Burn resuscitation: is it straightforward or a challenge?
ABSTRACT Burn shock resuscitation has been extensively studied over the past four decades. Many formulas exist and many parameters have been suggested to assess the adequacy of resuscitation. The most commonly used formula is the Parkland formula, the most commonly used fluids are crystalloids, and the most commonly used parameter is urine output. However, until now, no conclusive evidence has suggested that one formula is superior to another or that one parameter is a better predictor than another. In this article we will review the updated information about the subject and we will look into new advancements in this field. We will pose some questions at the end that will help researchers concentrate their future efforts to solve this important challenge in burn care.
- SourceAvailable from: George Sopko[show abstract] [hide abstract]
ABSTRACT: Randomized clinical trials (RCTs) evaluating the pulmonary artery catheter (PAC) have been limited by small sample size. Some nonrandomized studies suggest that PAC use is associated with increased morbidity and mortality. To estimate the impact of the PAC device in critically ill patients. MEDLINE (1985-2005), the Cochrane Controlled Trials Registry (1988-2005), the National Institutes of Health ClinicalTrials.gov database, and the US Food and Drug Administration Web site for RCTs in which patients were randomly assigned to PAC or no PAC were searched. Results from the ESCAPE trial of patients with severe heart failure were also included. Search terms included pulmonary artery catheter, right heart catheter, catheter, and Swan-Ganz. Eligible studies included patients who were undergoing surgery, in the intensive care unit (ICU), admitted with advanced heart failure, or diagnosed with acute respiratory distress syndrome and/or sepsis; and studies that reported death and the number of days hospitalized or the number of days in the ICU as outcome measures. Information on eligibility criteria, baseline characteristics, interventions, outcomes, and methodological quality was extracted by 2 reviewers. Disagreements were resolved by consensus. In 13 RCTs, 5051 patients were randomized. Hemodynamic goals and treatment strategies varied among trials. A random-effects model was used to estimate the odds ratios (ORs) for death, number of days hospitalized, and use of inotropes and intravenous vasodilators. The combined OR for mortality was 1.04 (95% confidence interval [CI], 0.90-1.20; P = .59). The difference in the mean number of days hospitalized for PAC minus the mean for no PAC was 0.11 (95% CI, -0.51 to 0.74; P = .73). Use of the PAC was associated with a higher use of inotropes (OR, 1.58; 95% CI, 1.19-2.12; P = .002) and intravenous vasodilators (OR, 2.35; 95% CI, 1.75-3.15; P<.001). In critically ill patients, use of the PAC neither increased overall mortality or days in hospital nor conferred benefit. Despite almost 20 years of RCTs, a clear strategy leading to improved survival with the PAC has not been devised. The neutrality of the PAC for clinical outcomes may result from the absence of effective evidence-based treatments to use in combination with PAC information across the spectrum of critically ill patients.JAMA The Journal of the American Medical Association 10/2005; 294(13):1664-70. · 29.98 Impact Factor
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ABSTRACT: Despite the introduction of various less-invasive concepts of cardiac output measurement, pulmonary arterial thermodilution is still the most common measurement technique. This prospective controlled study was designed to compare different methods of cardiac output measurement simultaneously. Pulmonary arterial thermodilution, transpulmonary thermodilution (PiCCO), trans-oesophageal echo-Doppler probe (HemoSonic) and partial carbon dioxide rebreathing technique (NICO monitor) were evaluated against a peri-aortic transit-time flow-probe as reference method in a clinically relevant animal model. After approval from the Local Ethics Committee on Animal Research, the investigations were conducted in nine anesthetized domestic pigs. Systemic haemodynamics were modulated systematically by the application of catecholamines, caval occlusion and exsanguination. Statistical analysis was performed with Bland-Altman and linear regression. A total of 366 paired cardiac output measurements were carried out at a reference cardiac output between 0.5 and 7 L min(-1). The correlation coefficients for pulmonary arterial and transpulmonary thermodilution against reference were 0.93 and 0.95, for trans-oesophageal Doppler and partial rebreathing technique 0.84 and 0.77. Pulmonary arterial thermodilution and transpulmonary thermodilution showed comparable bias and limits of agreement. Where HemoSonic showed an overestimation of cardiac output at a higher precision, NICO overestimated low and underestimated higher cardiac output values. Our data suggest that pulmonary arterial thermodilution and PiCCO may be interchangeably used for cardiac output measurement even under acute haemodynamic changes. The method described by Bland and Altman demonstrated an overestimation of cardiac output for both thermodilution methods. HemoSonic and NICO offer non-invasive alternatives and complementary monitoring tools in numerous clinical situations. Trend monitoring and haemodynamic optimizing can be applied sufficiently, when absolute measures are judged critically in a clinical context. The use of the NICO system seems to be limited during acute circulatory changes.European Journal of Anaesthesiology 02/2006; 23(1):23-30. · 2.79 Impact Factor
- [show abstract] [hide abstract]
ABSTRACT: Impedance cardiography (ICG) technology has improved dramatically, and at least one device now can give a measurement of fluid status by using thoracic fluid content (TFC), along with cardiac output (CO) and cardiac index (CI). With a built-in sphygmomanometer cuff, it can also provide blood pressure (BP) and systemic vascular resistance index (SVRI). A currently available small portable ICG that provides reliable measures of fluid status could be an ideal noninvasive monitor for hemodialysis (HD), with the potential of helping avoid significant hemodynamic instability during HD. A case series of patients with chronic renal failure was studied while undergoing HD using ICG (BioZ, CardioDynamics, Int. Corp., San Diego, CA). Parameters recorded at 15-min intervals included TFC, CI, BP (systolic, diastolic, and mean arterial), SVRI, and heart rate. Using the Pearson method, the percentage changes in each of the parameters during the HD session were correlated to the amount of fluid removed (FR), normalized to body weight. Forty-one patients were enrolled, but six patients were excluded due to incomplete data; therefore, 35 patients (13 men and 22 women) formed the basis of the analysis. The age range was 28 to 87 (mean 55.1 +/- 16.1) years. The amount of FR was 2.88 +/- 1.13 L (37.3 +/- 14.6 ml/kg). TFC decreased in all patients during the HD session (average reduction 12.7 +/- 8 kohms(-1)); whereas all other hemodynamic parameters showed both increases and decreases. The correlation of change in TFC with FR was moderate (r = 0.579, P = 0.0003); other hemodynamic parameters showed a poor correlation with FR. Neither the standard hemodynamic parameters nor the ICG device's special parameters were able to identify the five patients in this series who experienced significant hemodynamic instability or intradialytic hypotension. TFC, measured easily and noninvasively using ICG, correlates with the amount of fluid removed during HD. In comparison with the other hemodynamic parameters measured, TFC changed most consistently with fluid removal. Whether or not serial TFC measurements in a given patient at different HD sessions can guide the extent of FR will require additional study. This compact, easily operated, and nonobtrusive ICG device with the capability for continuously providing the standard hemodynamic parameters plus CO, TFC, and standard limb lead electrocardiography could replace current monitoring systems.Journal of Surgical Research 07/2006; 133(1):55-60. · 2.02 Impact Factor
Annals of Burns and Fire Disasters - vol. XXIV - n. 1 - March 2011
The earliest documentation of interest in fluid shifts
and resuscitation in burn injuries dates back to the early
twentieth century.1Underhill’s understanding of the rela-
tion between fluid shifts and burn shock during his expe-
rience in the Rialto Theater2fire in 1921 and Moore’s sug-
gestion that oedema occurring after burn contributes to the
burn shock3can be considered cornerstones in under-
standing the physiology of burn shock and the importance
of adequate and timely burn resuscitation.1This led to the
Evans formula in 1952 and later to Moyer’s formula1in
1965, which used body weight and burned body surface
area as a reference for calculating the fluids to be given.
Research in this field continued and, although the capil-
lary leak syndrome was suggested by Arturson4in 1979,
it was Baxter and Shire who performed isotope studies in-
dicating that the fluids leaking from the capillaries of
burned patients had a similar protein content to serum, sug-
gesting that proteins given during this period would leak
out into the tissues.5Then, in 1974, the same authors pub-
lished their Parkland formula, which they developed after
inflicting burns on dogs and giving them different amounts
of fluids, finding that the animals that received 4 cc of
crystalloids /kg/percentage burned body surface area were
the ones that survived longest.6Baxter recognized that this
was a valid estimate of fluid requirements only in the first
24 h post-burn and that the best indicator for the adequa-
cy of the resuscitation was urine output.1,6His formula has
remained the most commonly used until our own days.7
Around the time of Baxter’s work, the Brook formu-
la developed by Pruitt and Moncrief in San Antonio, Texas,
came out. This suggested the use of colloids at a rate of
2 cc/kg/percentage of burned body surface area.8This was
later modified to lactated Ringer’s solution instead of col-
loids.1Alternatively, hypertonic saline was also explored
for burn shock resuscitation.1However, unlike the previ-
ous formulas utilizing colloids or crystalloids, studies on
the use of hypertonic saline yielded conflicting results,9-13
even suggesting it might have adverse effects on the kid-
Since the 1970s several other solutions have been sug-
gested for use in burn shock resuscitation, including fresh
frozen plasma, Dextran 40, Dextran 70, and many oth-
ers.1,15-19However, there is still no consensus on the best
fluid resuscitation solution or volume.1,7
The pathophysiology of burn oedema
The development, extent, and resolution of oedema
differ between superficial and deep-thickness burns.1,20In
partial-thickness burns there is increased blood flow to the
injured area which pushes more fluids out of the capillar-
ies, resulting in oedema.20The oedema increases rapidly
within the first few hours and then gradually desorbs over
a period of 3-4 days.20The rapid decrease in oedema is
secondary to the preserved lymphatic channels under the
burned area.20In deep burns oedema increases at a slow-
BURN RESUSCITATION: IS IT STRAIGHTFORWARD OR A
Hayek S.,* Ibrahim A., Abu Sittah G., Atiyeh B.
Plastic and Reconstructive Surgery, American University of Beirut, Beirut, Lebanon
SUMMARY. Burn shock resuscitation has been extensively studied over the past four decades. Many formulas exist and many pa-
rameters have been suggested to assess the adequacy of resuscitation. The most commonly used formula is the Parkland formula, the
most commonly used fluids are crystalloids, and the most commonly used parameter is urine output. However, until now, no conclu-
sive evidence has suggested that one formula is superior to another or that one parameter is a better predictor than another. In this ar-
ticle we will review the updated information about the subject and we will look into new advancements in this field. We will pose
some questions at the end that will help researchers concentrate their future efforts to solve this important challenge in burn care.
Keywords: burn resuscitation, resuscitation fluids, resuscitation formulas, pathophysiology of burn shock, fluid creep
* Corresponding author: Prof. Shady Hayek, MD, Assistant Professor, Plastic and Reconstructive Surgery, Hand Surgery, Burn Surgery, American University of
Beirut, Lebanon. Tel.: +961 3 621179; e-mail: email@example.com
Annals of Burns and Fire Disasters - vol. XXIV - n. 1 - March 2011
er rate and resolves over a longer period owing to the dam-
age to the dermal vascular and lymphatic channels in these
wounds.20Demling reported that in deep burns tissue oede-
ma peaked 18 h post-injury and that about 25% of the
oedema fluid was present one week post-injury.20Another
difference is that in partial-thickness burns most of the ex-
cess fluid is in the dermis whereas in deep burns most of
this fluid resides in the subcutaneous tissues.20The accu-
mulation of oedema fluid is due not only to the increase
in the local blood flow in the injured area but also to the
disturbance of many other factors.1For example the per-
fusion coefficient increases two to three times after injury
as a result of vasodilating factors, and this leads to in-
creased capillary permeability.20The capillary hydrostatic
pressure also increases, especially after partial-thickness
burns, and can reach values that are double the normal
pressure.20In contrast, the interstitial hydrostatic pressure
becomes more negative; this may be due either to the break-
down of proteins into smaller more osmotically active mol-
ecules or to the coiling of the collagen and hyalouronic
acid molecules creating a suctioning effect.20Capillary va-
sodilation not only increases the flow but also alters the
permeability of these vessels, making it possible for larg-
er molecules to pass through their walls into the intersti-
tial space.20This will lead to a decrease in the intravascu-
lar plasma oncotic pressure and to an increase in the in-
terstitial oncotic pressure.20One should not forget the pro-
duction of oxygen free radicals that occurs after burn in-
juries - this can contribute to tissue destruction and to in-
creased capillary permeability.20
Despite the large amount of research and data avail-
able in the field of resuscitation there is still no consen-
sus on the right amount or the best solution for resuscita-
tion.1,7Many formulas exist and many end point parame-
ters have been recommended but the commonest strategy
is to use the Parkland formula to calculate the initial flu-
id amount and then to adjust the fluid rate according to
the hourly urine output.1,7
In 2010 David Greenhalgh, publishing the results of a
survey administered to directors of burn units, staff sur-
geons, and nurses from all the continents except Africa,7
reported the following:
1. The cut-off point for resuscitation was burns in
15% total body surface area
2. Most responders preferred peripheral intravenous
catheters (70%); fewer used central lines (45.7%)
3. The most commonly used formula was the Park-
land formula (69.3%)
4. The most commonly used solution was lactated
5. About 50% of the responders added colloids to
their resuscitation regimen within the first 24 h
6. The most commonly used end point parameter to
assess resuscitation adequacy was urine output
7. Although 88.8% of responders felt that their pro-
tocol was adequate, 55.1% believed they gave more
than the amount recommended by the formula.
Greenhalgh concluded that no protocol was perfect and
that there was a great need to develop randomized prospec-
tive trials to determine the best practice for choosing the
right fluid at the right rate, adjusted with a better indica-
tor for adequate resuscitation.7
With the liberal use of fluids, burn care providers start-
ed to notice that patients frequently received larger amounts
of fluids than required. The expression “fluid creep” was
coined by Basil Pruitt in 2000 to define this phenomenon.21
Several publications appearing after Pruitt’s comments con-
firmed that the amount of fluid used for resuscitation ex-
ceeded the Parkland formula by an average of 4.8 to 6.7
cc/kg/% burn surface area.21-27Over- resuscitation is not be-
nign and is associated with several morbidities that may
lead to mortality. For example, it predisposes the patient
to peripheral compartment syndromes, abdominal com-
partment syndrome, and pulmonary oedema.21,28This phe-
nomenon is not new and was recognized long ago by Bax-
ter, who observed that fluids in excess of his formula were
required in patients with inhalation injury, patients with
electrical injury, and patients whose resuscitation was de-
layed.6Other patients who may require additional fluid re-
suscitation include those with multiple trauma and those
suffering from alcohol or drug addiction.28Another im-
portant cause of over-resuscitation is physician-related: un-
der- or over-estimation of burn depth or surface area will
affect the amount of fluid given to the patient and may
lead to under- or over-resuscitation.28It is worth noting,
however, that many recent reports have appeared describ-
ing over-resuscitation in patients who did not have any of
the usual predisposing conditions.22,23,25,29Possible contribu-
tors to this “fluid creep” phenomenon include:
1. The inaccuracy of the Parkland formula, especial-
ly in large surface area burns24,28-30
2. The tendency of clinicians to be more inclined to
increase the fluid rate liberally in the presence of
low urine output than to decrease the fluid rate in
the presence of high urine output24,28
3. The more liberal use of opiates and narcotics for
pain control, leading to peripheral vasodilation25,28,31
4. The tendency of some centres to perform goal-
directed resuscitation using lactic acid, base deficit,
cardiac index, and oxygen delivery to assess the
5. The effect of excessive crystalloid infusion on the
imbalance of oncotic pressures in the intravascular
and interstitial compartments20,40
Annals of Burns and Fire Disasters - vol. XXIV - n. 1 - March 2011
End points of resuscitation
Until now, the end points used to guide fluid resusci-
tation in burn patients have been inaccurate. This was
agreed upon during the State of Science meeting held in
Washington DC in October 2006.1In our humble opinion,
all the end points studied so far occur after the event and
do not predict the future. As such, these parameters will
not tell us what will happen but rather reflect what hap-
pened. It is clear that all the formulas suggested in the
course of time are just estimates and none is accurate,1 all
of them needing to be adjusted according to certain pa-
rameters. Of these, urine output is the one most commonly
used worldwide to assess the need to increase or decrease
the fluid rate.1,7Yet this is not the only parameter that is
used or recommended, and the use of urine output as an
indicator of resuscitation adequacy has in fact been chal-
lenged in several publications.21,22,25,41,42However, other pa-
rameters that were studied as potential end points for re-
suscitation failed to show their superiority to urine output
and were not cost effective.1For example, invasive mon-
itoring using central venous pressure and pulmonary ar-
tery catheterization failed to change mortality or morbidi-
ty in burn patients.43-46A relatively newly developed method
for monitoring the adequacy of resuscitation utilizes the
shape or the arterial waveform to predict cardiac output
and is termed “pulse contour analysis”.1,47Information from
this less invasive method might be useful in guiding re-
suscitation by monitoring cardiac output, intrathoracic
blood volume, global end-diastolic volume, extravascular
lung water, the pulmonary vascular permeability index, the
cardiac function index, the global ejection fraction, pulse
pressure variation, and stroke volume variation.47Until now
all the studies performed on this method have come from
single centres, assessing a limited number of patients, and
thus cannot be considered as gold standard until large
prospective randomized trials are available to indicate their
utilization and cost effectiveness.47Other less used meth-
ods include transoesophageal echo cardiography, partial
carbon dioxide rebreathing, and impedance electrocardio-
graphy.1None of these methods have been validated in
Pharmacological modulation of resuscitation
Despite the fact that mediators such as histamine, sero-
tonin, prostaglandin, and many others have been found to
be active in burn shock, the exact pathophysiology of this
process has not yet been well delineated.1,50-52Blockers of
these vasoactive substances have been used to try to re-
verse the processes that occur in burn shock but the re-
sults were not very encouraging, apart from some minor
effects that decreased the extent of the process.53-55Recently,
Matsuda and Tanaka used high-dose vitamin C (L-ascor-
bic acid) in the early post-burn period and reported a sig-
nificant decrease in the volume of resuscitation in both an-
imals and humans, together with a significantly decreased
rate of compartment syndromes in the extremities and ab-
domen.56-58Although promising, vitamin C administration
needs to be studied further in multicentre trials in order to
delineate the extent of reversal of the burn shock and to
uncover any side effects that might arise from giving such
a high dose of vitamin C.1
Plasmaphoresis and exchange transfusions have also
been tried and have shown promising results probably by
removing the mediators from the circulation.59-61Both treat-
ments require considerable personnel and equipment and
are associated with significant risks, thus being reserved for
patients not responding to regular resuscitation methods.1
Looking back over the past three decades one can eas-
ily see that there has been very little advancement in re-
suscitation since the development of resuscitation formu-
las. Vitamin C is a promising area in our opinion and should
be further explored to delineate its advantages and disad-
vantages. Another new advancement is the development of
a computerized system that will predict the volume of flu-
ids for the next hour based on the urine output for the pre-
vious hour.62This is a valuable instrument, especially in
combat areas where burn specialists are far away and most
casualties are treated by undertrained personnel.63In our
opinion, although this system still utilizes urine output
(which is an after-effect), it can surpass human calculation
by normalizing the data and helping the system to become
a better predictor every time new data are fed into the equa-
tion. Other areas that are still waiting for clear answers in-
clude: what is the best solution, or combination of solu-
tions, to be used in burn shock resuscitation? How can we
improve on oral resuscitation formulas and can we extend
their use to moderate burn injuries, especially if we are
able to reverse the capillary leak syndrome? Is urine out-
put the best indicator of resuscitation adequacy or can we
develop a predictor of resuscitation fluid requirements? Is
there a way to reverse burn shock pharmacologically with-
out major adverse events? All these questions should be
considered in our future research endeavours to serve our
patients in the best way we can.
In conclusion, the resuscitation of patients suffering
from burn shock is a challenging process that for many
decades has attracted the attention of physicians and re-
searchers. Much has been discovered, yet much still needs
to be done in order to answer all the questions posted
above; hence the challenge.
Annals of Burns and Fire Disasters - vol. XXIV - n. 1 - March 2011
RÉSUMÉ. La réanimation des patients atteints du choc des brûlés a été largement étudiée au cours des quatre dernières décen-
nies. On peut utiliser de nombreuses formules et de nombreux paramètres pour évaluer l’opportunité de l’une ou l’autre méthode
de réanimation. La formule la plus couramment utilisée est la formule de Parkland, les fluides les plus couramment utilisés sont
les cristalloïdes, et le paramètre le plus fréquemment utilisé est la production d’urine. Cependant, jusqu’ici, aucune preuve n’a dé-
montré en manière irréfutable la supériorité d’une formule par rapport à une autre ni la capacité d’un paramètre de permettre de
prédire les résultats en manière plus efficace que les autres. Nous nous sommes proposés de passer en revue les informations à
jour sur le sujet et nous allons examiner les progrès les plus récents dans ce domaine. Nous allons poser en conclusion quelques
questions qui devraient aider les chercheurs à concentrer leurs efforts futurs sur la solution de ce grand problème qui intéresse tous
Mots-clés: réanimation des patients brûlés, fluides pour la réanimation, formules pour la reanimation, pathophysiologie du choc des
brûlés, déplacement des fluides
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This paper was accepted on 22 March 2011.