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Abstract
Colloids have been used in varying capacities throughout the history of formula-based burn resuscitation. There is sound experimental evidence that demonstrates colloids' ability to improve intravascular colloid osmotic pressure, expand intravascular volume, reduce resuscitation requirements, and limit edema in unburned tissue following a major burn. Fresh frozen plasma appears to be a useful and effective immediate burn resuscitation fluid but its benefits must be weighed against its costs, and risks of viral transmission and acute lung injury. Albumin, in contrast, is less expensive and safer and has demonstrated ability to reduce resuscitation requirements and possibly limit edema-related morbidity.
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Affiliation(s)
- Robert Cartotto
- Department of Surgery, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, University of Toronto, Room D712, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada.
| | - David Greenhalgh
- Department of Surgery, Shriners Hospitals for Children Northern California, University of California, Davis, 2425 Stockton Boulevard, Sacramento, CA 95817, USA
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Abstract
Modern trauma management has recognized the importance of using conservative fluid resuscitation regimes in order to prevent complications from fluid overload arising. Hypertonic/hyperoncotic fluids appear to provide an ideal means of facilitating this, requiring only small volumes to rapidly elevate blood pressure. Hypertonic saline dextran (HSD) was introduced in 1985 but its take up has been slow, a large part of this has been due to the lack of human trials and concerns about complications. The current evidence has been reviewed and it is clear that HSD is an efficient means of correcting hypotension, doing so mainly by the mobilizing endogenous water. It is becoming apparent that early administration has the potential to modulate the inflammatory cascade in patients at risk of developing adult respiratory distress syndrome (ARDS) and multiorgan failure. This is reflected in the handful of human trials that show a trend towards increased survival (particularly for head injuries) and a possible reduction in ARDS. The side effect profile appears to be good, even in the presence of dehydration or penetrating trauma. Published human trials have methodological problems and lack of power of study this has led to a reliance on animal studies. Clearly there is great potential, but before large-scale prehospital usage can be justified further well-conducted randomized human trials are needed.
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Affiliation(s)
- AM Perera
- University Hospital (Selly Oak) Birmingham, Birmingham, UK,
| | - KM Porter
- University Hospital (Selly Oak) Birmingham, Birmingham, UK
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Zhao JX, Wang B, You GX, Wang Y, Chen G, Wang Q, Zhang XG, Zhao L, Zhou H, He YZ. Hypertonic Saline Dextran Ameliorates Organ Damage in Beagle Hemorrhagic Shock. PLoS One 2015; 10:e0136012. [PMID: 26317867 PMCID: PMC4552817 DOI: 10.1371/journal.pone.0136012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 07/30/2015] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The goal of this study was to investigate the effect of hypertonic saline with 6% Dextran-70 (HSD) resuscitation on organ damage and the resuscitation efficiency of the combination of HSD and lactated ringers (LR) in a model of hemorrhage shock in dogs. METHODS Beagles were bled to hold their mean arterial pressure (MAP) at 50 ± 5 mmHg for 1 h. After hemorrhage, beagles were divided into three groups (n = 7) to receive pre-hospital resuscitation for 1 h (R1): HSD (4 ml/kg), LR (40 ml/kg), and HSD+LR (a combination of 4 ml/kg HSD and 40 ml/kg LR). Next, LR was transfused into all groups as in-hospital resuscitation (R2). After two hours of observation (R3), autologous blood was transfused. Hemodynamic responses and systemic oxygenation were measured at predetermined phases. Three days after resuscitation, the animals were sacrificed and tissues including kidney, lung, liver and intestinal were obtained for pathological analysis. RESULTS Although the initial resuscitation with HSD was shown to be faster than LR with regard to an ascending MAP, the HSD group showed a similar hemodynamic performance compared to the LR group throughout the experiment. Compared with the LR group, the systemic oxygenation performance in the HSD group was similar but showed a lower venous-to-arterial CO2 gradient (Pv-aCO2) at R3 (p < 0.05). Additionally, the histology score of the kidneys, lungs and liver were significantly lower in the HSD group than in the LR group (p < 0.05). The HSD+LR group showed a superior hemodynamic response but higher extravascular lung water (EVLW) and lower arterial oxygen tension (PaO2) than the other groups (p < 0.05). The HSD+LR group showed a marginally improved systemic oxygenation performance and lower histology score than other groups. CONCLUSIONS Resuscitation after hemorrhagic shock with a bolus of HSD showed a similar hemodynamic response compared with LR at ten times the volume of HSD, but HSD showed superior efficacy in organ protection. Our findings suggest that resuscitation with the combination of HSD and LR in the pre-hospital setting is an effective treatment.
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Affiliation(s)
- Jing-xiang Zhao
- Institute of Transfusion Medicine, Academy of Military Medical Sciences, No. 27th Taiping Road, HaiDian, Beijing, China
| | - Bo Wang
- Institute of Transfusion Medicine, Academy of Military Medical Sciences, No. 27th Taiping Road, HaiDian, Beijing, China
| | - Guo-xing You
- Institute of Transfusion Medicine, Academy of Military Medical Sciences, No. 27th Taiping Road, HaiDian, Beijing, China
| | - Ying Wang
- Institute of Transfusion Medicine, Academy of Military Medical Sciences, No. 27th Taiping Road, HaiDian, Beijing, China
| | - Gan Chen
- Institute of Transfusion Medicine, Academy of Military Medical Sciences, No. 27th Taiping Road, HaiDian, Beijing, China
| | - Quan Wang
- Institute of Transfusion Medicine, Academy of Military Medical Sciences, No. 27th Taiping Road, HaiDian, Beijing, China
| | - Xi-gang Zhang
- Emergency department, Chinese People’s Liberation Army 307 hospital, No. 8th Dongda Street, Fengtai, Beijing, China
| | - Lian Zhao
- Institute of Transfusion Medicine, Academy of Military Medical Sciences, No. 27th Taiping Road, HaiDian, Beijing, China
- * E-mail: (LZ); (HZ); (YH)
| | - Hong Zhou
- Institute of Transfusion Medicine, Academy of Military Medical Sciences, No. 27th Taiping Road, HaiDian, Beijing, China
- * E-mail: (LZ); (HZ); (YH)
| | - Yue-zhong He
- Science and Technology department, Academy of Military Medical Sciences, No. 27th Taiping Road, HaiDian, Beijing, China
- * E-mail: (LZ); (HZ); (YH)
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Dulhunty JM, Boots RJ, Rudd MJ, Muller MJ, Lipman J. Increased fluid resuscitation can lead to adverse outcomes in major-burn injured patients, but low mortality is achievable. Burns 2008; 34:1090-7. [PMID: 18468802 DOI: 10.1016/j.burns.2008.01.011] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2007] [Accepted: 01/21/2008] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Joel M Dulhunty
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD 4029, Australia.
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Abstract
Several reports have documented that modern burn patients receive far more resuscitation fluid than predicted by the Parkland formula-a phenomenon termed "fluid creep." This article reviews the incidence, consequences, and possible etiologies of fluid creep in modern practice and uses this information to propose some therapeutic strategies to reduce or eliminate excessive fluid resuscitation in burn care. A literature review was performed of historical references that form the foundation of modern fluid resuscitation, as well as reports of fluid creep and its consequences. The original Parkland formula required a 24-hour volume of 4 ml/kg/%TBSA lactated Ringer's solution followed by an infusion of 0.3-0.5 ml/kg/ %TBSA plasma. Modern iterations of this formula have omitted the colloid bolus. Numerous exceptions to the formula have been noted, most consistently patients with inhalation injuries. In contrast, recent reports document greatly increased fluid requirements in unselected patients, which seems to consist largely of progressive edema formation in unburned areas, increasing after the first 8 hours post-burn. This has been linked to occurrence of the abdominal compartment syndrome and other serious complications. Strategies to reduce fluid creep include the avoidance of early overresuscitation, use of colloid as a routine component of resuscitation or for "rescue," and adherence to protocols for fluid resuscitation. Fluid creep is a significant problem in modern burn care. Review of original investigations of burn shock, coupled with modern reports of fluid creep, suggests several mechanisms by which this problem can be controlled. Prospective trials of these therapies are needed to confirm their effectiveness.
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Affiliation(s)
- Jeffrey I L Saffle
- Department of Surgery, 3B-306, University of Utah Health Center, 50 N. Medical Drive, Salt Lake City, UT 84132, USA
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Abstract
BACKGROUND Management of burn patients requires a complex interaction of surgical, medical, critical care, and rehabilitation approaches. Severe burn patients are some of the most challenging critically ill patients who may have multiple-system organ failure with life-threatening complications. OBJECTIVE To review and highlight some of the recent advances in burn critical care. We focused on some of the new treatment modalities in the management of respiratory complications, advances in burn resuscitation, management of the metabolic response to burns, and recent ideas in burn immunotherapy. DATA SOURCE A search of the MEDLINE database and manual review of published articles and abstracts from national and international meetings. DATA SYNTHESES AND CONCLUSIONS: The respiratory management of burn patients includes strategies to minimize iatrogenic injury with low tidal volume ventilation, to improve ventilation/perfusion mismatch, and to diagnosis pneumonia. Many aspects of burn resuscitation remain controversial, and the best form of fluid resuscitation has yet to be identified. Recent research in the metabolic response to thermal injury has identified many potentially beneficial treatments. Although immunomodulation therapy is promising, currently most of these treatments are not clinically viable, and further clinical and translational research is warranted.
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Maybauer DM, Maybauer MO, Traber DL. Resuscitation with hypertonic saline in burn shock and sepsis*. Crit Care Med 2006; 34:1849-50. [PMID: 16715001 DOI: 10.1097/01.ccm.0000220055.80587.04] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hoskins SL, Elgjo GI, Lu J, Ying H, Grady JJ, Herndon DN, Kramer GC. Closed-Loop Resuscitation of Burn Shock. J Burn Care Res 2006; 27:377-85. [PMID: 16679909 DOI: 10.1097/01.bcr.0000216512.30415.78] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Fluid therapy for burn shock is adjusted to establish a target level of urinary output. However, the means for adjusting infusion rate are not defined. Our objective was to compare the performance of automated computer-controlled resuscitation with manual control for burn resuscitation. Sheep with a 40% TBSA full-thickness burn, administered under halothane anesthesia, were resuscitated to restore and maintain normal sheep urinary outputs in a target range of 1 to 2 ml/kg per hour over the course of 48 hours using closed-loop resuscitation (n = 10) or manual hourly adjustment of infusion rate (n = 11). The automated closed-loop resuscitation system is based on a proportional-integral-derivative algorithm, which adjusted infusion rate based on continuous monitoring and changes in urinary output. Mean urinary outputs over the course of 48 hours were in target range and were virtually identical at 1.9 +/- 0.5 ml/kg per hour for the closed-loop group and 2.0 +/- 0.7 ml/kg per hour for the technician group. Mean infusion rates and infused volumes also were similar. The closed-loop group exhibited significantly lower hourly variation for both urinary output and infusion rate compared hourly control. Hourly targets were achieved in 41% of the measurements in technician group compared with 48% for the closed-loop group (P = .23). Hourly urinary output in the technician group was undertarget by 25% as opposed to 16% with the closed-loop group (P = .02). Automated closed-loop control of infusion rates after burn injury produced urinary outputs in target ranges with less variation and less under target values than manual hourly adjustments. Closed-loop resuscitation may provide an improvement over current resuscitation regimens.
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Affiliation(s)
- Stephen L Hoskins
- Resuscitation Research Laboratory, Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas 77555-0801, USA
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Fodor L, Fodor A, Ramon Y, Shoshani O, Rissin Y, Ullmann Y. Controversies in fluid resuscitation for burn management: literature review and our experience. Injury 2006; 37:374-9. [PMID: 16118012 DOI: 10.1016/j.injury.2005.06.037] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2005] [Revised: 06/20/2005] [Accepted: 06/20/2005] [Indexed: 02/02/2023]
Abstract
The purpose of this review is to summarise the commonly used formulae for fluid resuscitation in major burns and to discuss the controversy surrounding the use of protein-based colloids as a component of these types of formulae. Fluid resuscitation in major burns is one of the most critical steps in managing this type of injury. In practice, a wide variety of formulae for fluid resuscitation has been suggested. Some propose only the use of crystalloids, while others combine the colloids together with crystalloids. A review was performed of the literature addressing fluid resuscitation formulae and our experience using our formula is presented. At the authors' burn centre a unique formula is in use, which combines plasma and crystalloids. Our experience using this specific formula extends over a period of 15 years and 356 patients with major burns have been resuscitated using this protocol. At our centre, 27 deaths were recorded, 19 of which had third degree burns of more than 80% total body surface area (TBSA). The protein-based colloids are included in most of the formulae and the beneficial effect is considered to be higher than the potential side effects. We are in favour of administering colloids during the resuscitation period for major burns, starting in the early period after injury.
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Affiliation(s)
- Lucian Fodor
- Department of Plastic and Reconstructive Surgery, Rambam Medical Centre & Bruce Rapaport Faculty of Medicine, Haifa, Israel
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O'Mara MS, Slater H, Goldfarb IW, Caushaj PF. A prospective, randomized evaluation of intra-abdominal pressures with crystalloid and colloid resuscitation in burn patients. ACTA ACUST UNITED AC 2005; 58:1011-8. [PMID: 15920417 DOI: 10.1097/01.ta.0000162732.39083.15] [Citation(s) in RCA: 144] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The volume of resuscitation in burn patients has been shown to correlate with intra-abdominal pressure (IAP). Limiting volume may reduce consequences of IAP and abdominal compartment syndrome. Colloid resuscitation has been previously shown to limit the volume required initially after burn. METHODS Thirty-one patients were prospectively followed. Inclusion criteria were a burn of 25% total body surface area with inhalation injury or 40% total body surface area without. Patients received crystalloid (Parkland formula) or plasma resuscitation. IAP was measured by means of urinary bladder transduction. RESULTS Mean age, area of burn, and baseline IAP were not different. Urine output was maintained. There was a greater increase in IAP with crystalloid (26.5 vs. 10.6 mmHg, p < 0.0001). Two patients in the plasma group developed IAP greater than 25 mmHg; only one patient in the crystalloid group maintained IAP less than 25 mmHg. More fluid volume was required with crystalloid resuscitation, 0.26 L/kg, versus 0.21 L/kg (p < 0.005). Correlation was seen in both groups between volume of fluid and IAP (crystalloid, r = 0.351; plasma, r = 0.657; all patients, r = 0.621). CONCLUSION Plasma-resuscitated patients maintained an IAP below the threshold of complications of intra-abdominal hypertension. This appears to be a direct result of the decrease in volume required. Lower fluid volume regimens should be given consideration as the incidence and consequences of intra-abdominal hypertension in burn patients continue to be defined.
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Affiliation(s)
- Michael S O'Mara
- Department of Burns Surgery, Shriner's Hospital for Children of Northern California, USA
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Thomas SJ, Kramer GC, Herndon DN. Burns: military options and tactical solutions. THE JOURNAL OF TRAUMA 2003; 54:S207-18. [PMID: 12768127 DOI: 10.1097/01.ta.0000065013.27877.f3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Burn injury remains a constant source of morbidity and mortality in the military environment. The logistic constraints of combat casualty care can make it impossible to provide the large volumes of crystalloid typically used for burn resuscitation. Unlike penetrating trauma, the immediate and sustained fluid requirements necessary for resuscitation of thermal injury preclude the use of limited or hypotensive resuscitation. We examine the physiology, traditional resuscitation strategies, and rationales for the use of novel regimens in the resuscitation of thermal injury. Although strategies such as early use of colloids or hypertonic saline may not reduce morbidity or mortality when compared with large-volume infusions of lactated Ringer's, they can be volume sparing for some hours and sustain life until more definitive therapy is initiated. An intriguing hypothesis is that oral resuscitation can effectively restore plasma volume after thermal injury. We present data from recent experiments of gastric and intestinal infusions of an oral rehydration solution in a porcine burn model that demonstrates restoration of plasma volumes and improvement in hemodynamic parameters associated with significant gastric emptying and intestinal absorption.
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Affiliation(s)
- Steven J Thomas
- Department of Surgery, The University of Texas Medical Branch, Galveston 77555-0801, USA
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Tan TS, Tan KHS, Ng HP, Loh MW. The effects of hypertonic saline solution (7.5%) on coagulation and fibrinolysis: an in vitro assessment using thromboelastography. Anaesthesia 2002; 57:644-8. [PMID: 12059821 DOI: 10.1046/j.1365-2044.2002.02603.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We studied the effects of hypertonic (7.5%) and normal saline on coagulation and fibrinolysis in an in vitro model using thromboelastography of human whole blood. Reaction times increased and alpha angles decreased with hypertonic saline replacement at 7.5% blood volume compared with similar dilution with normal saline. At 10% blood volume replacement with hypertonic saline, reaction and coagulation times were significantly increased and alpha angles were decreased. Clot lysis at 30 min was also significantly reduced. We conclude that 7.5% hypertonic saline solution has anticoagulant effects if it replaces 7.5% or more of blood volume.
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Affiliation(s)
- T S Tan
- Department of Anaesthesia, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074
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Stapley SA, Clasper JC, Horrocks CL, Kenward CE, Watkins PE. The effects of repeated dosing with 7.5% sodium chloride/6% dextran following uncontrolled intra-abdominal hemorrhage. Shock 2002; 17:146-50. [PMID: 11837791 DOI: 10.1097/00024382-200202000-00011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The use of hypertonic saline Dextran (HSD) for resuscitation following trauma has many potential benefits, especially for the treatment of military casualties, but there is very limited data on the responses following multiple dosing with this fluid. The effects of a second dose of hypertonic saline dextran for resuscitation of uncontrolled intra-abdominal haemorrhage were studied in an experimental model. Under general anaesthesia, 17 large white pigs (weight range, 48-67 kg) were subjected to uncontrolled hemorrhage produced by a tear in the common iliac artery. This resulted in a significant (P < 0.01) reduction of both mean arterial pressure (MAP) and cardiac index. One hour after injury, animals were assigned to one of three groups, receiving either no resuscitation (Group A), or two doses of HSD (at a dose rate of 4 mL/kg), administered either 1 and 4 h after injury (Group B) or 1 and 7 h after injury (Group C). Animals were monitored for 12 h post-injury. A second infusion of HSD caused a significant hypernatremia and diuresis (P< 0.01) in both Groups B and C. There was a non-significant rise in MAP in both treatment groups, and in Group B only, there was a significant increase in cardiac index (P= 0.014). It is concluded that repeat administration of HSD for the resuscitation of uncontrolled hemorrhage results in limited cardiovascular improvements, but that the metabolic sequelae are potentially detrimental to survival.
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Affiliation(s)
- Sarah A Stapley
- Biomedical Sciences, DERA Porton Down, Salisbury, Wiltshire, United Kingdom
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Perioperative Management of the Severely Burned Patient. Intensive Care Med 2002. [DOI: 10.1007/978-1-4757-5551-0_76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Berger MM, Bernath MA, Chioléro RL. Resuscitation, anaesthesia and analgesia of the burned patient. Curr Opin Anaesthesiol 2001; 14:431-5. [PMID: 17019126 DOI: 10.1097/00001503-200108000-00009] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Burns resuscitation has evolved over the past few decades towards more evidence-based management. It has been shown that patients with major burns (i.e. involving more than 30% of the body surface) benefit from invasive monitoring, and physiological variable targeted resuscitation using vasoactive agents for cardiovascular support. The invasive approach results in a reduction of mortality rates. Since the introduction of the Parkland formula in 1968, there has been a trend towards the administration of fluid resuscitation far in excess of the volume predicted with this formula. This has led to an increase in complication rates, with more pulmonary oedema, and the appearance of abdominal compartment syndrome. Hypertonic saline solutions, whether with dextran or not, have shown no advantage over the classic Ringer's lactate solution. The colloid controversy has reached burns resuscitation, with the demonstration that the liberal use of albumin is associated with higher mortality rates. Fresh frozen plasma should only be used for specific coagulation disorders. On the other hand, artificial colloids, particularly gelatine, remain a useful tool in patients with major burns and haemodynamic instability, particularly, and can be given as early as 6 h after injury. Considering the actual evidence, using inotropes and vasopressors to reach supranormal haemodynamic endpoints seems preferable to delivering unrestricted amounts of fluid.
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Affiliation(s)
- M M Berger
- Surgical and Burns Intensive Care Unit, CHUV, 1011 Lausanne, Switzerland.
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Affiliation(s)
- W G Cioffi
- Department of Surgery, Brown University, Rhode Island Hospital, Providence 02903, USA
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Kinsky MP, Milner SM, Button B, Dubick MA, Kramer GC. Resuscitation of severe thermal injury with hypertonic saline dextran: effects on peripheral and visceral edema in sheep. THE JOURNAL OF TRAUMA 2000; 49:844-53. [PMID: 11086774 DOI: 10.1097/00005373-200011000-00009] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Edema of tissue not directly injured by heat is a common complication after resuscitation of burn shock. Hypertonic 7.5% NaCl 6% dextran (HSD) infusion reduces early fluid requirements in burn shock, but the effects of HSD on peripheral and visceral tissue edema are not well-defined. METHODS We measured the microcirculatory absorptive pressures of burned and nonburned skin and tissue water content of skin and other tissues in anesthetized sheep after 70% to 85% total body surface area scald and resuscitation. Fluid infusion was initiated 30 minutes after injury using 10 mL/kg HSD (n = 11) or lactated Ringer's (LR) (n = 12), with infusion rates titrated to restore and maintain preburn oxygen delivery (DO2). Thereafter, both groups received LR infusions as needed to maintain DO2 until the study's end at 8 hours. Colloid osmotic pressure was measured in plasma, and combined interstitial colloid osmotic and hydrostatic pressures were measured in skin. RESULTS Both treatments successfully restored DO2, but fluid requirements were less with the HSD group than with the LR group (43+/-19 mL/kg vs. 194+/-38 mL/kg, respectively, p < 0.05). The peripheral and visceral tissue water contents at 8 hours postinjury until the end of the study in both burn groups were significantly higher than in nonburn controls. However, HSD-treated sheep had significantly less water content in the colon (less 28%), liver (less 9%), pancreas (less 55%), skeletal muscle (less 21%), and nonburned skin (less 12%) compared with LR-treated sheep (p < 0.05 for each). HSD-treated sheep maintained significantly higher (3 to 5 mm Hg) plasma colloid osmotic pressure than LR-treated sheep. CONCLUSION There were no observed differences in edema in burn skin between the two treatment groups. The early volume-sparing effect of HSD and reduction in tissue edema are likely attributed to an increased extracellular osmolarity and a better maintenance of the plasma oncotic pressure.
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Affiliation(s)
- M P Kinsky
- Department of Anesthesiology, University of Texas Medical Branch and Shriners Burns Institute, Galveston, Texas 77555-0801, USA
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Elgjo GI, Traber DL, Hawkins HK, Kramer GC. Burn resuscitation with two doses of 4 mL/kg hypertonic saline dextran provides sustained fluid sparing: a 48-hour prospective study in conscious sheep. THE JOURNAL OF TRAUMA 2000; 49:251-63; discussion 263-5. [PMID: 10963536 DOI: 10.1097/00005373-200008000-00011] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The large fluid volumes usually required for burn resuscitation can be suppressed for 8 to 12 hours by intravenous infusion of 4 mL x kg(-1) hypertonic saline dextran (HSD) 1 hour after burn. We hypothesized that a double (8 mL x kg(-1)) dose of HSD or two repeated doses of 4 mL x kg(-1) could enhance or prolong the volume sparing. METHODS We produced a full-thickness flame burn covering 40% of the body surface on 18 anesthetized sheep. One hour after the burn, the animals were awake and resuscitated with either (1) lactated Ringer's solution (LR) only, (2) 8 mL x kg(-1) HSD followed by LR, or (3) 4 mL x kg(-1) HSD followed by LR, with a second dose of 4 mL x kg(-1) HSD administered when net fluid accumulation increased to 20 mL x kg(-1). For all regimens, infusion rates were adjusted to produce a urine output of 1 to 2 mL x kg(-1) x h(-1). RESULTS Animals resuscitated with only LR required fluid volumes identical to that predicted by the Parkland formula for the first 12 hours. Infusion of 8 mL x kg(-1) HSD initially created a net fluid loss (urine output > infused volume), followed by a rebound fluid requirement eventually equaling that of animals treated with LR only. Animals treated with two separate doses of 4 mL x kg(-1) HSD generally did not experience a net fluid loss or a rebound fluid requirement. Also in the HSD x 2 group, peak and net fluid accumulation was less than that of the other two groups from 18 hours through 48 hours, although the difference was not significant. CONCLUSION An initial 4 mL x kg(-1) dose of HSD reduces fluid requirements early after burn, and a second dose administered after an appropriate interval may prolong volume sparing through 48 hours. An 8 mL x kg(-1) continuously infused initial dose was without prolonged fluid sparing effect. The volume-sparing effect of HSD is thus dependent on all of the following: dose, dosing interval, and infusion rate.
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Affiliation(s)
- G I Elgjo
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, USA.
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