Elsevier

Burns

Volume 34, Issue 3, May 2008, Pages 328-338
Burns

Fluid management in burn patients: Results from a European survey—More questions than answers

https://doi.org/10.1016/j.burns.2007.09.005Get rights and content

Abstract

Many strategies were proposed for fluid management in burn patients with different composition containing saline solution, colloids, or plasma. The actual clinical use of volume replacement regimen in burn patients in Europe was analysed by an international survey. A total of 187 questionnaires consisting of 20 multiple-choice questions were sent to 187 burn units listed by the European Burn Association.

The response rate was 43%. The answers came from a total of 20 European countries. Volume replacement is mostly exclusively with crystalloids (always: 58%; often: 28%). The majority still use fixed formulae: 12% always use the traditional Baxter formula, in 50% modifications of this formula are used. The most often used colloid is albumin (always: 17%, often: 38%), followed by HES (always: 4%, often: 34%). Gelatins, dextrans, and hypertonic saline are used only very rarely. Fresh frozen plasma (FFP) is given in 12% of the units as the colloid of choice. Albumin was named most often to be able to improve patients’ outcome (64%), followed by HES (53%), and the exclusive use of crystalloids (45%). Central venous pressure (CVP) is most often used to monitor volume therapy (35%), followed by the PiCCO-system (23%), and mixed-venous saturation (ScVO2; 10%).

It is concluded that the kind of volume therapy differs widely among European burn units. This survey supported that no generally accepted volume replacement strategy in burn patients exists. New results, e.g. importance of goal-directed therapy or data concerning use of albumin in the critically ill, have not yet influenced strategies of volume replacement in the burn patient.

Introduction

Appropriate fluid replacement is essential when treating the burn patient because the failure to treat hypovolemia adequately may progress to organ dysfunction or death [1], [2], [3]. Hypovolemia is common among these patients and occur also in the absence of obvious fluid loss secondary to vasodilation or to generalized alteration of the endothelial barrier resulting in diffuse capillary leak [4]. This condition is characterized by endothelial injury with subsequent development of increased endothelial permeability, leading to a loss of proteins and a shift of fluid from the intravascular to the interstitial compartment [4], [5]. Early and adequate correction of hypovolemia appear to be fundamental: a prospective study of patients who died in hospital after admission for treatment of injuries showed that inadequate fluid resuscitation constituted the most common medical error [2].

Although the importance of adequate volume replacement in burn patients is generally accepted, the ideal strategy is still a focus of debate [5], [6]. Different formulae varying with the amount and kind of fluid exist—timing and monitoring of fluid therapy are also controversially discussed issues. This survey was designed to analyse the actual practice of fluid resuscitation in the burn patient in Europe. Additionally, a literature review was done to examine actual results concerning the optimal strategy for correcting hypovolemia in these patients.

Section snippets

Methods

After approval by the Institutional Review Board (IRB), a total of 187 questionnaires were sent to 187 burn units in Europe (full questionnaire in Appendix). The addresses of the burn centers have been kindly offered by the European Burn Association (EBA). The blinded survey consisted of 20 multiple-choice questions that also allows personal comments and additions. Along with the questionnaire a cover letter explaining background information and the rationale of the survey was added.

Results

The response rate was 43%. The answers came from a total of 20 European countries. Forty-six percent were from university hospitals, 10% from hospitals with >1.000 beds, 35% from hospitals with <1.000 beds, and 8% from intensive care units (ICU) from hospitals caring exclusively for burn patients (Table 1a). Mostly plastic surgeons and anesthetists are responsible for the burn patients on the ICU (Table 1b). Approximately 52% of the answers were from units including <5 burn ICU beds, 42% are

Discussion

Major burns of >40% is associated with overwhelming release of inflammatory mediators leading to local and systemic inflammation, local and generalized capillary leakage, and subsequently hypovolemia [7]. Early fluid resuscitation remains the only treatment, which obviously reduces the incidence of organ dysfunction, e.g. acute renal failure [8]. Ryan et al. [3] evaluated 1665 burn patients from 1990 to 1994 and found that one-third of the patients died secondary to multiple organ failure

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    There was no funding from pharmaceutical companies. A hospital grant payed for all expenditures (mailing costs).

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