Colloid Administration Normalizes Resuscitation Ratio and Ameliorates "Fluid Creep"
Although colloid was a component of the original Parkland formula, it has been omitted from standard Parkland resuscitation for over 30 years. However, some burn centers use colloid as "rescue" therapy for patients who exhibit progressively increasing crystalloid requirements, a phenomenon termed "fluid creep." We reviewed our experience with this procedure. With Institutional Review Board approval, we reviewed all adult patients with > or =20%TBSA burns admitted from January 1, 2005, through December 31, 2007, who completed formal resuscitation. Patients were resuscitated using the Parkland formula, adjusted to maintain urine output of 30 to 50 ml/hr. Patients who required greater amounts of fluid than expected were given a combination of 5% albumin and lactated Ringer's until fluid requirements normalized. Results were expressed as an hourly ratio (I/O ratio) of fluid infusion (ml/kg/%TBSA/hr) to urine output (ml/kg/hr). Predicted values for this ratio vary for individual patients but are usually less than 0.5 to 1.0. Fifty-two patients were reviewed, of whom 26 completed resuscitation using crystalloid alone, and the remaining 26 required albumin supplementation (AR). The groups were comparable in age, gender, weight, mortality, and time between injury and admission. AR patients had larger total and full-thickness burns and more inhalation injuries. Patients managed with crystalloid alone maintained mean resuscitation ratios from 0.13 to 0.40, whereas AR patients demonstrated progressively increasing ratios to a maximum mean of 1.97, until albumin was started. Administration of albumin produced a dramatic and precipitous return of ratios to within predicted ranges throughout the remainder of resuscitation. No patient developed abdominal compartment syndrome. Measuring hourly I/O ratios is an effective means of expressing and tracking fluid requirements. The addition of colloid to Parkland resuscitation rapidly reduces hourly fluid requirements, restores normal resuscitation ratios, and ameliorates fluid creep. This practice can be applied selectively as needed using predetermined algorithms.
Available from: Armin Sablotzki
- "There continues to be no consensus on best fluid type or volume to achieve this with a variety of practices found in burns units . The focus of debate has revolved around overall fluid volume used and the role of colloids    . The detailed reflection of crystalloid type used has been largely neglected. "
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ABSTRACT: 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.
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.
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.
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).
Available from: Charles Wade
- "They might benefit from adjunctive therapies to the traditional crystalloid resuscitation . Further investigation as to the clinical utility of using the KMAC ratio is warranted . "
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Resuscitation fluid rates following burn are currently guided by a weight and burn size formulae, then titrated to urine output. Traditionally, 24h resuscitation is reported as volume of resuscitation received without direct consideration for the physiologic response. We propose an input-to-output ratio to describe the course of burn resuscitation and predict eventual outcomes.
We reviewed admissions to a burn center from January 2003 through August 2006. Inclusion criteria were ≥20%TBSA, admission ≤8h after burn, and survived ≥24h. Demographics, input volume and urine output, and clinical outcomes were recorded. A ratio of input volume (cc/kg/%TBSA/h) to urine output (cc/kg/h) was calculated at 24h. The ratio of fluid intake to urine output reflecting an 'expected' response was developed: 4cc/kg/%TBSA/24h (0.166cc/kg/%TBSA/h) divided by 0.5-1.0cc urine/kg/h for an expected range 0.166-0.334. Subjects were classified based upon the ratio: over-responders (<0.166), expected (0.166-0.334), or under-responders (>0.334). Clinical outcomes were compared and concordance of classification to values was calculated at 12h.
102 subjects met inclusion criteria; 29 in the over-responders, 37 in the expected, and 36 in the under-responders. Resuscitation volume was directly proportional to the calculated ratio while urine output was inversely proportional. Group mortality was 21%, 11%, and 44%, respectively, with a significant difference between the expected and under-responders (p<0.002). We found decreased ventilator-free days in the under-responders, and when deaths were excluded, decreased ICU-free days as well (p<0.05). Concordance of paired data gathered at 12h and 24h was 67% for the under-responder group.
We describe a novel ratio to classify acute resuscitation after severe burn including the patient's response. Such a classification is associated with eventual outcomes.
Available from: David J Dries
- "After colloid infusion began, patients quickly returned to predicted fluid rates and stayed at those lower volumes for the remainder of their resuscitation. Neither the colloid nor crystalloid group had any patients with abdominal compartment syndrome, though the colloid patients had more extremity escharotomies, likely related to their larger average burn size . In a previous study from the same center, Cochran et al. performed a case-control analysis of large burns (>20% TBSA) that either did or did not receive albumin during their resuscitation. "
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ABSTRACT: Fluid resuscitation following burn injury must support organ perfusion with the least amount of fluid necessary and the least physiological cost. Under resuscitation may lead to organ failure and death. With adoption of weight and injury size-based formulas for resuscitation, multiple organ dysfunction and inadequate resuscitation have become uncommon. Instead, administration of fluid volumes well in excess of historic guidelines has been reported. A number of strategies including greater use of colloids and vasoactive drugs are now under investigation to optimize preservation of end organ function while avoiding complications which can include respiratory failure and compartment syndromes. Adjuncts to resuscitation, such as antioxidants, are also being investigated along with parameters beyond urine output and vital signs to identify endpoints of therapy. Here we briefly review the state-of-the-art and provide a sample of protocols now under investigation in North American burn centers.
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