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Greenhalgh DG. Current Thoughts on Burn Resuscitation. Adv Surg 2024; 58:1-17. [PMID: 39089770 DOI: 10.1016/j.yasu.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
The optimal treatment of burn shock is still unresolved. The problem of "fluid creep" continues despite modern devices that fail to improve outcomes over hourly urine output. Colloids, especially albumin, reduce fluid requirements. Albumin can be used either immediately at the start of resuscitation, or as a "rescue" when crystalloid use is excessive. Several studies confirm that when crystalloid resuscitation is "out of control" the majority of caregivers will add albumin to reduce fluid rates. A multi-center trial is underway comparing crystalloids with albumin to confirm the benefit of colloids. The next question is whether albumin or plasma is as the better colloid choice.
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Affiliation(s)
- David G Greenhalgh
- Burn Department, Shriners Children's Northern California, 2425 Stockton Boulevard, Sacramento, CA 95817, USA; Emeritus, Department of Surgery, University of California, Davis, CA, USA.
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2
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Greenhalgh DG, Hill DM, Burmeister DM, Gus EI, Cleland H, Padiglione A, Holden D, Huss F, Chew MS, Kubasiak JC, Burrell A, Manzanares W, Gómez MC, Yoshimura Y, Sjöberg F, Xie WG, Egipto P, Lavrentieva A, Jain A, Miranda-Altamirano A, Raby E, Aramendi I, Sen S, Chung KK, Alvarez RJQ, Han C, Matsushima A, Elmasry M, Liu Y, Donoso CS, Bolgiani A, Johnson LS, Vana LPM, de Romero RVD, Allorto N, Abesamis G, Luna VN, Gragnani A, González CB, Basilico H, Wood F, Jeng J, Li A, Singer M, Luo G, Palmieri T, Kahn S, Joe V, Cartotto R. Surviving Sepsis After Burn Campaign. Burns 2023; 49:1487-1524. [PMID: 37839919 DOI: 10.1016/j.burns.2023.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 05/02/2023] [Indexed: 10/17/2023]
Abstract
INTRODUCTION The Surviving Sepsis Campaign was developed to improve outcomes for all patients with sepsis. Despite sepsis being the primary cause of death after thermal injury, burns have always been excluded from the Surviving Sepsis efforts. To improve sepsis outcomes in burn patients, an international group of burn experts developed the Surviving Sepsis After Burn Campaign (SSABC) as a testable guideline to improve burn sepsis outcomes. METHODS The International Society for Burn Injuries (ISBI) reached out to regional or national burn organizations to recommend members to participate in the program. Two members of the ISBI developed specific "patient/population, intervention, comparison and outcome" (PICO) questions that paralleled the 2021 Surviving Sepsis Campaign [1]. SSABC participants were asked to search the current literature and rate its quality for each topic. At the Congress of the ISBI, in Guadalajara, Mexico, August 28, 2022, a majority of the participants met to create "statements" based on the literature. The "summary statements" were then sent to all members for comment with the hope of developing an 80% consensus. After four reviews, a consensus statement for each topic was created or "no consensus" was reported. RESULTS The committee developed sixty statements within fourteen topics that provide guidance for the early treatment of sepsis in burn patients. These statements should be used to improve the care of sepsis in burn patients. The statements should not be considered as "static" comments but should rather be used as guidelines for future testing of the best treatments for sepsis in burn patients. They should be updated on a regular basis. CONCLUSION Members of the burn community from the around the world have developed the Surviving Sepsis After Burn Campaign guidelines with the goal of improving the outcome of sepsis in burn patients.
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Affiliation(s)
- David G Greenhalgh
- Department of Burns, Shriners Children's Northern California and Department of Surgery, University of California, Davis, Sacramento, CA, USA.
| | - David M Hill
- Department of Clinical Pharmacy & Translational Scre have been several studies that have evaluatedience, College of Pharmacy, University of Tennessee, Health Science Center; Memphis, TN, USA
| | - David M Burmeister
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Eduardo I Gus
- Division of Plastic & Reconstructive Surgery, The Hospital for Sick Children; Department of Surgery, University of Toronto, Toronto, Canada
| | - Heather Cleland
- Department of Surgery, Monash University and Alfred Hospital, Melbourne, Australia
| | - Alex Padiglione
- Department of Surgery, Monash University and Alfred Hospital, Melbourne, Australia
| | - Dane Holden
- Department of Surgery, Monash University and Alfred Hospital, Melbourne, Australia
| | - Fredrik Huss
- Department of Surgical Sciences, Plastic Surgery, Uppsala University/Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - John C Kubasiak
- Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Aidan Burrell
- Department of Epidemiology and Preventative Medicine, Monash University and Alfred Hospital, Intensive Care Research Center (ANZIC-RC), Melbourne, Australia
| | - William Manzanares
- Department of Critical Care Medicine, Universidad de la República (UdelaR), Montevideo, Uruguay
| | - María Chacón Gómez
- Division of Intensive Care and Critical Medicine, Centro Nacional de Investigacion y Atencion de Quemados (CENIAQ), National Rehabilitation Institute, LGII, Mexico
| | - Yuya Yoshimura
- Department of Emergency and Critical Care Medicine, Hachinohe City Hospital, Hachinohe, Japan
| | - Folke Sjöberg
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Wei-Guo Xie
- Institute of Burns, Tongren Hospital of Wuhan University (Wuhan Third Hospital), Wuhan, China
| | - Paula Egipto
- Centro Hospitalar e Universitário São João - Burn Unit, Porto, Portugal
| | | | | | | | - Ed Raby
- Infectious Diseases Department, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | | | - Soman Sen
- Department of Burns, Shriners Children's Northern California and Department of Surgery, University of California, Davis, Sacramento, CA, USA
| | - Kevin K Chung
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | | | - Chunmao Han
- Department of Burn and Wound Repair, Second Affiliated Hospital, Zhejiang University College of Medicine, Hangzhou, China
| | - Asako Matsushima
- Department of Emergency and Critical Care, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Moustafa Elmasry
- Department of Hand, Plastic Surgery and Burns, Linköping University, Linköping, Sweden
| | - Yan Liu
- Department of Burn, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Carlos Segovia Donoso
- Intensive Care Unit for Major Burns, Mutual Security Clinical Hospital, Santiago, Chile
| | - Alberto Bolgiani
- Department of Surgery, Deutsches Hospital, Buenos Aires, Argentina
| | - Laura S Johnson
- Department of Surgery, Emory University School of Medicine and Grady Health System, Georgia
| | - Luiz Philipe Molina Vana
- Disciplina de Cirurgia Plastica da Escola Paulista de Medicina da Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | | | - Nikki Allorto
- Grey's Hospital Pietermaritzburg Metropolitan Burn Service, University of KwaZulu Natal, Pietermaritzburg, South Africa
| | - Gerald Abesamis
- Alfredo T. Ramirez Burn Center, Division of Burns, Department of Surgery, University of Philippines Manila - Philippine General Hospital, Manila, Philippines
| | - Virginia Nuñez Luna
- Unidad Michou y Mau Xochimilco for Burnt Children, Secretaria Salud Ciudad de México, Mexico
| | - Alfredo Gragnani
- Disciplina de Cirurgia Plastica da Escola Paulista de Medicina da Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Carolina Bonilla González
- Department of Pediatrics and Intensive Care, Pediatric Burn Unit, Clinical Studies and Clinical Epidemiology Division, Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Hugo Basilico
- Intensive Care Area - Burn Unit - Pediatric Hospital "Prof. Dr. Juan P. Garrahan", Buenos Aires, Argentina
| | - Fiona Wood
- Department of Surgery, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - James Jeng
- Department of Surgery, University of California, Irvine, CA, USA
| | - Andrew Li
- Department of Surgery, Monash University and Alfred Hospital, Melbourne, Australia
| | - Mervyn Singer
- Department of Intensive Care Medicine, University College London, London, United Kingdom
| | - Gaoxing Luo
- Institute of Burn Research, Southwest Hospital, Army (Third Military) Medical University, Chongqing, China
| | - Tina Palmieri
- Department of Burns, Shriners Children's Northern California and Department of Surgery, University of California, Davis, Sacramento, CA, USA
| | - Steven Kahn
- The South Carolina Burn Center, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Victor Joe
- Department of Surgery, University of California, Irvine, CA, USA
| | - Robert Cartotto
- Department of Surgery, Sunnybrook Medical Center, Toronto, Ontario, Canada
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Tacon SL, Falaize A, Mellati N, Picard Y, Goetz C, Gette S, Losser MR. Evolution of hematocrit in burn patients as a marker of early fluid management during acute phase. Burns 2023; 49:1356-1362. [PMID: 36813604 DOI: 10.1016/j.burns.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/16/2023] [Accepted: 02/05/2023] [Indexed: 02/12/2023]
Abstract
OBJECTIVE To evaluate the value of hematocrit for monitoring fluid resuscitation of burn patients in the acute phase of their care. METHOD We conducted a single-center retrospective study focused on patients admitted with a burn surface of more than 20 % of the total body surface area (TBSA) from 2014 to 2021. We investigated the relationship between the change in hematocrit and the volume administered for patient resuscitation. The change in hematocrit is the difference between an admission hematocrit and a second one taken between the eighth and twenty-fourth hour. RESULTS We included 230 patients with an average burn size of 39.1 ± 20.3 % TBSA, in 94.4 % by a thermal mechanism. The management seems to be in accordance with the current recommendations, with a volume administered during the first 24 h of 4.3 ± 2.5 ml/kg/ % BSA, allowing to obtain an hourly diuresis of 0.9 ± 0.7 ml/kg/h. We did not find any correlation between the pre-hospital volume administration and the hematocrit at admission (p = 0.36). Hematocrit decreased on average to -4.5 ± 8.1 % between admission and a control performed after the 8th hour. This decrease was weakly correlated with the volumes infused between the two samples (r2 =0.13, p < 0.001). A resuscitation above 5.2 ml/kg/ % Burn surface area is an independent factor for excess mortality. CONCLUSION Hematocrit or its variations in our limited data base appears to not reliably detect over-resuscitation, therefore it is possible that it may not be a relevant marker. These conclusions should be clarified in a multi-institutional prospective or real-world analysis to validate the findings and null hypothesis.
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Affiliation(s)
- Serge Le Tacon
- Intensive Care Unit, Centre Hospitalier Régional de Metz-Thionville, France.
| | - Alexandre Falaize
- Intensive Care Unit, Burn Centre, Centre Hospitalier Régional de Metz-Thionville, France
| | - Nouchan Mellati
- Intensive Care Unit, Burn Centre, Centre Hospitalier Régional de Metz-Thionville, France
| | - Yoann Picard
- Intensive Care Unit, Centre Hospitalier Régional de Metz-Thionville, France
| | - Christophe Goetz
- Research and Innovation Department, Centre Hospitalier Régional de Metz-Thionville, France
| | - Sébastien Gette
- Intensive Care Unit, Burn Centre, Centre Hospitalier Régional de Metz-Thionville, France
| | - Marie-Reine Losser
- Intensive Care Unit, Burn Centre, Centre Hospitalier Régional de Metz-Thionville, France
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Venkatesh K, Henschke A, Lee RP, Delaney A. Patient-centred outcomes are under-reported in the critical care burns literature: a systematic review. Trials 2022; 23:199. [PMID: 35246209 PMCID: PMC8896280 DOI: 10.1186/s13063-022-06104-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 02/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Developments in the care of critically ill patients with severe burns have led to improved hospital survival, but long-term recovery may be impaired. The extent to which patient-centred outcomes are assessed and reported in studies in this population is unclear. METHODS We conducted a systematic review to assess the outcomes reported in studies involving critically ill burns patients. Randomised controlled trials (RCTs) and cohort studies on the topics of fluid resuscitation, analgesia, haemodynamic monitoring, ventilation strategies, transfusion targets, enteral nutrition and timing of surgery were included. We assessed the outcomes reported and then classified these according to two suggested core outcome sets. RESULTS A comprehensive search returned 6154 studies; 98 papers met inclusion criteria. There were 66 RCTs, 19 clinical studies with concurrent controls and 13 interventional studies without concurrent controls. Outcome reporting was inconsistent across studies. Pain, reported using the visual analogue scale, fluid volume administered and mortality were the only outcomes measured in more than three studies. Sixty-six studies (67%) had surrogate primary outcomes. Follow-up was poor, with median longest follow-up across all studies 5 days (IQR 3-28). When compared to the suggested OMERACT core outcome set, 53% of papers reported on mortality, 28% reported on life impact, 30% reported resource/economic outcomes and 95% reported on pathophysiological manifestations. Burns-specific Falder outcome reporting was globally poor, with only 4.3% of outcomes being reported across the 98 papers. CONCLUSION There are deficiencies in the reporting of outcomes in the literature pertaining to the intensive care management of patients with severe burns, both with regard to the consistency of outcomes as well as a lack of focus on patient-centred outcomes. Long-term outcomes are infrequently reported. The development and validation of a core outcome dataset for severe burns would improve the quality of reporting.
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Affiliation(s)
- Karthik Venkatesh
- Malcolm Fisher Department of Intensive Care, The Royal North Shore Hospital, St Leonards, NSW, 2065, Australia. .,The University of New South Wales, Kensington, Sydney, NSW, Australia.
| | - Alice Henschke
- Department of Intensive Care, Orange Base Hospital, Orange, NSW, Australia.,Northern Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Richard P Lee
- Malcolm Fisher Department of Intensive Care, The Royal North Shore Hospital, St Leonards, NSW, 2065, Australia.,Northern Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Anthony Delaney
- Malcolm Fisher Department of Intensive Care, The Royal North Shore Hospital, St Leonards, NSW, 2065, Australia.,Northern Clinical School, University of Sydney, Sydney, NSW, Australia.,The George Institute for Global Health, Sydney, NSW, Australia
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Duan Z, Cai G, Li J, Chen F, Chen X. Meta-Analysis of Renal Replacement Therapy for Burn Patients: Incidence Rate, Mortality, and Renal Outcome. Front Med (Lausanne) 2021; 8:708533. [PMID: 34434946 PMCID: PMC8381047 DOI: 10.3389/fmed.2021.708533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 07/05/2021] [Indexed: 12/29/2022] Open
Abstract
Background: Renal replacement therapy (RRT) was often needed by some severe burn patients with acute kidney injury (AKI). The primary aim of this study was to review incidence rate and mortality of RRT in severe burn patients. Second aims were to review RRT complications and renal outcome. Methods: We searched multiple databases for studies published between 1 January 1960 and 31 December 2019. Studies about adult populations with burn injury, providing epidemiologic data on prevalence or mortality of RRT, were included. Results: A total of selected 57 studies, including 27,437 patients were enrolled in our analysis. The prevalence rates of RRT were 8.34% (95% CI 7.18–9.5%) in all burn patients and 37.05% (95% CI 29.85–44.24%) in AKI patients. The mortality of all burn patients with RRT was 65.52% (95% CI 58.41–72.64%). The prevalence rates of RRT in sample size≥100 group were 6.86% (95% CI 5.70–8.03%), which was lower than that of <100 group (17.61%, 95% CI 13.39–21.82%). With the increase of TBSA, the prevalence of RRT may have the increasing trend. The prevalence rates of RRT in Asian group was 12.75% (95% CI 9.50–16.00%), which was higher than that of European (10.45%, 95% CI 7.30–13.61%) and North America group (5.61%, 95% CI 4.27–6.95%). The prevalence rates of RRT in 2010–2019 group was 12.22% (95% CI 10.09–14.35%), which was higher than that of 2009–2000 group (5.17%, 95% CI 2.88–7.46%). The prevalence rates of RRT in 1989 and before group was the lowest, which was 1.56% (95% CI 0–3.68%). However, there was no significant correlation between the year of publication and the mortality of burn patients with RRT. Dialysis-requiring AKI in burn patients could increases the risk of chronic kidney disease progression and end-stage renal disease. About 35% of RRT patients need to maintain haemodialysis temporarily, even if they survive and leave hospital. Conclusions: The prevalence rate of RRT is about 6–8%; approximately, one-third of burn patients with AKI need RRT. The prevalence rate of RRT increased over time, but the mortality did not change. The prevalence rates of RRT in Asian group was higher than that of European and North America group.
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Affiliation(s)
- ZhiYu Duan
- State Key Laboratory of Kidney Diseases, Department of Nephrology, National Clinical Research Center for Kidney Diseases, Chinese People's Liberation Army Institute of Nephrology, Chinese People's Liberation Army General Hospital, Beijing, China.,Department of Nephrology, The Fourth Medical Center of People's Liberation Army General Hospital, Beijing, China
| | - GuangYan Cai
- State Key Laboratory of Kidney Diseases, Department of Nephrology, National Clinical Research Center for Kidney Diseases, Chinese People's Liberation Army Institute of Nephrology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - JiJun Li
- State Key Laboratory of Kidney Diseases, Department of Nephrology, National Clinical Research Center for Kidney Diseases, Chinese People's Liberation Army Institute of Nephrology, Chinese People's Liberation Army General Hospital, Beijing, China.,Department of Nephrology, The Fourth Medical Center of People's Liberation Army General Hospital, Beijing, China
| | - FengKun Chen
- State Key Laboratory of Kidney Diseases, Department of Nephrology, National Clinical Research Center for Kidney Diseases, Chinese People's Liberation Army Institute of Nephrology, Chinese People's Liberation Army General Hospital, Beijing, China.,Department of Nephrology, The Fourth Medical Center of People's Liberation Army General Hospital, Beijing, China
| | - XiangMei Chen
- State Key Laboratory of Kidney Diseases, Department of Nephrology, National Clinical Research Center for Kidney Diseases, Chinese People's Liberation Army Institute of Nephrology, Chinese People's Liberation Army General Hospital, Beijing, China
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Xiao K, Zhao F, Wan J, LE A. Effect of the infusion ration between frozen plasma and plasma substitutes on the prognosis of adult patients with major burn in shock stage. ZHONG NAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF CENTRAL SOUTH UNIVERSITY. MEDICAL SCIENCES 2021; 46:393-399. [PMID: 33967086 PMCID: PMC10930309 DOI: 10.11817/j.issn.1672-7347.2021.190565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVES In recent years, it has been reported that the anti-shock effect of plasma substitutes in adult patients with major burn in shock stage is not good. However, due to the shortage of clinical frozen plasma supply, it is impossible to guarantee that frozen plasma is used as colloidal solution for anti-shock treatment. The purpose of this study is to explore the effect of the infusion ration between frozen plasma and plasma substitutes on the prognosis of adult patients with major burn in shock stage. METHODS This study enrolled 586 adult patients with major burn by selecting the hospitalization burn patients, who had been hospitalized at the Jiangxi province burn center from September 2014 to April 2019. The patients with the infusion ratio of frozen plasma to plasma substitutes ≥2꞉1 at 48 hours after admission were included in the experimental group, otherwise they were included in the control group. The basic clinical data and clinical prognosis indicator in the 2 groups were compared. Logistic univariate regression analysis was used to screen the influential factors of 30-day mortality in adult patients with major burn, and logistic multivariate regression analysis was used to obtain independent risk and protective factors; Kaplan-Meier method was used to draw the survival curve of the 2 groups, and log-rank test was used to compare the 30-day survival rate of the 2 groups. RESULTS There were significant differences in the infusion volume of frozen plasma and plasma substitutes between the 2 groups at 48 hours after admission (both P<0.05). The duration of mechanical ventilation in the experimental group was shorter than that in the control group, the percentage of continuous renal replacement therapy (CRRT) in the experimental group was lower than that in the control group, and the in-hospital mortality and 30-day mortality in the experimental group were lower than those in the control group, the differences were statistically significant (all P<0.05). The percentage of burn area and total body surface area (TBSA) was an independent risk factor for 30-day mortality of adult patients with major burn (OR=1.228, 95% CI 1.010 to 1.439, P=0.039), while the infusion ration between of frozen plasma and plasma substitutes 48 hours after admission was an independent protective factor (OR=0.016, 95% CI 0.001 to 0.960, P=0.023). The 30-day survival rate of the experimental group was significantly higher than that in the control group (P<0.001). CONCLUSIONS Infusion ration between frozen plasma to plasma substitutes at 48 hours after admission is an independent protective factor for 30-day mortality of adult patients with major burn. In the early stage of adult patients with major burn, frozen plasma should be used as the anti-shock therapy as far as possible (frozen plasma꞉plasma substitute ≥2꞉1) to improve the prognosis and reduce the of 30-day mortality.
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Affiliation(s)
- Kun Xiao
- Department of Blood Transfusion, First Affiliated Hospital of Nanchang University, Nanchang 330006.
| | - Fei Zhao
- Department of Neurology, First Affiliated Hospital of Nanchang University, Nanchang 330006
| | - Jiangbo Wan
- Department of Burn, First Affiliated Hospital of Nanchang University, Nanchang 330006, China
| | - Aiping LE
- Department of Blood Transfusion, First Affiliated Hospital of Nanchang University, Nanchang 330006.
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Li D, Li X, Cui W, Shen H, Zhu H, Xia Y. Liberal versus conservative fluid therapy in adults and children with sepsis or septic shock. Cochrane Database Syst Rev 2018; 12:CD010593. [PMID: 30536956 PMCID: PMC6517253 DOI: 10.1002/14651858.cd010593.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Sepsis and septic shock are potentially life-threatening complications of infection that are associated with high morbidity and mortality in adults and children. Fluid therapy is regarded as a crucial intervention during initial treatment of sepsis. Whether conservative or liberal fluid therapy can improve clinical outcomes in patients with sepsis and septic shock remains unclear. OBJECTIVES To determine whether liberal versus conservative fluid therapy improves clinical outcomes in adults and children with initial sepsis and septic shock. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, intensive and critical care conference abstracts, and ongoing clinical trials on 16 January 2018, and we contacted study authors to try to identify additional studies. SELECTION CRITERIA We planned to include all randomized controlled trials (RCTs), quasi-RCTs, and cluster RCTs comparing liberal fluid therapy versus conservative fluid therapy for adults and children with sepsis or septic shock. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. We assessed risk of bias of all included trials by using the Cochrane risk of bias tool. When appropriate, we calculated risk ratios (RRs) and 95% confidence intervals (CIs) for dichotomous outcomes, and mean differences (MDs) and 95% CIs for continuous outcomes. Our primary outcomes were all-cause mortality in hospital and at follow-up. Secondary outcomes included adverse events (organ dysfunction, allergic reaction, and neurological sequelae). We used GRADE to assess the quality of evidence for each outcome. MAIN RESULTS We identified no adult studies that met our selection criteria.This review included three paediatric RCTs (N = 3402), but we were able to extract data from only two of the three trials (n = 3288). These trials were conducted in India (two studies) and Africa. Participants were children from one month to 12 years old with sepsis or septic shock. All three included trials investigated liberal versus conservative fluid therapy, although definitions of liberal and conservative fluid therapy varied slightly across included studies. Results of the two trials included in the analyses show that liberal fluid therapy may increase risk of in-hospital mortality by 38% (2 studies; N = 3288; RR 1.38, 95% CI 1.07 to 1.77; number needed to treat for an additional harmful outcome (NNTH) = 34; moderate-quality evidence) and may increase risk of mortality at follow-up (at four weeks) by 39% (1 study; N = 3141; RR 1.39, 95% CI 1.11 to 1.74; NNTH = 29; high-quality evidence). The third study reported inconclusive results for in-hospital mortality (very low-quality evidence).We are uncertain whether there is a difference in adverse events between liberal and conservative fluid therapy because the single-study results are imprecise (organ dysfunction - hepatomegaly: RR 0.95, 95% CI 0.60 to 1.50; n = 147; low-quality evidence; organ dysfunction - need for ventilation: RR 1.17, 95% CI 0.83 to 1.65; n = 147; low-quality evidence; allergic reaction: RR 1.74, 95% CI 0.36 to 8.37; n = 3141; low-quality evidence; neurological sequelae: RR 1.03, 95% CI 0.61 to 1.75; n = 2983; low-quality evidence). Results are also uncertain for other adverse events such as desaturation, tracheal intubation, increased intracranial pressure, and severe hypertension. AUTHORS' CONCLUSIONS No studies compared liberal versus conservative fluid therapy in adults. Low- to high-quality evidence indicates that liberal fluid therapy might increase mortality among children with sepsis or septic shock in hospital and at four-week follow-up. It is uncertain whether there are any differences in adverse events between liberal and conservative fluid therapy because the evidence is of low quality. Trials including adults, patients in other settings, and patients with a broader spectrum of pathogens are needed. Once published and assessed, three ongoing studies may alter the conclusions of this review.
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Affiliation(s)
- Danyang Li
- Second Affiliated Hospital Medical College, Zhejiang UniversityIntensive Care Unit88 Jiefang RoadHangzhouChina310009
| | - Xueyang Li
- Dongfang College, Zhejiang University of Finance and EconomicsForeign Language Department2 Yangshan Road, Chang?an TownHainingChina314400
| | - Wei Cui
- Second Affiliated Hospital Medical College, Zhejiang UniversityIntensive Care Unit88 Jiefang RoadHangzhouChina310009
| | - Huahao Shen
- Second Affiliated Hospital Medical College, Zhejiang UniversityDepartment of Respiratory Medicine88 Jiefang RoadHangzhouChina310009
| | - Hong Zhu
- Second Affiliated Hospital Medical College, Zhejiang UniversityIntensive Care Unit88 Jiefang RoadHangzhouChina310009
| | - Yi Xia
- Second Affiliated Hospital Medical College, Zhejiang UniversityIntensive Care Unit88 Jiefang RoadHangzhouChina310009
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Commereuc M, Schortgen F. Néphrotoxicité des produits de remplissage. Nephrol Ther 2018; 14:555-563. [DOI: 10.1016/j.nephro.2018.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
As a result of many years of research, the intricate cellular mechanisms of burn injury are slowly becoming clear. Yet, knowledge of these cellular mechanisms and a multitude of resulting studies have often failed to translate into improved clinical treatment for burn injuries. Perhaps the most valuable information to date is the years of clinical experience and observations in the management and treatment of patients, which has contributed to a gradual improvement in reported outcomes of mortality. This review provides a discussion of the cellular mechanisms and pathways involved in burn injury, resultant systemic effects on organ systems, current management and treatment, and potential therapies that we may see implemented in the future.
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10
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Guilabert P, Abarca L, Martin N, Usua G, Barret JP, Colomina MJ. What about HES in burn patients?: Evaluation of the actual evidence. Burns 2017; 44:489-493. [PMID: 29029856 DOI: 10.1016/j.burns.2017.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 09/21/2017] [Indexed: 11/17/2022]
Affiliation(s)
- Patricia Guilabert
- Anesthesia and Critical Care Department, University Hospital Vall d'Hebron, Barcelona, Spain.
| | - Luis Abarca
- Anesthesia and Critical Care Department, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Nuria Martin
- Anesthesia and Critical Care Department, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Gemma Usua
- Anesthesia and Critical Care Department, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Juan P Barret
- Plastic Surgery Department and Burn Centre, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Maria J Colomina
- Anesthesia and Critical Care Department, University Bellvitge Hospital, Barcelona, Spain
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11
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Wiedermann C, Eisendle K. Acute kidney injury in critically burned patients treated with hydroxyethyl starch: a response to Sánchez-Sánchez et al. ANNALS OF BURNS AND FIRE DISASTERS 2017; 30:220-221. [PMID: 29849528 PMCID: PMC5946756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 04/12/2017] [Indexed: 06/08/2023]
Affiliation(s)
- C.J. Wiedermann
- Department of Research, College of Health Professions ‘Claudiana’, Bolzano, Italy
- Department of Internal Medicine, Central Hospital of Bolzano, Bolzano, Italy
| | - K. Eisendle
- Department of Research, College of Health Professions ‘Claudiana’, Bolzano, Italy
- Department of Dermatology, Central Hospital of Bolzano, Bolzano, Italy
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12
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Effects of Fluid Treatment With Hydroxyethyl Starch on Renal Function in Patients With Aneurysmal Subarachnoid Hemorrhage. J Neurosurg Anesthesiol 2017; 28:187-94. [PMID: 26147464 DOI: 10.1097/ana.0000000000000205] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Recent reports have doubted the efficacy and safety of hydroxyethyl starch (HES) for volume resuscitation. HES has been reported to promote renal insufficiency particularly in sepsis and trauma patients. This analysis investigated the effects of HES 6% 130/0.4 for fluid therapy in patients with intact renal function who suffered aneurysmal subarachnoid hemorrhage (SAH). METHODS This retrospective analysis included 107 patients and was conducted in the framework of a clinical trial assessing the efficacy of magnesium sulfate in SAH. Because magnesium is renally eliminated, patients with renal insufficiency had been excluded. Standard therapy after aneurysm occlusion included the daily administration of HES 6% 130/0.4. Serum and urine creatinine and fluid balance were measured daily. RESULTS Patients received a daily mean of 1101±524 mL HES and 3353±1396 mL Ringer's solution. The highest creatinine values were recorded on day 3 after admission (0.88±0.25 mg/100 mL) and continuously decreased thereafter. In 6 patients, creatinine values temporarily increased by >0.3 mg/100 mL but recovered to admission values at the end of the observation period. CONCLUSIONS Concerning renal function, the first days after SAH seem to be a vulnerable phase in which a variety of interventions are performed, including contrast-enhanced neuroradiologic procedures. In this period, HES 6% 130/0.4 should be administered with caution. However, no patient suffered from renal failure and required temporary or permanent renal replacement therapy. These results suggest that the administration of HES 6% 130/0.4 is safe in SAH patients without preexisting renal insufficiency.
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13
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Romanowski KS, Palmieri TL. Pediatric burn resuscitation: past, present, and future. BURNS & TRAUMA 2017; 5:26. [PMID: 28879205 PMCID: PMC5582395 DOI: 10.1186/s41038-017-0091-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 07/07/2017] [Indexed: 01/20/2023]
Abstract
Burn injury is a leading cause of unintentional death and injury in children, with the majority being minor (less than 10%). However, a significant number of children sustain burns greater than 15% total body surface area (TBSA), leading to the initiation of the systemic inflammatory response syndrome. These patients require IV fluid resuscitation to prevent burn shock and death. Prompt resuscitation is critical in pediatric patients due to their small circulating blood volumes. Delays in resuscitation can result in increased complications and increased mortality. The basic principles of resuscitation are the same in adults and children, with several key differences. The unique physiologic needs of children must be adequately addressed during resuscitation to optimize outcomes. In this review, we will discuss the history of fluid resuscitation, current resuscitation practices, and future directions of resuscitation for the pediatric burn population.
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Affiliation(s)
- Kathleen S Romanowski
- Department of Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, JCP 1500, Iowa City, IA 52242 USA
| | - Tina L Palmieri
- Shriners Hospitals for Children Northern California, Sacramento, California USA.,University of California Davis, Davis, California USA
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14
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Hodgman EI, Subramanian M, Arnoldo BD, Phelan HA, Wolf SE. Future Therapies in Burn Resuscitation. Crit Care Clin 2017; 32:611-9. [PMID: 27600132 DOI: 10.1016/j.ccc.2016.06.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Since the 1940s, the resuscitation of burn patients has evolved with dramatic improvements in mortality. The most significant achievement remains the creation and adoption of formulae to calculate estimated fluid requirements to guide resuscitation. Modalities to attenuate the hypermetabolic phase of injury include pharmacologic agents, early enteral nutrition, and the aggressive approach of early excision of large injuries. Recent investigations into the genomic response to severe burns and the application of computer-based decision support tools will likely guide future resuscitation, with the goal of further reducing mortality and morbidity, and improving functional and quality of life outcomes.
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Affiliation(s)
- Erica I Hodgman
- Division of Burns, Trauma, and Critical Care, Department of Surgery, University of Texas-Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9158, USA
| | - Madhu Subramanian
- Division of Burns, Trauma, and Critical Care, Department of Surgery, University of Texas-Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9158, USA
| | - Brett D Arnoldo
- Division of Burns, Trauma, and Critical Care, Department of Surgery, University of Texas-Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9158, USA
| | - Herb A Phelan
- Division of Burns, Trauma, and Critical Care, Department of Surgery, University of Texas-Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9158, USA
| | - Steven E Wolf
- Division of Burns, Trauma, and Critical Care, Department of Surgery, University of Texas-Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9158, USA.
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15
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Abstract
Intravenous fluid management of trauma patients is fraught with complex decisions that are often complicated by coagulopathy and blood loss. This review discusses the fluid management in trauma patients from the perspective of the developing world. In addition, the article describes an approach to specific circumstances in trauma fluid decision-making and provides recommendations for the resource-limited environment.
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16
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Spinal-induced hypotension: Incidence, mechanisms, prophylaxis, and management: Summarizing 20 years of research. Best Pract Res Clin Anaesthesiol 2017. [DOI: 10.1016/j.bpa.2017.01.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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17
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Sánchez-Sánchez M, Garcia-de-Lorenzo A, Cachafeiro L, Herrero E, Asensio MJ, Agrifoglio A, Flores E, Estebanez B, Extremera P, Iglesias C, Martinez J. Acute kidney injury in critically burned patients resuscitated with a protocol that includes low doses of Hydroxyethyl Starch. ANNALS OF BURNS AND FIRE DISASTERS 2016; 29:183-188. [PMID: 28149246 PMCID: PMC5266234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 07/04/2016] [Indexed: 06/06/2023]
Abstract
Acute kidney injury (AKI) is an important complication in burn patients. Recently, it has been recommended that hydroxyethyl starch (HES) be avoided in burn patients because it increases the incidence of AKI. Our purpose was to study incidence of AKI in critically ill burn patients resuscitated with Ringer's solution and supplements of HES. We conducted an observational study of 165 patients admitted to the critical care burn unit (with 30 ± 15% TBSA burned). The main outcome measures were incidence of AKI, contributions of colloids and crystalloids, various severity scores, comorbidities, complications and mortality. According to the RIFLE criteria, 10 (6.1%) patients presented with Risk, 11 (6.7%) presented with Injury and 11 (6.7%) presented with Failure. According to the AKIN criteria, 9.7% presented stage I, 3% stage II and 10.3% stage III. Replacement therapy (RRT) was performed in 15 patients (9.1%), but in 6 of them RRT was employed in the final stages of multi-organ failure. The incidence of AKI in severe burn patients is high according to the RIFLE or AKIN criteria and these patients experience more complications and higher mortality. Our study suggests that the use of HES in low doses in the burn resuscitation phase does not cause more AKI than resuscitation without HES, but further evaluation is required. Further studies should be conducted.
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Affiliation(s)
- M. Sánchez-Sánchez
- Department of Intensive Care Medicine, University Hospital La Paz-Carlos III/IdiPAZ, Madrid, Spain
| | - A. Garcia-de-Lorenzo
- Department of Intensive Care Medicine, University Hospital La Paz-Carlos III/IdiPAZ, Madrid, Spain
| | - L. Cachafeiro
- Department of Intensive Care Medicine, University Hospital La Paz-Carlos III/IdiPAZ, Madrid, Spain
| | - E. Herrero
- Department of Intensive Care Medicine, University Hospital La Paz-Carlos III/IdiPAZ, Madrid, Spain
| | - MJ. Asensio
- Department of Intensive Care Medicine, University Hospital La Paz-Carlos III/IdiPAZ, Madrid, Spain
| | - A. Agrifoglio
- Department of Intensive Care Medicine, University Hospital La Paz-Carlos III/IdiPAZ, Madrid, Spain
| | - E. Flores
- Department of Intensive Care Medicine, University Hospital La Paz-Carlos III/IdiPAZ, Madrid, Spain
| | - B. Estebanez
- Department of Intensive Care Medicine, University Hospital La Paz-Carlos III/IdiPAZ, Madrid, Spain
| | - P. Extremera
- Department of Intensive Care Medicine, University Hospital La Paz-Carlos III/IdiPAZ, Madrid, Spain
| | - C. Iglesias
- Department of Plastic Surgery, University Hospital La Paz-Carlos III/IdiPAZ, Madrid, Spain
| | - J.R.. Martinez
- Department of Plastic Surgery, University Hospital La Paz-Carlos III/IdiPAZ, Madrid, Spain
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18
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Henschke A, Lee R, Delaney A. Burns management in ICU: Quality of the evidence: A systematic review. Burns 2016; 42:1173-82. [PMID: 27268108 DOI: 10.1016/j.burns.2016.02.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 02/23/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND The objective of this study was to assess the quality of readily available evidence regarding critical care aspects of the management of patients with severe burn injuries. METHOD PUBMED, EMBASE, Cochrane Databases and bibliographies of included studies and burns review articles were searched from inception of databases to end of February 2015. We included systematic reviews, randomised controlled trials (RCTs) and cohort studies with concurrent controls on the topics of (a) fluid resuscitation (b) analgesia (c) haemodynamic monitoring and targets (d) ventilation (e) blood transfusion. The quality of the studies was assessed using validated tools. RESULTS Fifty six studies fulfilled the inclusion criteria. Twenty three on fluid resuscitation, 22 on analgesia, nine on haemodynamic monitoring and two on ventilation. No studies were found on blood transfusion practice. There were ten systematic reviews, 38 RCTs and eight cohort studies with concurrent controls. The majority of studies were single centre trials with small numbers of patients, surrogate outcomes and high risk of bias. CONCLUSIONS There is very little high quality evidence to guide clinical practice in early management of the severely burnt patient. Eleven of 56 studies found in our search of critical care topics were of good methodological quality with low risk of bias.
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Affiliation(s)
- Alice Henschke
- Intensive Care Unit, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia.
| | - Richard Lee
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, NSW 2065, Australia; Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, Australia.
| | - Anthony Delaney
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, NSW 2065, Australia; Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, Australia
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19
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First resuscitation of critical burn patients: progresses and problems. Med Intensiva 2016; 40:118-24. [PMID: 26873418 DOI: 10.1016/j.medin.2015.12.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 12/06/2015] [Accepted: 12/12/2015] [Indexed: 11/24/2022]
Abstract
Currently, the aim of the resuscitation of burn patients is to maintain end-organ perfusion with fluid intake as minimal as possible. To avoid excess intake, we can improve the estimation using computer methods. Parkland and Brooke are the commonly used formulas, and recently, a new, an easy formula is been used, i.e. the 'Rule of TEN'. Fluid resuscitation should be titrated to maintain the urine output of approximately 30-35 mL/h for an average-sized adult. The most commonly used fluids are crystalloid, but the phenomenon of creep flow has renewed interest in albumin. In severely burn patients, monitoring with transpulmonary thermodilution together with lactate, ScvO2 and intraabdominal pressures is a good option. Nurse-driven protocols or computer-based resuscitation algorithms reduce the dependence on clinical decision making and decrease fluid resuscitation intake. High-dose vitamin C, propranolol, the avoidance of excessive use of morphine and mechanical ventilation are other useful resources.
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20
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Coetzee A, Dyer RA, James MFM, Joubert IA, Levin A, Piercy J, Swanevelder J, Van der Merwe W. Evidence-based approach to the use of starch-containing intravenous fluids: an official response by two Western Cape University Hospitals. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2014. [DOI: 10.1080/22201173.2013.10872922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- A Coetzee
- 1Department of Anesthesiology and Critical Care, University of Stellenbosch and Tygerberg Hospital
| | - RA Dyer
- 2Department of Anaesthesia, University of Cape Town and Groote Schuur Hospital
| | - MFM James
- 2Department of Anaesthesia, University of Cape Town and Groote Schuur Hospital
| | - IA Joubert
- 3Department of Critical Care, University of Cape Town and Groote Schuur Hospital Authors in alphabetical order
| | - A Levin
- 1Department of Anesthesiology and Critical Care, University of Stellenbosch and Tygerberg Hospital
| | - J Piercy
- 3Department of Critical Care, University of Cape Town and Groote Schuur Hospital Authors in alphabetical order
| | - J Swanevelder
- 2Department of Anaesthesia, University of Cape Town and Groote Schuur Hospital
| | - W Van der Merwe
- 1Department of Anesthesiology and Critical Care, University of Stellenbosch and Tygerberg Hospital
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21
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James MFM. Volume therapy in trauma and neurotrauma. Best Pract Res Clin Anaesthesiol 2014; 28:285-96. [PMID: 25208963 DOI: 10.1016/j.bpa.2014.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 06/25/2014] [Accepted: 06/27/2014] [Indexed: 11/30/2022]
Abstract
Volume therapy in trauma should be directed at the restitution of disordered physiology including volume replacement to re-establishment of tissue perfusion, correction of coagulation deficits and avoidance of fluid overload. Recent literature has emphasised the importance of damage control resuscitation, focussing on the restoration of normal coagulation through increased use of blood products including fresh frozen plasma, platelets and cryoprecipitate. However, once these targets have been met, and in patients not in need of damage control resuscitation, clear fluid volume replacement remains essential. Such volume therapy should include a balance of crystalloids and colloids. Pre-hospital resuscitation should be limited to that required to sustain a palpable radial artery and adequate mentation. Neurotrauma patients require special consideration in both pre-hospital and in-hospital management.
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Affiliation(s)
- M F M James
- Department of Anaesthesia, University of Cape Town, Anzio Road, Observatory, Cape Town, Western Cape 7925, South Africa.
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22
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23
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Arulkumaran N, Corredor C, Hamilton MA, Ball J, Grounds RM, Rhodes A, Cecconi M. Cardiac complications associated with goal-directed therapy in high-risk surgical patients: a meta-analysis. Br J Anaesth 2014; 112:648-59. [PMID: 24413429 DOI: 10.1093/bja/aet466] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Patients with limited cardiopulmonary reserve are at risk of mortality and morbidity after major surgery. Augmentation of oxygen delivery index (DO2I) with i.v. fluids and inotropes (goal-directed therapy, GDT) has been shown to reduce postoperative mortality and morbidity in high-risk patients. Concerns regarding cardiac complications associated with fluid challenges and inotropes may prevent clinicians from performing GDT in patients who need it most. We hypothesized that GDT is not associated with an increased risk of cardiac complications in high-risk, non-cardiac surgical patients. We performed a systematic search of Medline, Embase, and CENTRAL databases for randomized controlled trials (RCTs) of GDT in high-risk surgical patients. Studies including cardiac surgery, trauma, and paediatric surgery were excluded. We reviewed the rates of all cardiac complications, arrhythmias, myocardial ischaemia, and acute pulmonary oedema. Meta-analyses were performed using RevMan software. Data are presented as odds ratios (ORs), [95% confidence intervals (CIs)], and P-values. Twenty-two RCTs including 2129 patients reported cardiac complications. GDT was associated with a reduction in total cardiovascular (CVS) complications [OR=0.54, (0.38-0.76), P=0.0005] and arrhythmias [OR=0.54, (0.35-0.85), P=0.007]. GDT was not associated with an increase in acute pulmonary oedema [OR=0.69, (0.43-1.10), P=0.12] or myocardial ischaemia [OR=0.70, (0.38-1.28), P=0.25]. Subgroup analysis revealed the benefit is most pronounced in patients receiving fluid and inotrope therapy to achieve a supranormal DO2I, with the use of minimally invasive cardiac output monitors. Treatment of high-risk surgical patients GDT is not associated with an increased risk of cardiac complications; GDT with fluids and inotropes to optimize DO2I during early GDT reduces postoperative CVS complications.
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Affiliation(s)
- N Arulkumaran
- Department of Intensive Care Medicine, St George's Hospital, London SW17 0QT, UK
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Béchir M, Puhan MA, Fasshauer M, Schuepbach RA, Stocker R, Neff TA. Early fluid resuscitation with hydroxyethyl starch 130/0.4 (6%) in severe burn injury: a randomized, controlled, double-blind clinical trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R299. [PMID: 24365167 PMCID: PMC4057504 DOI: 10.1186/cc13168] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 12/02/2013] [Indexed: 01/28/2023]
Abstract
Introduction There are limited data on the efficacy of early fluid resuscitation with third-generation hydroxyethyl starch (HES 130) in burn injury. Adverse effects of HES on survival and organ function have been reported. Methods In this randomized, controlled, double-blind trial, 48 patients with severe burn injury were assigned to receive either lactated Ringer’s solution plus 6% HES 130/0.4 in a ratio of 2:1 or lactated Ringer’s solution with no colloid supplement for the first 72 hours. Primary outcome parameter was the group difference of administered total fluid from intensive care unit (ICU) admission up to day 3. Secondary outcomes included kidney and lung injury and failure, length of stay, and mortality. Results Three-day totals of administered resuscitation fluid (medians) were 21,190 mL in the lactated Ringer’s group and 19,535 mL in the HES group (HES: −1,213 mL; P = 0.39). Creatinine levels from day 1 to 3 (HES: +0.4 μmol/L; 95% confidence interval (CI) −18.7 to 19.5; P = 0.97) and urinary outputs from day 1 to 3 (HES: −58 mL; 95% CI −400 to 283; P = 0.90) were not different. Six patients in each group developed acute respiratory distress syndrome (ARDS) (risk ratio 0.96; 95% CI 0.35 to 2.64; P = 0.95). Length of ICU stay (HES vs. lactated Ringer’s: 28 vs. 24 days; P = 0.80) and length of hospital stay (31 vs. 29 days; P = 0.57) were similar. Twenty-eight-day mortality was 4 patients in each group (risk ratio 0.96; 95% CI 0.27 to 4.45; P = 0.95), and in-hospital mortality was 8 in the HES group vs. 5 patients in the lactated Ringer’s group (hazard ratio 1.86; 95% CI 0.56 to 6.19; P = 0.31). Conclusions There was no evidence that early fluid resuscitation with balanced HES 130/0.4 (6%) in addition to lactated Ringer’s solution would lead to a volume-sparing effect in severe burn injury. Together with the findings that early renal function, incidence of ARDS, length of stay, and mortality were not negatively influenced by HES in this setting, balanced HES 130/0.4 (6%) plus lactated Ringer’s solution could not be considered superior to lactated Ringer’s solution alone. Trial registration ClinicalTrials.gov NCT01012648
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Abstract
In 1984, Col. Ronald Bellamy launched a worldwide challenge to develop a new resuscitation fluid to aid survival after catastrophic blood loss on the battlefield. In 1996, after careful compromise among need, cube weight and efficacy, the US military and later coalition forces adopted 6% hetastarch (HES) fluids for early resuscitation. In the intervening years, evidence has amassed indicating that the HES fluids may not be safe, and in June 2013 the US Food and Drug Administration issued a warning that HES solutions should not be used to treat patients with hypovolaemia or the critically ill. We review the unique challenges of early battlefield resuscitation, why the 'Bellamy challenge' remains open and discuss a number of forward-looking strategies that may help to solve the problem. The first two pillars of resuscitation that we believe have not been adequately addressed are rescuing and stabilising the heart (and brain) and the vascular system. The 'ideal' resuscitation fluid needs to nurture the heart and body slowly back to health, and not 'shock' it a second time with unnatural colloids or large volumes of unphysiological saline-based solutions.
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Affiliation(s)
- Geoffrey P Dobson
- Department of Physiology and Pharmacology, Heart and Trauma Research Laboratory, James Cook University, Townsville, Queensland, Australia
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26
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Abstract
PURPOSE OF REVIEW To summarize and highlight recent advances in the understanding and management of burn injuries. RECENT FINDINGS The review focuses on topics which are of particular relevance for critical care practitioners involved in burn care: resuscitation, management of infection and sepsis, epidemiology and outcome, and organization and costs of burn care. SUMMARY While being the mainstay of early survival in burn victims, various aspects of burn resuscitation are still contentious and highlighted in this review. In particular, several strategies to overcome the repeatedly observed 'fluid creep' in burn patients are discussed, including the use of computerized resuscitation algorithms and the administration of colloids. Sepsis and multiorgan failure have become the major causes of death in patients surviving the initial phase of burn shock. Various aspects of sepsis management are reviewed, amongst which diagnosis, antibiotic treatment and prophylaxis. Recent epidemiologic data allow to identify risk factors associated with mortality as these are potentially amenable to targeted prevention and therapy. Examples are acute kidney injury and sepsis. The overview is completed by recent findings on organization and costs of burn care, including the adherence to referral criteria and the main determinants of cost.
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Cecconi M, Corredor C, Arulkumaran N, Abuella G, Ball J, Grounds RM, Hamilton M, Rhodes A. Clinical review: Goal-directed therapy-what is the evidence in surgical patients? The effect on different risk groups. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:209. [PMID: 23672779 PMCID: PMC3679445 DOI: 10.1186/cc11823] [Citation(s) in RCA: 221] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Patients with limited cardiac reserve are less likely to survive and develop more complications following major surgery. By augmenting oxygen delivery index (DO2I) with a combination of intravenous fluids and inotropes (goal directed therapy (GDT)), postoperative mortality and morbidity of high-risk patients may be reduced. However, although most studies suggest that GDT may improve outcome in high-risk surgical patients, it is still not widely practiced. We set out to test the hypothesis that GDT results in greatest benefit in terms of mortality and morbidity in patients with the highest risk of mortality and have undertaken a systematic review of the current literature to see if this is correct. We performed a systematic search of Medline, Embase and CENTRAL databases for randomized controlled trials (RCTs) and reviews of GDT in surgical patients. To minimize heterogeneity we excluded studies involving cardiac, trauma, and paediatric surgery. Extremely high risk, high risk and intermediate risks of mortality were defined as >20%, 5 to 20% and <5% mortality rates in the control arms of the trials, respectively. Meta analyses were performed and Forest plots drawn using RevMan software. Data are presented as odd ratios (OR; 95% confidence intervals (CI), and P-values). A total of 32 RCTs including 2,808 patients were reviewed. All studies reported mortality. Five studies (including 300 patients) were excluded from assessment of complication rates as the number of patients with complications was not reported. The mortality benefit of GDT was confined to the extremely high-risk group (OR = 0.20, 95% CI 0.09 to 0.41; P < 0.0001). Complication rates were reduced in all subgroups (OR = 0.45, 95% CI 0.34 to 0.60; P < 0.00001). The morbidity benefit was greatest amongst patients in the extremely high-risk subgroup (OR = 0.27, 95% CI 0.15 to 0.51; P < 0.0001), followed by the intermediate risk subgroup (OR = 0.43, 95% CI 0.27 to 0.67; P = 0.0002), and the high-risk subgroup (OR 0.56, 95% CI 0.36 to 0.89; P = 0.01). Despite heterogeneity in trial quality and design, we found GDT to be beneficial in all high-risk patients undergoing major surgery. The mortality benefit of GDT was confined to the subgroup of patients at extremely high risk of death. The reduction of complication rates was seen across all subgroups of GDT patients.
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Abstract
PURPOSE OF REVIEW The examination of the recent literature aimed at analysing the most recent data that could affect decisions regarding the use of colloids in trauma resuscitation. RECENT FINDINGS Animal data have generally shown a beneficial effect of colloids in trauma resuscitation, with improvements in capillary leak demonstrated in lung, intestine and brain. In most studies, hydroxyethyl starch resuscitation was more effective than crystalloid and decreased markers of inflammatory processes were observed. Brain injury in animals was attenuated with colloids. In uncontrolled haemorrhage, resuscitation with colloid increased bleeding and mortality.Human studies have also failed to confirm the suggestion that albumin resuscitation may be associated with a worse outcome in head injury. However, there is a strong suggestion that aggressive prehospital resuscitation, particularly with colloid, may be harmful. Studies in burns have consistently shown an improvement in the tendency to fluid overload with the inclusion of colloid in the resuscitation strategy, but so far no outcome benefit has been shown.Two studies of general trauma resuscitation have shown apparent benefit from the use of HES in early resuscitation with reductions in mortality and in renal injury. SUMMARY Recent trauma studies provide ongoing, but not conclusive, evidence of a benefit from colloid resuscitation in trauma.
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Struck MF, Illert T, Schmidt T, Reichelt B, Steen M. Secondary abdominal compartment syndrome in patients with toxic epidermal necrolysis. Burns 2012; 38:562-7. [DOI: 10.1016/j.burns.2011.10.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Revised: 10/06/2011] [Accepted: 10/12/2011] [Indexed: 10/15/2022]
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30
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Endorf FW, Dries DJ. Burn resuscitation. Scand J Trauma Resusc Emerg Med 2011; 19:69. [PMID: 22078326 PMCID: PMC3226577 DOI: 10.1186/1757-7241-19-69] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Accepted: 11/11/2011] [Indexed: 01/18/2023] Open
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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Affiliation(s)
- Frederick W Endorf
- The Burn Center, Regions Hospital, 640 Jackson Street, St, Paul, MN 55101, USA.
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