Ringer's acetate solution in severe burn (VolTRAB)—an observational trial

.

Burns

2014

;

40

:

871

–

80

32

Perner

A

Hydroxyethyl starch 130/0.42 versus Ringer's acetate in severe sepsis

.

N Engl J Med

2012

;

367

:

124

–

34

33

Guidet

B

Assessment of hemodynamic efficacy and safety fluid replacement in patients with severe sepsis: The CRYSTMAS study

.

Crit Care

2012

;

16

:

R94

34

Myburgh

JA

Hydroxyethyl starch or saline for fluid resuscitation in intensive care

.

N Engl J Med

2012

;

367

:

1901

–

11

35

Annane

D

Effects of fluid resuscitation with colloids vs crystalloids on mortality in critically ill patients presenting with hypovolemic shock: the CRISTAL randomized trial

.

JAMA

2013

;

310

:

1809

–

17

36

Béchir

M

Early fluid resuscitation with hydroxyethyl starch 130/0.4 (6%) in severe burn injury: a randomized, controlled, double-blind clinical trial

.

Crit Care

2013

;

17

:

R299

37

O'Mara

MS

A prospective, randomized evaluation of intra-abdominal pressures with crystalloid and colloid resuscitation in burn patients

.

J Trauma Inj Infect Crit Care

2005

;

58

:

1011

–

8

38

Cooper

AB

Five percent albumin for adult burn shock resuscitation: lack of effect on daily multiple organ dysfunction score

.

Transfusion

2006

;

46

:

80

–

9

39

Cochran

A

Burn patient characteristics and outcomes following resuscitation with albumin

.

Burns

2007

;

33

:

25

–

30

40

Lawrence

A

Colloid administration normalizes resuscitation ratio and ameliorates “fluid creep”

.

J Burn Care Res

2010

;

31

:

40

–

7

41

Park

SH

Early albumin use improves mortality in difficult to resuscitate burn patients

.

J Trauma Acute Care Surg

2012

;

73

:

1294

–

7

42

Caleman

G

Use of albumin as a risk factor for hospital mortality among burn patients in Brazil: non-concurrent cohort study

.

Sao Paulo Med J

2010

;

128

:

289

–

95

43

Baxter

CR

Fluid volume and electrolyte changes of the early post-burn period

.

Clin Plast Surg

1974

;

1

:

693

–

703

44

Pham

TN

American Burn Association

.

American Burn Association practice guidelines burn shock resuscitation

.

J Burn Care Res

2016

;

29

:

257

–

66

45

Orbegozo Cortés

D

Crystalloids versus colloids: exploring differences in fluid requirements by systematic review and meta-regression

.

Anesth Analg

2015

;

120

:

389

–

402

46

Myburgh

JA

Resuscitation fluids

.

N Engl J Med

2013

;

369

:

1243

–

51

47

Vlachou

E

Microalbuminuria: a marker of endothelial dysfunction in thermal injury

.

Burns

2006

;

32

:

1009

–

16

48

Wang

G-Y

Esophageal echo-Doppler monitoring in burn shock resuscitation: are hemodynamic variables the critical standard guiding fluid therapy?

J Trauma

2008

;

65

:

1396

–

401

49

Etherington

L

Use of transesophageal echocardiography in burns: a retrospective review

.

J Burn Care Res

2010

;

31

:

36

–

9

50

Sánchez

M

A protocol for resuscitation of severe burn patients guided by transpulmonary thermodilution and lactate levels: a 3-year prospective cohort study

.

Crit Care

2013

;

17

:

R176

51

Andel

D

Base deficit and lactate: early predictors of morbidity and mortality in patients with burns

.

Burns

2007

;

33

:

973

–

8

52

Samuelsson

A

Microdialysis shows metabolic effects in skin during fluid resuscitation in burn-injured patients

.

Crit Care

2006

;

10

:

R172

53

Powell-Tuck

J

British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (GIFTASUP)

.

54

Raghunathan

K

Choice of fluid in acute illness: what should be given? An international consensus

.

Br J Anaesth

2014

;

113

:

772

–

83

55

McFarlane

C

A comparison of plasmalyte 148 and 0.9% saline for intra-operative fluid replacement

.

Anaesthesia

1994

;

49

:

779

–

81

56

Hadimioglu

N

The effect of different crystalloid solutions on acid-base balance and early kidney function after kidney transplantation

.

Anesth Analg

2008

;

107

:

264

–

9

57

Shaw

AD

Major complications, mortality, and resource utilization after open abdominal surgery: 0.9% saline compared to Plasma-Lyte

.

Ann Surg

2012

;

255

:

821

–

9

58

Yunos

NM

Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults

.

JAMA

2012

;

308

:

1566

–

72

59

Shin

W-J

Lactate and liver function tests after living donor right hepatectomy: a comparison of solutions with and without lactate

.

Acta Anaesthesiol Scand

2011

;

55

:

558

–

64

60

Bunn

F

Hypertonic versus near isotonic crystalloid for fluid resuscitation in critically ill patients

.

Cochrane Database Syst Rev

2004

;

3

:

CD002045

61

Endorf

FW

Burn resuscitation

.

Scand J Trauma Resusc Emerg Med

2011

;

19

:

6

–

9

62

Strang

SG

A systematic review on intra-abdominal pressure in severely burned patients

.

Burns

2014

;

40

:

9

–

16

63

European Medicines Agency

.

Hydroxyethyl-starch solutions (HES) should no longer be used in patients with sepsis or burn injuries or in critically ill patients – CMDh endorses PRAC recommendations HES will be available in restricted patient populations

.

Ema/640658/2013

2013

;

44

:

1

–

3

64

Libert

N

Il y a-t-il une place pour le sérum salé hypertonique dans les états septiques graves?

Ann Fr Anesth Reanim

2010

;

29

:

25

–

35

65

Thomas-Rueddel

DO

Safety of gelatin for volume resuscitation—a systematic review and meta-analysis

.

Intensive Care Med

2012

;

38

:

1134

–

42

66

Saw

MM

Benefits and risks of using gelatin solution as a plasma expander for perioperative and critically ill patients: a meta-analysis

.

Anaesth Intensive Care

2012

;

40

:

17

–

32

67

Zarychanski

R

Association of hydroxyethyl starch administration with mortality and acute kidney injury in critically ill patients requiring volume resuscitation: a systematic review and meta-analysis

.

JAMA

2013

;

309

:

678

–

88

68

Mutter

TC

Hydroxyethyl starch (HES) versus other fluid therapies: effects on kidney function

.

Cochrane Database Syst Rev

2013

;

7

:

CD007594

69

Van Der Linden

P

Safety of modern starches used during surgery

.

Anesth Analg

2013

;

116

:

35

–

48

70

Meybohm

P

Re-evaluating currently available data and suggestions for planning randomised controlled studies regarding the use of hydroxyethyl starch in critically ill patients - a multidisciplinary statement

.

Crit Care

2013

;

17

:

R166

71

Chappell

D

Twisting and ignoring facts on hydroxyethyl starch is not very helpful

.

Scand J Trauma Resusc Emerg Med

2013

;

21

:

85

72

Chappell

D

Hydroxyethyl starch - the importance of being earnest

.

Scand J Trauma Resusc Emerg Med

2013

;

21

:

61

73

Brunkhorst

FM

Intensive insulin therapy and pentastarch resuscitation in severe sepsis

.

N Engl J Med

2008

;

358

:

125

–

39

74

Lissauer

ME

Association of 6% hetastarch resuscitation with adverse outcomes in critically ill trauma patients

.

Am J Surg

2011

;

202

:

53

–

8

75

Chen

J

Evaluation of effectiveness and safety of a new hydroxyethyl starch used in resuscitation of burn shock

.

Zhonghua Shao Shang Za Zhi

2006

;

22

:

333

–

6

76

Vlachou

E

Hydroxyethylstarch supplementation in burn resuscitation—a prospective randomised controlled trial

.

Burns

2010

;

36

:

984

–

91

77

Yang

L

Is fresh-frozen plasma clinically effective? An update of a systematic review of randomized controlled trials

.

Transfusion

2012

;

52

:

1673

–

86

;

quiz 1673

78

Ivy

ME

Intra-abdominal hypertension and abdominal compartment syndrome in burn patients

.

J Trauma

2000

;

49

:

387

–

91

79

Cochrane Injuries Group Albumin Reviewers

.

Human albumin administration in critically ill patients: systematic review of randomised controlled trials

.

Br Med J

1998

;

317

:

235

–

40

80

Finfer

S

A comparison of albumin and saline for fluid resuscitation in the intensive care unit

.

N Engl J Med

2004

;

350

:

2247

–

56

81

Myburgh

J

Saline or albumin for fluid resuscitation in patients with traumatic brain injury

.

N Engl J Med

2007

;

357

:

874

–

84

82

Finfer

S

Impact of albumin compared to saline on organ function and mortality of patients with severe sepsis

.

Intensive Care Med

2010

;

37

:

86

–

96

83

Caironi

P

Albumin replacement in patients with severe sepsis or septic shock

.

N Engl J Med

2014

;

370

:

1412

–

21

84

Hartog

CS

The efficacy and safety of colloid resuscitation in the critically ill

.

Anesth Analg

2011

;

112

:

156

–

64

85

Dellinger

RP

Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012

.

Intensive Care Med

2013

;

39

:

165

–

228

86

Navickis

RJ

Albumin in burn shock resuscitation: a meta-analysis of controlled clinical studies

.

J Burn Care Res

2016

;

37

:

e268

–

78

87

Sánchez

CA

Controversy over the use of hydroxyethyl starch solutions. Is the use of low molecular weight hydroxyethyl starch contraindicated?

Rev Esp Anestesiol Reanim

2016

;

61

:

299

–

303

© The Author 2016. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email:

© The Author 2016. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email:

Comments

1 Comment

Fluid resucitation management in patients with burns update - what about blood?

1 November 2016

David R Price

Anaesthetics Registrar (ST7), Nevill Hall Hospital, Abergavenny

I enjoyed reading Guilabert et al's review of the literature regarding fluid management in patients with burns. They compare the management of burns with that of patients with other types of major trauma. Given the recent trend towards minimizing the amount of crystalloid fluid given to these patients, in preference to early blood transfusion, to the point where air ambulances now carry blood direct to the patient; I found it curious that there was no mention the role of blood products in the burns patient. Do they feel that it has no role, as the pathophysiology is so different, or is there simply little evidence published?

Conflict of Interest:

None declared

Submitted on 01/11/2016 7:09 PM GMT

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