FLUID RESUSCITATION IN MAJOR BURNS

The relationships between routine admission blood tests and burn size, and length of stay in intensive care unit

BACKGROUND

Although blood test is a routine in major burns, its relationship with burn size and intensive care unit length of stay (ICULOS) remains undetermined. We investigated the feasibility of using these tests as a reference for definite diagnosis of major burn size, burn size >20% of the total body surface area (TBSA), and their relationships with ICULOS.

METHODS

Data of routine laboratory blood tests within 24 h after burns (n = 73) were collected retrospectively. Correlation tests and regression analyses were performed.

RESULTS

Burns ≥20 TBSA had higher incidences of leucocytosis, hypoalbuminaemia, elevated haemoglobin (Hb), and elevated haematocrit (Hct). Burn size was correlated negatively with albumin but positively with Hb, Hct, and white blood cell (WBC) count. For each unit increase in blood urea nitrogen (BUN)/creatinine (Cr), there was an increase of 1.2 days of ICULOS in females, while in males, there was a 6.7 day increase for every unit increase in Hb and a 3.1 day increase for each unit increase in BUN. A female model including Hb and WBC was derived, discriminating burns ≥20 TBSA with sensitivity and specificity 0.94 and 1.0 respectively, and area under the receiver operating characteristic curve (AUROC) 0.96 (95% CI 0.91-1.00). The male model had sensitivity 0.96, specificity 1.0, and AUROC 0.96 (95% CI 0.89-1.00).

CONCLUSION

Admission Hb and WBC could be used as a reference for definite diagnosis of major burn size, especially in borderline cases. BUN/Cr in females, and Hb and BUN in males, were related to ICULOS.

Carotid smooth muscle contractility changes after severe burn

Severe burns result in cardiovascular dysfunction, but responses in the peripheral vasculature are unclear. We hypothesize that severe burns disturb arterial contractility through acute changes in adrenergic and cholinergic receptor function. To address this, we investigated the changes in carotid artery contractility and relaxation following a severe burn. Thirty-four adult Sprague–Dawley male rats received a 40% total body surface area (TBSA) scald burn and fluid resuscitation using the Parkland formula. Control animals received sham burn procedure. Animals were serially euthanized between 6 h and 14 days after burn and endothelium-intact common carotid arteries were used for ex vivo force/relaxation measurements. At 6 h after burn, carotid arteries from burned animals demonstrated a > 50% decrease in cumulative dose-responses to norepinephrine (p < 0.05) and to 10⁻⁷ M angiotensin II (p < 0.05). Notably, pre-constricted carotid arteries also demonstrated reduced relaxation responses to acetylcholine (p < 0.05) 6 h after burn, but not to sodium nitroprusside. Histologic examination of cross-sectional planes revealed significant increases in carotid artery wall thickness in burned rats at 6 h versus 3 days, with increased collagen expression in tunica media at 3 days (p < 0.05). Carotid artery dysfunction occurs within 6 h after severe burn, demonstrating decreased sensitivity to adrenergic- and angiotensin II-induced vasoconstriction and acetylcholine-induced relaxation.

Orbital Compartment Syndrome Following Major Burn Resuscitation: A Case Series and Survey of Practice Patterns

Orbital compartment syndrome (OCS) is a rare but devastating complication of over-resuscitation in burn patients that may lead to permanent visual loss. The purpose of this study was to 1) present a series of burn patients with OCS and 2) survey practice patterns of monitoring intra-ocular pressure (IOP) during burn resuscitation. Cases of OCS at two American Burn Association (ABA)-verified burn centers were retrospectively reviewed. Patients were included if they 1) required lateral canthotomy/cantholysis for elevated IOPs or 2) developed blindness on admission unrelated to any other ocular pathology. Data were collected on demographics, burn characteristics, fluid administration, ophthalmologic findings, and complications. An eight-item electronic survey was distributed by email through the ABA to all physician members. Twelve patients with OCS were identified, with a mean age of 47.8 ± 12.4 years and TBSA of 63.7 ± 18.6%. Mean fluid resuscitation at 24 hours was 4.9 ± 1.6 ml/kg/%TBSA or 0.29 ± 0.06 liter/kg. Eight patients underwent canthotomy/cantholysis for OCS, whereas four were later found to have visual loss. A total of 83 (14%) ABA physicians responded to the survey. IOP was routinely measured by 23% of respondents during acute burn resuscitation. OCS appears to have developed despite a relatively low 24-hour ml/kg/% burn resuscitation volume, but with a relatively higher cumulative (liter/kg) fluid volume. Their survey found that monitoring of IOP during burn resuscitation is not routinely performed by the majority of providers. Taken together, the present study suggests clinical guidelines to recognize this complication of over-resuscitation.

The Variation of Hemodynamic Parameters Through PiCCO in the Early Stage After Severe Burns

To investigate early hemodynamics of severely burned patients via PiCCO and to discuss clinical significance of hemodynamic monitoring for burn shock resuscitation, 55 extensive burn patients were enrolled in this retrospective study. The fluid resuscitation was guided according to Chinese General Formula and adjusted with urinary output of 0.5-1.0 ml/h/kg as a resuscitation goal. All patients were diagnosed within a relatively stable condition during burn shock stage, and they received PiCCO monitoring within 6 hours after burn. The preload parameter intrathoracic blood volume index was low at first, then returned to normal. The flow parameter cardiac index and myocardial contractility parameter dPmax were gradually changed from low level in the early stage to high level in the fluid reabsorption stage. The afterload parameter systemic vascular resistance index had completely opposite tendency. The lung-related parameters extravascular lung water index and pulmonary vascular permeability index were roughly in the normal range. The change of cardiac index had a linear regression relationship with dPmax and systemic vascular resistance index but had no significant relationship with intrathoracic blood volume index. Under effective fluid resuscitation, the early hemodynamics after burn is still in dynamically changing status, characterized as transition from low cardiac output (CO)-high vascular resistance in early shock stage to high CO-low vascular resistance in fluid reabsorption stage. CO mainly depends on the myocardial contractility and vascular resistance, but not on the blood volume. Excessive fluid resuscitation cannot get normal CO. The normal value of hemodynamics cannot be used as end point of burn shock resuscitation. Dynamic observation of hemodynamics is of great importance.

Albumin in Burn Shock Resuscitation: A Meta-Analysis of Controlled Clinical Studies

Critical appraisal of outcomes after burn shock resuscitation with albumin has previously been restricted to small relatively old randomized trials, some with high risk of bias. Extensive recent data from nonrandomized studies assessing the use of albumin can potentially reduce bias and add precision. The objective of this meta-analysis was to determine the effect of burn shock resuscitation with albumin on mortality and morbidity in adult patients. Randomized and nonrandomized controlled clinical studies evaluating mortality and morbidity in adult patients receiving albumin for burn shock resuscitation were identified by multiple methods, including computer database searches and examination of journal contents and reference lists. Extracted data were quantitatively combined by random-effects meta-analysis. Four randomized and four nonrandomized studies with 688 total adult patients were included. Treatment effects did not differ significantly between the included randomized and nonrandomized studies. Albumin infusion during the first 24 hours showed no significant overall effect on mortality. However, significant statistical heterogeneity was present, which could be abolished by excluding two studies at high risk of bias. After those exclusions, albumin infusion was associated with reduced mortality. The pooled odds ratio was 0.34 with a 95% confidence interval of 0.19 to 0.58 (P < .001). Albumin administration was also accompanied by decreased occurrence of compartment syndrome (pooled odds ratio, 0.19; 95% confidence interval, 0.07–0.50; P < .001). This meta-analysis suggests that albumin can improve outcomes of burn shock resuscitation. However, the scope and quality of current evidence are limited, and additional trials are needed.

The effects of major burn related pathophysiological changes on the pharmacokinetics and pharmacodynamics of drug use: An appraisal utilizing antibiotics

Patients suffering major burn injury represent a unique population of critically ill patients. Widespread skin and tissue damage causes release of systemic inflammatory mediators that promote endothelial leak, extravascular fluid shifts, and cardiovascular derangement. This phase is characterized by relative intra-vascular hypovolaemia and poor peripheral perfusion. Large volume intravenous fluid resuscitation is generally required. The patients' clinical course is then typically complicated by ongoing inflammation, protein catabolism, and marked haemodynamic perturbation. At all times, drug distribution, metabolism, and elimination are grossly distorted. For hydrophilic agents, changes in volume of distribution and clearance are marked, resulting in potentially sub-optimal drug exposure. In the case of antibiotics, this may then promote treatment failure, or the development of bacterial drug resistance. As such, empirical dose selection and pharmaceutical development must consider these features, with the application of strategies that attempt to counter the unique pharmacokinetic changes encountered in this setting.

Hold the Pendulum: Rates of Acute Kidney Injury are Increased in Patients Who Receive Resuscitation Volumes Less than Predicted by the Parkland Equation

OBJECTIVE

To determine whether restrictive fluid resuscitation results in increased rates of acute kidney injury (AKI) or infectious complications.

BACKGROUND

Studies demonstrate that patients often receive volumes in excess of those predicted by the Parkland equation, with potentially detrimental sequelae. However, the consequences of under-resuscitation are not well-studied.

METHODS

Data were collected from a multicenter prospective cohort study. Adults with greater than 20% total burned surface area injury were divided into 3 groups on the basis of the pattern of resuscitation in the first 24 hours: volumes less than (restrictive), equal to, or greater than (excessive) standard resuscitation (4 to 6 cc/kg/% total burned surface area). Multivariable regression analysis was employed to determine the effect of fluid group on AKI, burn wound infections (BWIs), and pneumonia.

RESULTS

Among 330 patients, 33% received restrictive volumes, 39% received standard resuscitation volumes, and 28% received excessive volumes. The standard and excessive groups had higher mean baseline APACHE scores (24.2 vs 16, P < 0.05 and 22.3 vs 16, P < 0.05) than the restrictive group, but were similar in other characteristics. After adjustment for confounders, restrictive resuscitation was associated with greater probability of AKI [odds ratio (OR) 3.25, 95% confidence interval (95% CI) 1.18-8.94]. No difference in the probability of BWI or pneumonia among groups was found (BWI: restrictive vs standard OR 0.74, 95% CI 0.39-1.40, excessive vs standard OR 1.40, 95% CI 0.75-2.60, pneumonia: restrictive vs standard, OR 0.52, 95% CI 0.26-1.05; excessive vs standard, OR 1.12, 95% CI 0.58-2.14).

CONCLUSIONS

Restrictive resuscitation is associated with increased AKI, without changes in infectious complications.

Fluid Creep and Over-resuscitation

Fluid creep is the term applied to a burn resuscitation, which requires more fluid than predicted by standard formulas. Fluid creep is common today and is linked to several serious edema-related complications. Increased fluid requirements may accompany the appropriate resuscitation of massive injuries but dangerous fluid creep is also caused by overly permissive fluid infusion and the lack of colloid supplementation. Several strategies for recognizing and treating fluid creep are presented.

Evaluation of the "Early" Use of Albumin in Children with Extensive Burns: A Randomized Controlled Trial

OBJECTIVE

To compare early versus delayed albumin resuscitation in children with burns in terms of clinical outcome and response.

DESIGN

Randomized controlled trial.

SETTING

Burn center at a tertiary care teaching hospital.

PATIENTS

Forty-six children aged 1-12 years with burns greater than 15-45% total body surface area admitted within 12 hours of burn injury.

INTERVENTIONS

Fluid resuscitation was based on the Parkland formula (3 mL/kg/% total body surface area), adjusted according to urine output. Patients received 5% albumin solution between 8 and 12 hours post burn in the intervention group (n = 23) and 24 hours post burn in the control group (n = 23). Both groups were assessed for reduction in crystalloid fluid infusion during resuscitation, development of fluid creep, and length of hospital stay.

MEASUREMENTS AND MAIN RESULTS

There was no difference between groups regarding age, weight, sex, % total body surface area, cause of burn, or severity scores. The median crystalloid fluid volume required during the first 3 days post burn was lower in the intervention than in the control group (2.04 vs 3.05 mL/kg/% total body surface area; p = 0.025 on day 1; 1.2 vs 1.71 mL/kg/% total body surface area; p = 0.002 on day 2; and 0.82 vs 1.3 mL/kg/% total body surface area; p = 0.002 on day 3). The median urine output showed no difference between intervention and control groups (2.1 vs 2.0 mL/kg/hr; p = 0.152 on day 1; 2.58 vs 2.54 mL/kg/hr; p = 0.482 on day 2; and 2.9 vs 3.0 mL/kg/hr; p = 0.093 on day 3). Fluid creep was observed in 13 controls (56.5%) and in one patient (4.3%) in the intervention group. The median length of hospital stay was 18 days (range, 15-21 d) for controls and 14 days (range, 10-17 d) in the intervention group (p = 0.004).

CONCLUSIONS

Early albumin infusion in children with burns greater than 15-45% total body surface area reduced the need for crystalloid fluid infusion during resuscitation. Significantly fewer cases of fluid creep and shorter hospital stay were also observed in this group of patients.

The wound/burn guidelines - 6: Guidelines for the management of burns

Burns are a common type of skin injury encountered at all levels of medical facilities from private clinics to core hospitals. Minor burns heal by topical treatment alone, but moderate to severe burns require systemic management, and skin grafting is often necessary also for topical treatment. Inappropriate initial treatment or delay of initial treatment may exert adverse effects on the subsequent treatment and course. Therefore, accurate evaluation of the severity and initiation of appropriate treatment are necessary. The Guidelines for the Management of Burn Injuries were issued in March 2009 from the Japanese Society for Burn Injuries as guidelines concerning burns, but they were focused on the treatment for extensive and severe burns in the acute period. Therefore, we prepared guidelines intended to support the appropriate diagnosis and initial treatment for patients with burns that are commonly encountered including minor as well as moderate and severe cases. Because of this intention of the present guidelines, there is no recommendation of individual surgical procedures.

Evaluation of 2 novel devices for calculation of fluid requirements in pediatric burns

OBJECTIVES

The Parkland formula for maintenance and resuscitation fluid requirements in the first 24 hours after pediatric burns is widely used, but calculation errors frequently occur. Two different novel aids to calculation, a dedicated electronic device and a mechanical disc calculator, are described and compared with the conventional method of calculation (pen and paper, assisted by a general purpose calculator).

METHODS

In a blinded randomized volunteer study, 21 participants performed a total of 189 calculations using simulated patient data to compare the accuracy and speed of 3 different methods for calculating resuscitation fluid requirements based on the pediatric Parkland formula. Bespoke software generated the simulated patient data and recorded accuracy and speed of all participant responses.

RESULTS

Sixty-five percent of calculations with the electronic device, 35% using the disc and 44% using the pen/paper methods were within ±5% of the correct value and considered "correct" for clinical purposes. The method used strongly affected the tendency to make errors (logistic regression). With thresholds of error magnitude classed as very small (>5%), small (>25%), medium (>50%) and large (>100%) of the correct value respectively, the electronic method produced fewer errors than both disc and pen/paper methods at all error thresholds. Disc produced more errors than pen/paper at the greater than 5% threshold but fewer at the greater than 25%, greater than 50%, and greater than 100% thresholds.

CONCLUSIONS

Both novel devices provide safer and faster alternatives to conventional methods for calculation of fluid requirements in pediatric burns.

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

This pilot trial aims at gaining support for the optimization of acute burn resuscitation through noninvasive continuous real-time hemodynamic monitoring using arterial pulse contour analysis. A group of 21 burned patients meeting preliminary criteria (age range 18-75 years with second- third- degree burns and TBSA ≥10-75%) was randomized during 2010. A hemodynamic monitoring through lithium dilution cardiac output was used in 10 randomized patients (LiDCO group), whereas those without LiDCO monitoring were defined as the control group. The modified Brooke/Parkland formula as a starting resuscitative formula, balanced crystalloids as the initial solutions, urine output of 0.5 ml/kg/hr as a crucial value of adequate intravascular filling were used in both groups. Additionally, the volume and vasopressor/inotropic support were based on dynamic preload parameters in the LiDCO group in the case of circulatory instability and oligouria. Statistical analysis was done using t-tests. Within the first 24 hours postburn, a significantly lower consumption of crystalloids was registered in LiDCO group (P = .04). The fluid balance under LiDCO control in combination with hourly diuresis contributed to reducing the cumulative fluid balance approximately by 10% compared with fluid management based on standard monitoring parameters. The amount of applied solutions in the LiDCO group got closer to Brooke formula whereas the urine output was at the same level in both groups (0.8 ml/kg/hr). The new finding in this study is that when a fluid resuscitation is based on the arterial waveform analysis, the initial fluid volume provided was significantly lower than that delivered on the basis of physician-directed fluid resuscitation (by urine output and mean arterial pressure).

A new device to automate the monitoring of critical patients' urine output

Urine output (UO) is usually measured manually each hour in acutely ill patients. This task consumes a substantial amount of time. Furthermore, in the literature there is evidence that more frequent (minute-by-minute) UO measurement could impact clinical decision making and improve patient outcomes. However, it is not feasible to manually take minute-by-minute UO measurements. A device capable of automatically monitoring UO could save precious time of the healthcare staff and improve patient outcomes through a more precise and continuous monitoring of this parameter. This paper presents a device capable of automatically monitoring UO. It provides minute by minute measures and it can generate alarms that warn of deviations from therapeutic goals. It uses a capacitive sensor for the measurement of the UO collected within a rigid container. When the container is full, it automatically empties without requiring any internal or external power supply or any intervention by the nursing staff. In vitro tests have been conducted to verify the proper operation and accuracy in the measures of the device. These tests confirm the viability of the device to automate the monitoring of UO.

Comparison of three techniques for calculation of the Parkland formula to aid fluid resuscitation in paediatric burns

CONTEXT

Inadequate fluid resuscitation of acute burns may result in hypovolaemic shock. Excessive fluid resuscitation may result in fluid overload. A nomogram which uses the popular Parkland formula and '4-2-1' regime has been recently described to facilitate the calculation of fluid requirements in children during the first 24 h following burn injury.

OBJECTIVE

To compare the accuracy and speed of calculation of three different methods (pen and paper, electronic calculator and nomogram), which all use the Parkland formula and '4-2-1' regime to calculate maintenance and resuscitation fluid requirements for children in the first 24 h after burn injury.

DESIGN

A randomised volunteer study using computer-generated simulated patient data.

SETTING

Welsh Centre for Burns, ABM University Local Health Board, Swansea, UK. Data were collected between February 2011 and October 2011.

PARTICIPANTS

The group consisted of 36 volunteers including trainee and consultant surgeons and anaesthetists.

INTERVENTION

Thirty-six participants performed 318 calculations, using each of the three methods of calculation up to three times.

MAIN OUTCOME MEASURES

Accuracy, speed and acceptability of the different methods.

RESULTS

For nomogram, calculator and pen and paper: magnitude of error [low (≥25%), medium (≥50%) and high (≥75%)]: [5.7, 4.7 and 3.8%], [12.1, 12.1 and 7.5%], [28.6, 21.9 and 16.2%]; [P <0.001, P = 0.001 and P = 0.006]. Calculation time: [s; mean (SD)]: 121 (48), 109 (52) and 240 (140); P <0.001. The mean (SD) of the difficulty scores were 17.3 (13), 20.6 (13.4) and 62.2 (23.4); P <0.001.

CONCLUSION

The nomogram was the most accurate method of calculating fluid requirements using the Parkland formula, was only slightly slower than the electronic calculator and was deemed the easiest to use. The nomogram is also low cost, robust, and provides a rapid means of detecting and preventing the large errors that we have shown can occur when an electronic device is used as the primary method of resuscitation fluid calculation. We, therefore, suggest that the nomogram is a suitable method for the calculation of the Parkland formula to guide resuscitation and maintenance fluid requirements in the first 24 h of paediatric burns or for cross-checking the results obtained by other means of calculation.

Clinical review: the critical care management of the burn patient

Between 4 and 22% of burn patients presenting to the emergency department are admitted to critical care. Burn injury is characterised by a hypermetabolic response with physiologic, catabolic and immune effects. Burn care has seen renewed interest in colloid resuscitation, a change in transfusion practice and the development of anti-catabolic therapies. A literature search was conducted with priority given to review articles, meta-analyses and well-designed large trials; paediatric studies were included where adult studies were lacking with the aim to review the advances in adult intensive care burn management and place them in the general context of day-to-day practical burn management.

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

Introduction

The use of urinary output and vital signs to guide initial burn resuscitation may lead to suboptimal resuscitation. Invasive hemodynamic monitoring may result in over-resuscitation. This study aimed to evaluate the results of a goal-directed burn resuscitation protocol that used standard measures of mean arterial pressure (MAP) and urine output, plus transpulmonary thermodilution (TPTD) and lactate levels to adjust fluid therapy to achieve a minimum level of preload to allow for sufficient vital organ perfusion.

Methods

We conducted a three-year prospective cohort study of 132 consecutive critically burned patients. These patients underwent resuscitation guided by MAP (>65 mmHg), urinary output (0.5 to 1 ml/kg), TPTD and lactate levels. Fluid therapy was adjusted to achieve a cardiac index (CI) >2.5 L/minute/m² and an intrathoracic blood volume index (ITBVI) >600 ml/m², and to optimize lactate levels. Statistical analysis was performed using mixed models. We also used Pearson or Spearman methods and the Mann-Whitney U-test.

Results

A total of 98 men and 34 women (mean age, 48 ± 18 years) was studied. The mean total body surface area (TBSA) burned was 35% ± 22%. During the early resuscitation phase, lactate levels were elevated (2.58 ± 2.05 mmol/L) and TPTD showed initial hypovolemia by the CI (2.68 ± 1.06 L/minute/m²) and the ITBVI (709 ± 254 mL/m²). At 24 to 32 hours, the CI and lactic levels were normalized, although the ITBVI remained below the normal range (744 ± 276 ml/m²). The mean fluid rate required to achieve protocol targets in the first 8 hours was 4.05 ml/kg/TBSA burned, which slightly increased in the next 16 hours. Patients with a urine output greater than or less than 0.5 ml/kg/hour did not show differences in heart rate, mean arterial pressure, CI, ITBVI or lactate levels.

Conclusions

Initial hypovolemia may be detected by TPTD monitoring during the early resuscitation phase. This hypovolemia might not be reflected by blood pressure and hourly urine output. An adequate CI and tissue perfusion can be achieved with below-normal levels of preload. Early resuscitation guided by lactate levels and below-normal preload volume targets appears safe and avoids unnecessary fluid input.

Comparison of three techniques using the Parkland Formula to aid fluid resuscitation in adult burns

We performed a randomised study to compare the accuracy and speed of three different techniques (pen and paper, electronic calculator and a novel graphic device: 'nomogram') for calculation of resuscitation fluid requirements for adults in the first 24 h of burn injury, based on the Parkland Formula. We also assessed acceptability of each technique using visual analogue scores and qualitative analysis of free text responses. 28 participants performed 252 calculations using a series of computer generated simulated patient data. For nomogram, electronic calculator, pen and paper: Magnitude of error [low (≥25%), medium (≥50%), high (≥75%)]: [6.0%, 1.2%, 0%], [17.9%, 14.3%, 8.3%], [25%, 16.7%, 9.5%]; p<0.002. Calculation time: [sec: mean (SD)]: 94(34), 73(31), 214(103); p<0.001. The mean (SD) of the difficulty scores for each method were 23(17), 17(14) and 70(21) out of 100. Of the 28 participants 15 preferred the calculator, 12 preferred the nomogram and 1 scored the calculator and nomogram equally (table 3). The nomogram was significantly more accurate at all levels, almost as fast as an electronic calculator, and deemed easy to use. It is low cost and robust, and provides a rapid means of detecting and preventing the large errors that we have shown can occur when an electronic device is used as the only method of calculation. We therefore suggest that the Parkland Formula nomogram is a suitable method for calculation of resuscitation fluid requirements in adult burns. Fluid requirement should, however, be reviewed frequently, and adjusted to ensure adequate organ perfusion.

Graphic aids for calculation of fluid resuscitation requirements in pediatric burns

The Parkland formula is currently the most widely used protocol to guide fluid resuscitation of acute burns and has been adapted for pediatric use. We describe 3 novel graphic devices (a nomogram, slide rule, and disc calculator) based on this formula, which have significant advantages over existing graphic and electronic devices. The robust low-cost graphic devices would be particularly suited to developing countries and difficult locations, but could be used as the primary means of calculation in any environment. If a computer or calculator is used as the primary means of calculation, the graphic devices provide a simple and rapid means of checking and preventing errors that may arise because of inadvertent mis-keying of data or incorrect application of the pediatric Parkland formula.

Pediatric burn injuries

Pediatric burns comprise a major mechanism of injury, affecting millions of children worldwide, with causes including scald injury, fire injury, and child abuse. Burn injuries tend to be classified based on the total body surface area involved and the depth of injury. Large burn injuries have multisystemic manifestations, including injuries to all major organ systems, requiring close supportive and therapeutic measures. Management of burn injuries requires intensive medical therapy for multi-organ dysfunction/failure, and aggressive surgical therapy to prevent sepsis and secondary complications. In addition, pain management throughout this period is vital. Specialized burn centers, which care for these patients with multidisciplinary teams, may be the best places to treat children with major thermal injuries. This review highlights the major components of burn care, stressing the pathophysiologic consequences of burn injury, circulatory and respiratory care, surgical management, and pain management of these often critically ill patients.

An automatic critical care urine meter

Nowadays patients admitted to critical care units have most of their physiological parameters measured automatically by sophisticated commercial monitoring devices. More often than not, these devices supervise whether the values of the parameters they measure lie within a pre-established range, and issue warning of deviations from this range by triggering alarms. The automation of measuring and supervising tasks not only discharges the healthcare staff of a considerable workload but also avoids human errors in these repetitive and monotonous tasks. Arguably, the most relevant physiological parameter that is still measured and supervised manually by critical care unit staff is urine output (UO). In this paper we present a patent-pending device that provides continuous and accurate measurements of patient's UO. The device uses capacitive sensors to take continuous measurements of the height of the column of liquid accumulated in two chambers that make up a plastic container. The first chamber, where the urine inputs, has a small volume. Once it has been filled it overflows into a second bigger chamber. The first chamber provides accurate UO measures of patients whose UO has to be closely supervised, while the second one avoids the need for frequent interventions by the nursing staff to empty the container.

Review of a fluid resuscitation protocol: "fluid creep" is not due to nursing error

Recent reviews of burn resuscitation have included the suggestion that "fluid creep" may be influenced by practitioner error. Our center uses a nursing-driven resuscitation protocol that permits titration of fluid based on hourly urine output, including the addition of colloid when patients fail to respond appropriately. The purpose of this study was to examine protocol compliance. We reviewed 140 patients (26 children) with burns of ≥20% TBSA who received protocol-directed resuscitation from 2005 to 2010. We compared each patient's actual hourly fluid infusion with that predicted by the protocol. Sixty-seven patients (48%) completed resuscitation using crystalloid alone, whereas 73 patients required colloid supplementation. Groups did not differ in age, gender, weight, or time from injury to admission. Patients requiring colloid had larger median total burns (33.0 vs 23.5% TBSA) and full-thickness burns (15.5 vs 4.5% TBSA) and more inhalation injuries (60.3 vs 28.4%; P < .001) than those who resuscitated with crystalloid alone. Because we included basic maintenance fluids in their regimen, patients had median predicted requirements of 5.4 ml/kg/%TBSA. Crystalloid-only patients required fluid volumes close to Parkland predictions (4.7 ml/kg/%TBSA), whereas patients who received colloid required more fluid than the predicted volume (7.5 ml/kg/%TBSA). However, the hourly difference between the predicted and received fluids was a median of only 1.0% (interquartile range: -6.1 to 11.1%) and did not differ between groups. Pediatric patients had greater calculated differences than adults. Crystalloid patients exhibited higher urine outputs than colloid patients until colloid was started, suggesting that early over-resuscitation did not contribute to fluid creep. Adherence to our protocol for burn shock resuscitation was excellent overall. Fluid creep exhibited by more seriously injured patients was not due to nurses' failure to follow the protocol. This review has illuminated some opportunities for practice improvement, possibly using a computerized decision support system.

Multidisciplinary team response to a mass burn casualty event: outcomes and implications

OBJECTIVES

To describe the characteristics of patients with burn injury admitted to a major trauma hospital in Melbourne following the Black Saturday bushfires of 7 February 2009, and to provide a detailed analysis of the hospital's response to the crisis.

DESIGN, SETTING AND PARTICIPANTS

A retrospective chart review of ambulance and hospital records of patients admitted to the Victorian Adult Burns Service (VABS) at The Alfred Hospital (The Alfred) following the bushfires.

MAIN OUTCOME MEASURES

Patient characteristics and outcomes: age, sex, total and full thickness body surface area burnt, type and site of burn, hospital and intensive care unit length of stay (LOS) and receipt of standard burn care practices. Estimated glomerular filtration rate, theatre time and LOS data for the bushfire cohort compared with corresponding data for historical cohorts from VABS and from a similar institution in New Zealand.

RESULTS

Nineteen patients were admitted to VABS over the first 48 hours after the bushfires. Of these, nine patients were subsequently admitted to The Alfred's intensive care unit. Most patients (74%) were men with a mean age of 52.7 years (SD, 12.4 years). Seventeen patients (89%) underwent at least one surgical procedure, which resulted in 4355 minutes of theatre time for the bushfire cohort in the first week. Hospital LOS was similar for the bushfire and New Zealand cohorts. Compared with the VABS historical cohort, there was a higher incidence of abnormal renal function among the bushfire cohort patients.

CONCLUSIONS

Although relatively few patients with severe burns were admitted to VABS, significant increases in resource allocation were required to manage them in terms of additional theatre time, consumables and staffing. The experience of VABS may aid planning for future mass burns casualty events.

Fluid resuscitation protocols for burn patients at intensive care units of the United Kingdom and Ireland

Introduction: The objective of this study was to determine the thermal injury fluid resuscitation protocols at intensive care units (ICUs) in the United Kingdom and Ireland.

Materials and methods: A telephone questionnaire was designed to survey the fluid resuscitation protocols of ICUs at all hospitals with plastic/burn surgery departments in the British Isles in 2010. The feedback from the questionnaire was from the senior nurse in charge of the ICUs.

Results: 32/64 (50%) of these ICUs had provided care to burns patients. A 100% response from these 32 units was obtained. 71.4% commence fluid resuscitation at 15% total body surface area burn (TBSA), 21.4% at 20% TBSA and 7.1% at 10% TBSA in adults. The estimated resuscitation volume was most often calculated using the Parkland/Modified Parkland formula (87.5%) or the Muir and Barclay formula (12.5%). Interestingly, of the ICUs using formulae, two had recently moved from using the Muir and Barclay formula to Parkland formula and one had recently moved from using the Parkland formula to Muir and Barclay formula. Despite this, 37.5% of ICUs using a formula did not rigidly follow it exactly. The most commonly used resuscitation fluid was Ringer’s lactate solution (46.9%) and Human Albumin Solution was used in 12.5%. No ICU used red cell concentrate as a first line fluid. 18.8% used a central line. 40.6% ICUs considered changing the IV solution during resuscitation. 78.1% ICUs consider urine output to be the most important factor in modifying resuscitation volumes. 59.4% ICUs calculate a maintenance fluid rate after completion of resuscitation. The endpoint for resuscitation was at 24 h in 46.9% ICUs and at 36 h in 9.4%. 5/32 (16%) felt their protocol gave too little and 6/32 (19%) felt their protocol gave too much. 59.3% ICUs gave oral/enteral fluids by naso-gastric or naso-jejenal tubes. 21.9% felt that oral/enteral resuscitation worked. Exactly half of the units believed that the formula that they used provided approximately the right amount of fluid, with 25% believing that it provided too much and 21.9% that it provided too little.

Discussion and conclusion: There is substantial variation in the fluid resuscitation protocols for burns of ICUs in the British Isles. The different practices demonstrated in this survey may have important consequences as inadequate fluid resuscitation can limit perfusion to potentially recoverable burns, grafted tissue and body organs not directly injured.

The Alfred pre-hospital fluid formula for major burns

BACKGROUND

The Alfred pre-hospital fluid isotonic crystalloid resuscitation formula for major burns (body weight (kg)×%TBSA burnt=mls in the first 2 h) was adopted by Ambulance Victoria in 2007 for the early and consistent correction of fluid deficit in major burns patients. The aim of this study was to evaluate the associated change in pre-hospital fluid administration.

METHODS

A retrospective explicit chart review of patient records was conducted of all patients with major burns presenting to The Alfred Emergency & Trauma Centre over a 10 year period. Patient demographics, fluid resuscitation and outcomes in the period before the introduction of the new formula were compared to those in the post-introduction period.

RESULTS

There were 126 patients with major burns (≥20% total body surface area burnt) included in the study. The median fluid volume administration pre-hospital after introduction of The Alfred formula was 0.35 (0.22-0.44) mL/kg/%TBSA burnt, which was significantly higher than 0.14 (0.04-0.26) mL/kg/%TBSA administered in the prior period (p=0.013). There was no significant change in physiological endpoints associated with the increased volume. At 24 h, the volume of fluid administered in patients when The Alfred formula was used was 4.9±1.6 mL/kg/%TBSA, which was not significantly higher than the volume administered before 2007 of 4.8±2.2 mL/%TBSA/kg (p=0.802).

DISCUSSION

The Alfred pre-hospital fluid formula has resulted in patients receiving significantly more fluids early, although still below volumes suggested by the Parkland formula. There were no adverse effects of this increased volume detected over the study period. The Alfred pre-hospital fluid formula appears to be safe and more effective in delivering fluid volumes predicted by the current 'gold standard'.

A low cost device for monitoring the urine output of critical care patients

In critical care units most of the patients' physiological parameters are sensed by commercial monitoring devices. These devices can also supervise whether the values of the parameters lie within a pre-established range set by the clinician. The automation of the sensing and supervision tasks has discharged the healthcare staff of a considerable workload and avoids human errors, which are common in repetitive and monotonous tasks. Urine output is very likely the most relevant physiological parameter that has yet to be sensed or supervised automatically. This paper presents a low cost patent-pending device capable of sensing and supervising urine output. The device uses reed switches activated by a magnetic float in order to measure the amount of urine collected in two containers which are arranged in cascade. When either of the containers fills, it is emptied automatically using a siphon mechanism and urine begins to collect again. An electronic unit sends the state of the reed switches via Bluetooth to a PC that calculates the urine output from this information and supervises the achievement of therapeutic goals.

A device for automatically measuring and supervising the critical care patient's urine output

Critical care units are equipped with commercial monitoring devices capable of sensing patients’ physiological parameters and supervising the achievement of the established therapeutic goals. This avoids human errors in this task and considerably decreases the workload of the healthcare staff. However, at present there still is a very relevant physiological parameter that is measured and supervised manually by the critical care units’ healthcare staff: urine output. This paper presents a patent-pending device capable of automatically recording and supervising the urine output of a critical care patient. A high precision scale is used to measure the weight of a commercial urine meter. On the scale’s pan there is a support frame made up of Bosch profiles that isolates the scale from force transmission from the patient’s bed, and guarantees that the urine flows properly through the urine meter input tube. The scale’s readings are sent to a PC via Bluetooth where an application supervises the achievement of the therapeutic goals. The device is currently undergoing tests at a research unit associated with the University Hospital of Getafe in Spain.

Effects of burn injury on markers of hypermetabolism in rats

The basic metrics of hypermetabolism have not been thoroughly characterized in rat burn injury models. We examined three models expected to differ in sensitivity to burn injury to identify that which group(s) exhibited the most clinically relevant metabolic response. Six and 12 weeks old male CD (6 week mCD and 12 week mCD) rats, and 12 weeks old female Fischer (12 week fFI) rats received a 20% total body surface area burn, followed by saline resuscitation. Activity, core body temperature, heart rate (via implanted telemetry devices), body weight, food and water intake, and fecal output were measured daily for 1 week before and after burn. Rats lost weight initially postburn but resumed weight gain by 1 week, except for 12 week mCD rats. Core body temperature increased above normal 2 days postburn and returned to baseline by 1 week. Food intake, normalized to body weight, remained unchanged postburn for 12 week mCD rats, but decreased in 6 week mCD rats and increased in 12 week fFI rats. Heart rate in the 12 week mCD and 12 week fFI rats remained at 10 to 15% above baseline, whereas, in 6 week mCD, heart rates returned to baseline after 4 days. Activity levels were unchanged for 12 week fFI and 6 week mCD rats postburn, but decreased for 12 week mCD rats. Postburn hypermetabolism was most significant and sustained in 12 week mCD rats, of least consequence and brief in 6 week mCD rats, and intermediate in 12 week fFI rats. The disparate responses indicate that the choice of animal model should be carefully considered in hypermetabolism studies.

Critical care of the burn patient: the first 48 hours

OBJECTIVE

The goal of this concise review is to provide an overview of some of the most important resuscitation and monitoring issues and approaches that are unique to burn patients compared with the general intensive care unit population.

STUDY SELECTION

Consensus conference findings, clinical trials, and expert medical opinion regarding care of the critically burned patient were gathered and reviewed. Studies focusing on burn shock, resuscitation goals, monitoring tools, and current recommendations for initial burn care were examined.

CONCLUSIONS

The critically burned patient differs from other critically ill patients in many ways, the most important being the necessity of a team approach to patient care. The burn patient is best cared for in a dedicated burn center where resuscitation and monitoring concentrate on the pathophysiology of burns, inhalation injury, and edema formation. Early operative intervention and wound closure, metabolic interventions, early enteral nutrition, and intensive glucose control have led to continued improvements in outcome. Prevention of complications such as hypothermia and compartment syndromes is part of burn critical care. The myriad areas where standards and guidelines are currently determined only by expert opinion will become driven by level 1 data only by continued research into the critical care of the burn patient.

Black Saturday: the immediate impact of the February 2009 bushfires in Victoria, Australia

OBJECTIVE

To examine the response of the Victorian State Trauma System to the February 2009 bushfires.

DESIGN AND SETTING

A retrospective review of the strategic response required to treat patients with bushfire-related injury in the first 72 hours of the Victorian bushfires that began on 7 February 2009. Emergency department (ED) presentations and initial management of patients presenting to the state's adult burns centre (The Alfred Hospital [The Alfred]) were analysed, as well as injuries and deaths associated with the fires.

RESULTS

There were 414 patients who presented to hospital EDs as a result of the bushfires. Patients were triaged at the emergency scene, at treatment centres and in hospital. National and statewide burns disaster plans were activated. Twenty-two patients with burns presented to the state's burns referral centres, of whom 18 were adults. Adult burns patients at The Alfred spent 48.7 hours in theatre in the first 72 hours. There were a further 390 bushfire-related ED presentations across the state in the first 72 hours. Most patients with serious burns were triaged to and managed at burns referral centres. Throughout the disaster, burns referral centres continued to have substantial surge capacity.

CONCLUSIONS

Most bushfire victims either died, or survived with minor injuries. As a result of good prehospital triage and planning, the small number of patients with serious burns did not overload the acute health care system.

Fluid resuscitation for major burn patients with the TMMU protocol

BACKGROUND

Fluid resuscitation is one of the critical treatments for the major burn patient in the early phases after injury. We evaluated the practice of fluid resuscitation for severely burned patients with the Third Military Medical University (TMMU) protocol, which is most widely used in many regions of China.

METHODS

Patients with major burns (>30% total body surface area (TBSA)) presenting to Southwest Hospital, Third Military Medical University, between January 2005 and October 2007, were included in this study. Fluid resuscitation was initiated by the TMMU protocol.

RESULTS

A total of 71 patients were (46 adults and 25 children) included in this study. All patients survived the first 48 h after injury smoothly and none developed abdominal compartment syndrome or other recognised complications associated with fluid resuscitation. The average quantity of fluid infused was 3.3-61.33% more than that calculated based on the TMMU protocol in both adult and paediatric groups. The average urine output during the first 24h after injury was about 1.2 ml per kg body weight per hour in the two groups, but reached 1.2 ml and 1.7 ml during the second 24h in adult and pediatric groups, respectively.

CONCLUSION

This study indicates that the TMMU protocol for fluid resuscitation is a feasible option for burn patients. Individualised resuscitation - guided by the physiological response to fluid administration - is still important as in other protocols.

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

BACKGROUND

A number of target points have been used for fluid replacement in severely burned patients. The aim of our prospective randomized study was to compare the effect of two different types of fluid resuscitation regimes on the multiple organ dysfunction score (MODS) and central venous oxygen saturation (ScvO(2)) in the first 3 days after injury.

METHODS

Twenty-four patients admitted to the critical care unit of a university hospital with the presence of burn injury affecting more than 15% of the body surface area and in-hospital fluid resuscitation started within 3 h after burn injury were included. Patients were randomized into two groups. Fluid resuscitation was guided by the hourly urine output (HUO Group, n=12) or by the intrathoracic blood volume index (ITBVI Group, n=12). Invasive transpulmonary hemodynamic measurements utilizing pulse contour analysis with a single dilution technique and continuous ScvO(2) measurements were performed in both groups.

RESULTS

The mean ScvO(2) was significantly lower in the HUO Group than in the ITBVI Group (P=0.024) for the first 24 h. MODS was significantly higher in the HUO Group than in the ITBVI group 48 h (P=0.024) and 72 h after injury (P=0.014). The two main outcome parameters, i.e., MODS calculated at 48 and 72 h after injury and ScvO(2) were negatively correlated on day 1 (r=-0.684, P=0.004, r=-0.677, P=0.003). There were no statistical differences in clinical outcome parameters.

CONCLUSION

Our data suggest that ITBVI may be a better target parameter than HOU in the fluid resuscitation of severely burned patients after injury.

Increased fluid resuscitation can lead to adverse outcomes in major-burn injured patients, but low mortality is achievable

BACKGROUND

Excessive fluid resuscitation of large burn injuries has been associated with adverse outcomes. We reviewed our experience in patients with major-burn injury to assess the relationship between fluid, clinical outcome and cause of variance from expected resuscitation volumes as defined by the Parkland formula.

METHODS

Eighty patients with new burns > or =15% total body surface area (TBSA) admitted to the intensive care unit within 48 h of injury were included.

RESULTS

Mean fluid volume was 6.0+/-2.3 mL/kg/% TBSA at 24h. Bolus fluids for hypotension and oliguria explained 39% of excess variance from Parkland estimates and inaccurate burn size and weight assessment explained 9% of variance. Higher fluid volume was associated with pneumonia (adjusted odds ratio [AOR]=2.0; 95% confidence interval [CI] 1.2-3.4) and extremity compartment syndrome (AOR=7.9; 95% CI 2.4-26). Colloid use during the first 24h reduced the risk of extremity compartment syndrome (AOR=0.06; 95% CI 0.007-0.49) and renal failure (AOR=0.11; 95% CI 0.014-0.82). In-hospital mortality was low (10%) and not associated with >125% Parkland resuscitation (P=0.39).

CONCLUSIONS

Although fluid resuscitation in excess of the Parkland formula was associated with several adverse events, mortality was low. A multi-centre trial is needed to more specifically define the indications and volumes needed for burns fluid resuscitation and revise traditional formulae emphasising patient outcome. Improved training in burn size assessment is needed.

Factors affecting fluid requirement on the first day after severe burn trauma

BACKGROUND

Parkland formula (PF) is the most often used schema for calculating intravenous resuscitation fluid requirement in burn patients. Some studies have reported that PF underestimates the fluid requirement in 45-63% of patients. The aim of this retrospective study was to analyse factors influencing first-day intravenous fluid replacement set for a targeted urinary output in severely burnt patients.

METHODS

Data of 47 patients with burn injury affecting equal or more than 15% of body surface area were retrieved from the archived files. The local intensive care protocol rendered the infusion rate of lactated Ringer's solution to achieve a urinary output of 0.5-1.0 mL/kg per hour in the first 24 h after burn trauma.

RESULTS

First-day i.v. infusion volume was significantly higher than PF preferred. In the first 24 h the hourly volume of intravenous fluid resuscitation per bodyweight per burnt surface area showed significant negative correlation to the burnt body surface area and body mass index, (r = -0.553, P < 0.001; r = -0.570, P < 0.001, respectively) no correlation was found to bodyweight, height or patient age. Patients having deep-burn injury required higher intravenous fluid resuscitation rate than patients having superficial injury only (P < 0.01).

CONCLUSION

Our data suggest that fluid requirement is higher than predicted by PF if the extent of burn or body mass index is low and less if the extent of burn or body mass index is high. The presence of deep burn increases fluid requirement.