Elsevier

Burns

Volume 40, Issue 5, August 2014, Pages 871-880
Burns

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

https://doi.org/10.1016/j.burns.2013.11.021Get rights and content

Abstract

Background

A variety of crystalloids are available during fluid resuscitation of the severely burnt patient. There is a paucity of literature evidence on the comparative influence of these with regard to clinical outcomes. Significant differences in crystalloids may be clinically relevant given the large volumes employed during shock resuscitation.

Methods

The study compared two groups of severely burnt patients (TBSA 20–70%). Prospectively 40 consecutive patients treated with Ringer's acetate (RA group) against a retrospective control group of 40 patients treated with Ringer's lactate (RL group). Outcome parameters analysed included Sequential Organ Failure Assessment (SOFA)-scores at Days 3 and 7 after injury, mortality at 28 and 60 days, electrolyte and renal function, infection rates, cumulative volume administration and duration of ventilator support.

Results

Groups RA and RL were comparable w.r.t. age, total body surface area burn size and ABSI. SOFA-scores on Day 1 of admission also showed no significant difference but were significantly lower in RA group between the 3rd and 6th day. By Day 7 these differences could be attributed as a group effect (P = 0.019). In particular low cardiovascular organ function scores contributed to this. Total crystalloid use within the first 28 days were equal in both but differed within the RA group having lower observed volumes of colloid and incidence of blood transfusion. Furthermore group RA had distinctly higher levels of platelets throughout treatment. Elevated lactate levels were noted in RL group during the initial three days. Survival rates at 28 days and 60 days showed no significant difference.

Conclusion

Ringer's acetate solution is a suitable medium for the initial fluid management of the acutely burnt patient. In comparison to Ringer's lactate solution the study revealed lower SOFA-scores for Ringer's acetate solution (ClinicalTrials.gov number, NCT00609700).

Introduction

Clinical outcome is influenced greatly by appropriate initial fluid management during the shock phase of severe burns. The aim of this intravenous fluid treatment is to maintain adequate intravascular volume for effective organ perfusion. There continues to be no consensus on best fluid type or volume to achieve this with a variety of practices found in burns units [1]. The focus of debate has revolved around overall fluid volume used and the role of colloids [2], [3], [4], [5]. The detailed reflection of crystalloid type used has been largely neglected.

Globally, Hartmann's 1932 modification of Ringer's lactate solution remains the most widely used [1], [4], [6], [7], [8]. The compositional properties have continued to sustain Ringer's lactate as the seemingly ideal resuscitation fluid in severe burns. Physiologic chloride levels with reduced sodium ions and buffered with lactate that may be metabolised, ensures minimised acidosis risk following large volume infusion [3]. Recent critical review has nevertheless brought Ringer's lactate use into question [4]. Potential negative effects are listed in Table 1.

Acetate as an alternative anion has been proposed [9]. Its advantages over standard lactate include its aqueous solubility, stability at high concentrations, inert bioactivity and smaller molecular weight [7]. Unlike lactate, acetate is also more rapidly metabolised with less oxygen demand and extra hepatic [7]. The clinical application of this reduced metabolic demand becomes relevant within the intermediate Zone of Stasis in Jackson's burn wound model [10]. Comparisons of electrolytic composition between Ringer's acetate and lactate shows no difference and is felt also not to play a role in homeostasis.

There is a paucity of evidence in the literature on the comparative influence of crystalloid fluid of choice with regard to clinical outcomes in the severely burnt patient. Significant differences in composition of crystalloids may be clinically relevant given the large volumes employed during shock resuscitation. The aim of the current study was to evaluate the safety of Ringer's acetate compared to Ringer's lactate solution as the shock phase resuscitation fluid by using organ function scores as outcome measures.

Section snippets

Study population

Ethical approval was obtained from the Saxonian Chamber of Physicians. Study inclusion and exclusion criteria are shown in Table 2 and were applied to the initial 40 consecutive patients admitted and treated for severe burns after 1st January 2007 within a 12 bed intensive care burns unit. Ringer's acetate was used as the exclusive resuscitation fluid in these patients (RA group).

Data for control group RL was collated as the first 40 patients retrospectively from 1st January 2007 having all

Patient characteristics

Group RA and RL were comparable on day of admission with respect to demographics, severity of burn, SOFA-score and previous medical history (Table 5, Table 6).

Primary outcome parameter: SOFA-score

Group SOFA scores on day of admission were comparable as an expression of severity of injury [4 (4) v. 4 (5.25), P = 0.588]. On Day 2 values differed with lower scores in the RA group without getting significance [3.5 (6) v. 6 (6.25), P = 0.085]. By Day 3 significant divergence had manifested between group RA and RL at individual points [Day

Discussion

The current study compared the use of Ringer's acetate with Ringer's lactate solution in the fluid resuscitation of severe burns. The two randomised groups had similar burns and SOFA-scores on day of admission. The main findings of this study are the demonstration that Ringer's acetate is safe as a resuscitation medium, and further, that it might have some clinical advantages when compared to Ringer's lactate as a control group.

Summary

Fluid resuscitation with Ringer's acetate solution in patients with severe burns injury appears safe. The current study indicated better organ function of patients treated with Ringer's acetate solution when compared retrospectively to those treated with Ringer's lactate. Improved haemodynamics represented by a lower cardiovascular SOFA score is central to this difference. Due to the limitations of the study design this difference remains questionable.

Higher platelet concentrations noted in the

References (37)

  • A. Lawrence et al.

    Colloid administration normalizes resuscitation ratio and ameliorates “fluid creep”

    J Burn Care Res

    (2010)
  • J.A. Lee

    Sydney Ringer (1834–1910) and Alexis Hartmann (1898–1964)

    Anaesthesia

    (1981)
  • T. Nakatani

    Overview of the effects of Ringer's acetate solution and a new concept: renal ketogenesis during hepatic inflow occlusion

    Methods Find Exp Clin Pharmacol

    (2001)
  • M. Raum et al.

    Beeinflussung der Plasma-Laktat-konzentration durch laktathaltige Infusionslösungen

    AINS

    (2002)
  • R. Zander

    Flüssigkeitstherapie

    (2006)
  • D.M. Jackson

    The diagnosis of the depth of burning

    Br J Surg

    (1953)
  • J.L. Vincent et al.

    The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure

    Intensive Care Med

    (1996)
  • R. Moreno et al.

    The use of maximum SOFA score to quantify organ dysfunction/failure in intensive care. Results of a prospective, multicentre study

    Intensive Care Med

    (1999)
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