Elsevier

Burns

Volume 35, Issue 6, September 2009, Pages 757-767
Burns

Review
Modern trends in fluid therapy for burns

https://doi.org/10.1016/j.burns.2008.09.007Get rights and content

Abstract

The majority of burn centres use the crystalloid-based Parkland formula to guide fluid therapy, but patients actually receive far more fluid than the formula predicts. Resuscitation with large volumes of crystalloid has numerous adverse consequences, including worsening of burn oedema, conversion of superficial into deep burns, and compartment syndromes. Resuscitation fluids influence the inflammatory response to burns in different ways and it may be possible, therefore to affect this response using the appropriate fluid, at the appropriate time. Starches are effective volume expanders and early use of newer formulations may limit resuscitation requirements and burn oedema by reducing inflammation and capillary leak. Advanced endpoint monitoring may guide clinicians in when to ‘turn off’ aggressive fluid therapy and therefore avoid the problems of over-resuscitation.

Introduction

The goal of fluid therapy in the burn-injured patient is to maintain global tissue perfusion in the face of massive systemic inflammation, fluid extravasation and intravascular hypovolaemia. Early, aggressive treatment of burn shock has been the mainstay of burns resuscitation, but recently there have been growing concerns that burn-injured patients are being over fluid-resuscitated with excessive quantities of crystalloid, often with indistinct and inappropriate endpoint targets. The problems of this excess resuscitation have been well described, yet many centres still continue the practice. There have been efforts recently to address these concerns, particularly with the use of physiologically balanced fluids, advanced endpoint monitoring and therapies aimed at influencing the inflammatory response. It is still unclear how, or if these interventions can improve outcome. This review describes, and attempts to explain the recent trends in fluid therapy for burn-injured patients.

Section snippets

Pathophysiology of burn shock

An understanding of the pathophysiological mechanisms underlying burn injury is essential if clinicians are to resuscitate patients successfully.

Modern trends in fluid resuscitation volume

There is little doubt that the introduction of fluid resuscitation protocols in the 1960s and 1970s has helped to significantly reduce mortality from burns. Baxter and Shires devised the “Parkland Formula”, which calculates the amount of fluid required to resuscitate a patient based on percentage burn [10], [11]. 4 ml/kg/% burn are given in the first 24 h, with half of this fluid given in the first 8 h. The Parkland Formula remains the most commonly used formula in the UK and US today [12], [13].

Modern trends in choice of fluid

The ideal burn resuscitation fluid is one that effectively restores plasma volume, with no adverse effects [37]. The extensive choice of fluids available to resuscitate burn-injured patients has fuelled research efforts aimed at determining which fluid is best. None of them are ideal, and no valid study exists that implicates the superiority of a specific solution. Much of the evidence available to guide burn clinicians in choosing the right fluid has been pooled into meta-analyses. These often

Modern trends in fluid protocols

With such a wide variety of fluids available to resuscitate burn-injured patients, it is imperative that each individual burn unit has a well-defined fluid resuscitation protocol. With a lack of evidence-based literature supporting one protocol over another, modern burn resuscitation is often guided by local tradition of treating units.

Modern trends in endpoint monitoring

Arguably, more important than the choice of burn resuscitation fluid is the determination of the success, or otherwise of the resuscitation. Each patient will react differently to burn injury and may require varying amounts of fluid support. A myriad of factors will affect the patient's response to resuscitation such as age, depth of burn, concurrent inhalation injury, and pre-existing disease [73]. If burn clinicians used an endpoint of resuscitation that reliably and accurately measures the

Alternative approaches and adjuncts to fluid resuscitation

As we have seen, it may be impossible to restore normovolaemia during the early post-burn period using pure crystalloid resuscitation, and even despite adequate oxygen delivery tissue hypoxia still persists. This suggests that modern burn research should be focussed on developing methods to correct microcapillary leak and improve microcirculatory perfusion and cellular oxygen utilisation, and strategies aimed at reducing resuscitation volumes need to be pursued.

Conclusion

There is little doubt that excessive fluid therapy may worsen the burn injury, and the trend to over-resuscitate burn-injured patients is a worrying one, particularly in the light of increasing number of publications describing the adverse consequences of “fluid creep”. Any fluid regimen must, in the first instance do as little harm to the patient as possible. The use of colloids and hypertonic solutions have been shown to result in decreased fluid requirements and lower intraabdominal

Conflict of interest

None declared.

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