Fluid management in burn patients: Results from a European survey—More questions than answers☆
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
References (39)
Resuscitation in shock associated with burns. Tradition or evidence-based medicine?
Resuscitation
(2000)- et al.
Inhibition of nitric oxide synthase reverses the effect of albumin on lung damage in burn
J Am Coll Surg
(2005) - et al.
Pulmonary complications in burn patients resuscitated with a low-volume colloid solution
Burns
(1989) - et al.
Burn patient characteristics and outcomes following resuscitation with albumin
Burns
(2007) - et al.
Influences of different resuscitation regimens on acute early weight gain in extensively burned patients
Burns
(1991) - et al.
The role of gut mucosal hypoperfusion in the pathogenesis of postoperative organ dysfunction
Intensive Care Med
(1994) - et al.
The management of injuries—a review of deaths in hospital
Aust N Z J Surg
(1988) - et al.
Objective estimates of the probability of death from burn injuries
N Engl J Med
(1998) The burn edema process: current concepts
J Burn Care Rehabil
(2005)- et al.
Fluid resuscitation in major burns
ANZ J Surg
(2006)
Burns resuscitation: what place albumin?
Hosp Med
Acute renal dysfunction in severely burned adults
J Trauma
Guidelines for the use of fresh-frozen plasma
S Afr Med J
Influences on physicians’ choices for intravenous colloids
Intensive Care Med
How well does the Parkland formula estimate actual fluid resuscitation volumes?
J Burn Care Rehabil
Fluid volume and electrolyte changes of the early postburn period
Clin Plast Surg
Optimal composition of burn resuscitation fluids
Crit Care Med
Fluid resuscitation of pediatric burn victims: a critical appraisal
Pediatr Nephrol
Colloids versus crystalloids and tissue oxygen tension in patients undergoing major abdominal surgery
Anesth Analg
Cited by (39)
The quality of survey research in burn care: A systematic review
2022, BurnsCitation Excerpt :Many surveys (21%) were not sent to a specific individual, but rather to a “burn center” and not further specified. The survey studies covered a variety of themes related to burn care: education/training/workforce (21%) [17–46], resuscitation/critical care (17%) [1,2,47–69], wound care (14%) [70–88], rehabilitation (11%) [89–104], organization (8%) [44–46,51,105–112], acute surgery (8%) [3,69,85–88,104,113–117], pain/sedation/itch (8%) [84,118–127], psychosocial (6%) [103,128–135], scar care (4%) [136–141], infection/sepsis (3%) [67,68,142,143], nutrition (3%) [69,118,144,145], Steven-Johnson syndrome/toxic epidermal necrolysis (2%) [146–148], end-of-life care (2%) [149–151], prevention (1%) [152,153], and reconstructive surgery (1%) [154]. Table 2 describes questionnaire delivery, incentives, and sample selection.
Changes in total body surface area and the distribution of skin surfaces in relation to body mass index
2020, BurnsCitation Excerpt :Severe burns benefit from accurate fluid replacement volumes, nutritional support, long term treatment and are associated with additional socioeconomic burdens for these patients [3,20,21]. Unfortunately, this initial assessment is often conducted by a medical professional with limited experience with such patients (casualty officer, nurse, resident) with errors in estimation of %TBSA affected by a burn occurring frequently [22–26]. This was also found by Laing et al. who observed in their paper which reviewed 100 hospital referrals that the initial assessment is often inaccurate, resulting in sub-optimal treatment and inadequate fluid replacement with less than 10% of referrals being seen by senior casualty doctor [32].
Critical care in the severely burned: Organ support and management of complications
2018, Total Burn Care: Fifth EditionTRALI following fresh frozen plasma resuscitation from burn shock
2017, BurnsCitation Excerpt :The actual amount of FFP infused during the first 24 h of resuscitation for all patients [3725 ml mean (range 908–17,975)] was significantly less than the predicted Parkland Formula for the same time period [16,256 mean (range 0–18,618)] (p = 0.0002, Wilcoxon Signed Rank Sum test). Since its introduction in 1968, the Parkland Formula has become the most widely employed guide to the resuscitation of burn shock and deployed as a crystalloid-based estimate of resuscitation [1–3]. The shortfalls of an exclusively crystalloid resuscitation have been appreciated.
Critical Care in the Severely Burned: Organ Support and Management of Complications
2017, Total Burn Care, Fifth Edition
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There was no funding from pharmaceutical companies. A hospital grant payed for all expenditures (mailing costs).