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Fluidmanagementinmajorburninjuries

Fluidmanagementinmajorburninjuries
MehmetHaberal,A.EbruSakalliogluAbali,andHamdiKarakayali

Abstract
Itisawidelyacceptedfactthatseverefluidlossisthegreatestproblemfacedfollowingmajorburninjuries.Therefore,effectivefluid
resuscitationisoneofthecornerstonesofmodernburntreatment.Theaimofthisarticleistoreviewthecurrentapproachesavailablefor
moderntrendsinfluidmanagementformajorburnpatients.Asthesecurrentapproachesarebasedonvariousexperiencesalloverthe
world,theknowledgeisessentialtoimprovethestatusofthispatientgroup.
Keywords:Severeburns,burnshock,fluidresuscitation

INTRODUCTION
Appropriatefluidmanagementofmajorburnsdirectlyimprovesthesurvivalratesofburnpatients.Despitethevastarrayofexperience,
therearestillcontroversiesregardingthebesttypeoffluidmanagementinmajorburnsinthefirst24hoursafterinjury.Currently,fluid
resuscitationformulaswhichweredevelopedover30yearsago,havebeenacceptedasguidelines,butongoingstudiesarefocussedonthe
growingconcernsthatburnpatientsarebeingoverorunderfluidresuscitated,oftenwithindistinctandinappropriateendpointtargets.[1]
Theaimofthisarticleistoreviewthecurrentapproachesavailableformoderntrendsinfluidmanagementformajorburnpatients.

Pathophysiologyofburnshock
Majorburninjuriesresultinanareaofnecroticzone,beneaththisliesthezoneofstasisandresultsinreleaseofinflammatorymediators
(e.g.histamine,prostaglandins,thromboxane,nitricoxide)thatincreasecapillarypermeabilityandleadtolocalisedburnwoundoedema.
[2,3]Thisoccurswithinminutestohoursafterinjuryandisfollowedbytheproductionofhighlyreactiveoxygenspecies(ROS)during
reperfusionofischaemictissues.[46]ROSaretoxiccellmetabolitesthatincludeoxygenfreeradicalsandcauselocalcellularmembrane
dysfunctionandpropagateanimmuneresponse.Subsequently,thedecreaseincellulartransmembranepotentialisobservedinbothinjured
anduninjuredtissue.CellularmembranedysfunctionleadstothedistributionofsodiumATPaseactivity.Assuch,burnshock,whichisa
combinationofdistributive,hypovolemicandcardiogenicshock,beginsatthecellularlevel.DisruptionofsodiumATPaseactivity
presumablycausesanintracellularsodiumshiftwhichcontributestohypovolemiaandcellularoedema.[2,3]Heatinjuryalsoinitiatesthe
releaseofinflammatoryandvasoactivemediators.Thesemediatorsareresponsibleforlocalvasoconstriction,systemicvasodilation,and
increasedtranscapillarypermeability.Increaseintranscapillarypermeabilityresultsinarapidtransferofwater,inorganicsolutes,and
plasmaproteinsbetweentheintravascularandinterstitialspaces.Subsequently,intravascularhypovolemiaandhaemoconcentration
developandmaximumlevelsarereachedwithin12hoursafterinjury.Thesteadyintravascularfluidlossduetothesesequencesofevents
requiressustainedreplacementofintravascularvolumeinordertopreventendorganhypoperfusionandischaemia.[7,8]Reducedcardiac
outputisahallmarkinthisearlypostinjuryphase.Thereductionincardiacoutputisthecombinedresultofdecreasedplasmavolume,
increasedafterloadanddecreasedcardiaccontractility,inducedbycirculatingmediators.[9]
Asmentionedabove,duringthisearlyperiodinwhichvariouspathopysiologicalchangestakeplace,appropriatefluidmanagementplaysa
fundamentalrole.

FLUIDMANAGEMENT
Thegoaloffluidmanagementinmajorburninjuriesistomaintainthetissueperfusionintheearlyphaseofburnshock,inwhich
hypovolemiafinallyoccursduetosteadyfluidextravasationfromtheintravascularcompartment.

Currentapproachestofluidmanagement:Optimalrouteandnecessityofformalresuscitation
Burninjuriesoflessthan20%areassociatedwithminimalfluidshiftsandcangenerallyberesuscitatedwithoralhydration,exceptin
casesoffacial,handandgenitalburns,aswellasburnsinchildrenandtheelderly.Asthetotalbodysurfacearea(TBSA)involvedinthe
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burnapproaches1520%,thesystemicinflammatoryresponsesyndromeisinitiatedandmassivefluidshifts,whichresultinburnoedema
andburnshock,canbeexpected.Therouteforfluidmanagementisofimportanceintheseinstances.Althoughenteralresuscitationhas
beenattemptedforevenmajorburninjuries,vomitinghasbeenalimitingproblemforthisroute.[10]Currentrecommendationsareto
initiateformalintravascularfluidresuscitationwhenthesurfaceareaburnedisgreaterthan20%.Inotherwords,forpatientswithmajor
burns,theformalintravascularrouteisthepreferredchoice,exceptinmasscasualtysituationswhereaccesstomedicalcareislimited,
andprovidedthegastrointestinaltractisuninjured.Insuchcircumstances,enteralresuscitationwithbalancedsaltsolutionscanbe
initiated.[10,11]
Formalfluidresuscitationformulaswhichwereintroducedinthe1960sand1970shavebeenusedeffectivelyallovertheworld.[12]The
Parklandformula,whichcalculatestheamountoffluidrequiredtoresuscitateapatientbasedonpercentageburn,remainsthemost
commonlyusedformulaintheUnitedKingdomandIrelandwhere78%ofallburnunitsuseit.[13]Similarly,arecentsurveyofburn
unitsintheUnitedStatesandCanadarevealedthat78%ofunitsusetheParklandformulatoestimateresuscitationvolumes.[14]
Incentresexperiencedwithpaediatricburns,formulaswhicharesufficientforpaediatricfluidmanagementhavebeendeveloped,asthe
bodysurfaceareatomassratioinchildrenishigherthaninadultsandhepaticglycogenstoresinyoungchildrenaredepletedafter1214
hoursoffasting.[15,16]
Baxterfoundthatpatientswithinhalationinjuryrequiredadditionalfluidwhencomparedtoothers.[17]Pruittreportedthatpatientswith
electricalburnsandthoseinwhomresuscitationwasdelayedroutinelyalsorequiredadditionalfluid.[18]However,thereisgrowing
evidencethatotherpatientswithmajorburnsalsoreceivefarmorefluidthantheParklandformularecommends.[19,20]Theexplanation
ofthisexperienceisunclear,butlargevolumesofresuscitationfluidareassociatedwithincreasedriskofinfectiouscomplications,acute
respiratorydistresssyndrome(ARDS),abdominalcompartmentsyndromeanddeath.Pruitthascoinedthetermfluidcreeptodescribe
thisphenomenon.[21]

Formulasusedforfluidmanagementinmajorburns
ThemostcommonlyusedformulasaretheParkland,modifiedParkland,Brooke,modifiedBrooke,EvansandMonafosformulas.These
formulastakeintoaccountthebodyweightandtheburnsurfacearea.[22]Severalformulaswhichwerespecificallydevelopedfor
childrenbypaediatricburncentreshaveachievedequalpopularity.Givenbelowaretheformulasthathavebeendefinedandmodified
whileinuse:[17,2334]

Parklandformula
a. Initial24hours:Ringerslactated(RL)solution4ml/kg/%burnforadultsand3ml/kg/%burnforchildren.RLsolutionisadded
formaintenanceforchildren:
4ml/kg/hourforchildrenweighing010kg
40ml/hour+2ml/hourforchildrenweighing1020kg
60ml/hour+1ml/kg/hourforchildrenweighing20kgorhigher
Thisformularecommendsnocolloidintheinitial24hours.
b. Next24hours:Colloidsgivenas2060%ofcalculatedplasmavolume.Nocrystalloids.Glucoseinwaterisaddedinamounts
requiredtomaintainaurinaryoutputof0.51ml/hourinadultsand1ml/hourinchildren.

ModifiedParklandformula
a. Initial24hours:RL4ml/kg/%burn(adults)
b. Next24hours:Begincolloidinfusionof5%albumin0.31ml/kg/%burn/16perhour

Brookeformula
a. Initial24hours:RLsolution1.5ml/kg/%burnpluscolloids0.5ml/kg/%burnplus2000mlglucoseinwater
b. Next24hours:RL0.5ml/kg/%burn,colloids0.25ml/kg/%burnandthesameamountofglucoseinwaterasinthefirst24hours
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ModifiedBrooke
a. Initial24hours:Nocolloids.RLsolution2ml/kg/%burninadultsand3ml/kg/%burninchildren
b. Next24hours:Colloidsat0.30.5ml/kg/%burnandnocrystalloidsaregiven.Glucoseinwaterisaddedintheamountsrequired
tomaintaingoodurinaryoutput.

Evansformula(1952)
a. First24hours:Crystalloids1ml/kg/%burnpluscolloidsat1ml/kg/%burnplus2000mlglucoseinwater
b. Next24hours:Crystalloidsat0.5ml/kg/%burn,colloidsat0.5ml/kg/%burnandthesameamountofglucoseinwaterasinthe
first24hours

Monafoformula
Monaforecommendsusingasolutioncontaining250mEqNa,150mEqlactateand100mEqCl.Theamountisadjustedaccordingtothe
urineoutput.Inthefollowing24hours,thesolutionistitratedwith1/3normalsalineaccordingtourinaryoutput.

Formulasdevelopedforchildren
Theformulasdevelopedforchildren[35]areasfollows.

Shrinerscincinnati
Initial24hours:
a. Forolderchildren:
LactatedRingers(RL)solution4ml/kg/%burn+1500ml/m2total(1/2oftotalvolumeover8hours,restofthetotalvolume
duringthefollowing16hours)
b. Foryoungerchildren:
4ml/kg/%burn+1500ml/m2total,inthefirst8hours
RLsolution+50mEqNaHCO3
RLsolutioninthesecond8hours
5%albumininLRsolutioninthethird8hours

Galveston
Initial24hours:RL5000ml/m2burn+2000ml/m2total(1/2oftotalvolumeover8hours,restofthetotalvolumein16hours)

Choiceoffluid
Theidealburnresuscitationistheonethateffectivelyrestoresplasmavolume,withnoadverseeffects.Isotoniccrystalloids,hypertonic
solutionsandcolloidshavebeenusedforthispurpose,buteverysolutionhasitsadvantagesanddisadvantages.Noneofthemisideal,and
noneissuperiortoanyoftheothers.

Isotoniccrystalloids
Crystalloidsarereadilyavailableandcheaperthansomeoftheotheralternatives.RLsolution,Hartmannsolution(asolutionsimilarto
RLsolution)andnormalsalinearecommonlyused.Therearesomeadverseeffectsofthecrystalloids:highvolumeadministrationof
normalsalineproduceshyperchloremicacidosis,[36]RLincreasestheneutrophilactivationafterresuscitationforhaemorrhageorafter
infusionwithouthaemorrhage.[37] DlactateinRLsolutioncontainingaracemicmixtureofthe Dlactateand Llactateisomershasbeen
foundtoberesponsibleforincreasedproductionofROS.[38]RLusedinthemajorityofhospitalscontainsthismixture.Anotheradverse
effectthathasbeendemonstratedisthatcrystalloidshaveasubstantialinfluenceoncoagulation.Recentstudieshavedemonstratedthatin
vivodilutionwithcrystalloids(independentofthetypeofthecrystalloid)resultedinahypercoagulablestate.[3941]
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Despitetheseadverseeffects,themostcommonlyusedfluidforburnresuscitationintheUKandIrelandisHartmannssolution(adult
units76%,paediatricunits75%).[13]AnotherstudyhasrevealedthatRListhemostpopulartypeoffluidinburnunitslocatedinUSA
andCanada.[14]InourburncentreslocatedintwodifferentregionsofTurkey(Adanainthesouth,andKonyaandAnkarainthemore
centralzone),theinitialelectrolytemeasurementsandpotassiumlevelsguideonthechoiceoffluidtype,butwepreferRLsolution
throughtheinitialpostburn24hours.[42]

Hypertonicsolutions
Theimportanceofsodiumionsinthepathophysiologyofburnshockhasbeenemphasisedinsomepreviousstudies.Thesodiumshiftinto
thecellresultsincellularoedemaandhypoosmolarintravascularfluidvolume.Rapidinfusionofhypertonicsodiumsolutionshasproven
toincreasetheplasmaosmolalityandlimitcellularoedema.Usingsolutionswithaconcentrationof250mEq/l,Moyeretal.wereableto
achieveeffectivephysiologicalresuscitationwithalowertotalvolumewhencomparedtoisotonicsolutionsintheinitial24hours.[28,29]
ButHuangetal.foundthatafter48hourscumulativefluidloadsofthepatientgroupswhoweretreatedwithhypertonicsolutionsorRL
weresimilar.Theyalsodemonstratedthathypertonicsodiumsolutionresuscitationwasassociatedwithanincreasedincidenceofrenal
failureanddeath.[43]Currently,hypertonicfluidresuscitationseemstobeanattractivechoiceforitstheoreticallyphysiologicalfunction,
buttheneedforclosemonitoringandtheriskofhypernatraemiaandrenalfailurearethemainfocusofdebates.

Colloids
Leakageandaccumulationofplasmaproteinsoutsidethevascularcompartmentcontributessubstantiallytooedemaformation.Thetime
atwhichtheproteinleakagestopshasbeenfoundtodifferbyvariousauthors.Baxtersearlyworkshowedthatcapillaryleakmaypersist
for24hourspostburn.[17]Carvajal,[44]asreportedbyCocksetal.,foundthatalbuminextravasationstops8hoursafterinjury.
AccordingtoDemling,capillaryleakageofproteinceasessignificantlyabout12hoursfollowingtheburn.[45]Vlachouetal.recently
showedthatendothelialdysfunctionandcapillaryleakagearepresentwithin2hoursafterburninjuryandlastforamedianof5hours,
muchshorterthanthatpreviouslydescribed.[46]Colloids,ashyperosmoticsolutions,areusedtoelevatetheintravascularosmolalityand
tostoptheextravasationofthecrystalloids.Therefore,controversyfocussesontheadministrationofproteinbasedcolloids:whetherto
providethemornot,whichsolutionstouse,andwhentobegin.Somestudieshaveshownthatcolloidsprovidelittleclinicalbenefitwhen
giveninthefirst24hourspostburnandmayhavesomedetrimentaleffectsonpulmonaryfunction.[47,48]Thecolloidversuscrystalloid
debateintheliteraturehasreflectedabalanceofopinionmanyburncliniciansavoidtheuseofcolloidsintheearlypostburnperiod.
However,Cohraneetal.haverecentlydemonstrateddecreasedmortalityinpatientswhoreceivedalbumin.Additionally,someburn
cliniciansreportedsuccessfulresuscitationincludingalbuminintheearlypostburnperiodwithdecreasedvolumerequirementsandlow
weightgaincomparedwithpurecrystalloidresuscitation.[49,50]OMaraetal.demonstrateddecreasedfluidrequirementsandlower
intraabdominalpressureswithuseoffreshfrozenplasmainthefirst48hoursfollowinglargeburns(>50%).[51]Mostrecently,
Lawrenceetal.havefoundthattheadditionofcolloidtoParklandformularapidlyreducedhourlyfluidrequirements,restorednormal
resuscitationratios,andamelioratedfluidcreep.[52]
InourburncentreslocatedintwodifferentregionsofTurkey(Adanainthesouth,andKonyaandAnkarainthemorecentralzone),we
avoidusinghumanalbuminsolutionunlessbloodalbuminlevelsareunder2g/dl.Ifnecessary,albuminadministrationisstartedatleast5
hoursaftertheinjury.Thepreferreddoseofalbuminafterthefirst24hoursis0.51g/kg/%burn.Inthefollowingdays,thealbumin
supportiscontinueduntilthebloodlevelofalbuminis3g/dl.Butdecisionsforeachindividualpatientaremadeaccordingtocurrentdata
frommonitoringparameterssuchasexistenceofoedema,urineoutput,centralvenouspressure,pulserate,pulseoximetry,andsoon.
[42,53]

Considerationsforeffectiveresuscitation
Antioxidanttherapy ThemembranelipidperoxidationandROSarethemaincomponentsofburnshock.Inaddition,itiswellknownthatthe
changedpermeabilityofleukocytemembranesduetothermalinjurycausesanincreaseinserumenzymelevels.Assuch,ithasbeen
assumedthatmembranestabilisingagentssuchaszinc,seleniumandvitaminEcouldhelpintherecoveryofburnedpatients.[55]
Antioxidanttherapyhasbeentheinterestofvariousstudies.[54,55]Inaninvitrostudy,wefoundthattheadditionofthemembrane
stabilisingvitaminE,zincandseleniumpreventedtheincreaseofacidphosphatase(amarkeroflysosomalenzymeactivity)significantly
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(P<0.01).[55]Inaprospectiveclinicaltrialinwhichantioxidantascorbicacidwasadministeredtomajorburnpatients,theascorbic
acidgrouprequired45%lessfluidwhencomparedtothecontrolgroup.[56]Recently,BiesalskiandMcGregorreviewedtheascorbic
acidtreatmentincriticalcarepatients,includingthosewithmajorburns.Theyconcludedthatasignificantbodyofpharmacological
evidenceandsoundpreliminaryclinicalevidencesupportsthebiologicalfeasibilityofusingtheexemplaryantioxidant,vitaminC,inthe
treatmentofcriticallyillpatients.[57]
Opioidsandfluidresuscitation Opioidshavebeenthemainstayofpaincontrolinburnpatients.Thesedrugshaveasignificanteffectonthe
cardiovascularsystem.Useofthesedrugsisassociatedwithdecreasedbloodpressure.Inarecentstudy,Sullivanetal.comparedburn
patientgroupstreatedin19751979withsimilarpatientstreatedin2000.[20]Thiscomparisonemphasisedthattheopioiddosage
correlatedwiththefluidrequirementsinthesepatientsandfluidcreepwasaconsequenceoftheincreasinguseofnarcoticsduringinitial
burncare.
Monitoring Allresuscitationformulasaremeanttoserveasguidesonly.Consequently,fluidmanagementinmajorburnsshouldbe
monitoredusingclinicalandlaboratoryparameters.Insevereburns,ifperipheralintravenousaccesscannotbeachieved,centralvenous
catheterisationorsurgicalvascularaccessmustbeconsidered.Afterthevenouslineisinplace,aurinarycatheterandanasogastrictube
shouldbeinsertedtocontrolandmonitorthepatientsfluidbalance.[58]Hypotensionisalatefindinginburnshockso,pulserateisa
muchmoresensitivemonitoringparameterthanarterialbloodpressure.Fluidshiftsarerapidduringtheearlyperiodofburnshock(2472
hours)so,serialdeterminationsofhaematocrit,serumelectrolytes,osmolality,calcium,glucose,andalbuminareessentialtohelp
determinetheappropriatemethodoffluidreplacement.Thebestsingleindicatoristheurineoutputonanhourlybasis.Inaddition,major
burnpatientsmustbefullymonitoredwithcontinuouselectrocardiography,continuousrespiratoryrateandpulseoximetry,centralvenous
pressureline,arterialline,foleycatheter,andtemperatureprobes.Inunstable,severelyburnedpatientsandventilatedpatients,
capnometry,pulmonaryarterialcatheteroroesophagealDopplerandDopplermonitorforcompartmentsyndromesarerecommended.[59]
Recently,Lawrenceetal.suggestedthatmeasuringthehourlyratiooffluidinfusion(ml/kg/%TBSA/kg)andurineoutput(ml/kg/hour)
wasaneffectivemeansofexpressingandtrackingfluidrequirements.[52]

BURNCAREPROCEDURESATBAKENTUNIVERSITYHOSPITALS
Thetreatmentofallpatientsbeginsatthetimeofhospitalisation.Followingaroutineexamination,IVfluid(salineorsalinewith
dextrose)isadministered,andfollowingtheresultsoftheelectrolytemeasurements,providedpotassiumlevelsarenormal,thesolutionis
changedtoRingerslactate.Therateofadministrationisadjustedaccordingtourineoutputofatleast50ml/hour.Ifthepatientis
oliguricandacidotic,sodiumbicarbonate,2040gofmannitoland40100mgfurosemidearegiven.Ifthepatientstillremainsoliguric
andpotassium,bloodureanitrogen,andcreatininelevelsarerising,peritonealorhaemodialysisusingadoublelumensubclaviancatheter
isresorted.Wethinkthatthissystemisveryeasytouseforbothhaemodialysisandparenteralnutrition.Aurinarycatheterandacentral
venouspressurelineareusedonlyinseverecasesorifclinicalevaluationsoindicated.
Followinginitialstabilisation,thepatientsaretakentothedressingroomforreevaluation,andifnecessary,debridement,escharotomy,
andfasciotomyarepreformed.[60,61]Escharotomyandfasciotomyareneededwhencompartmentsyndromeisabouttooccurinaspace
thathasreacheduptoitsmaximumdistensibility(30mmHg).Inthecaseofsevereflameburnsandhighvoltageelectricalburnswith
suspectedcompartmentsyndrome,theincisionshouldincludetheescharandthedeepfasciaofeachoftheaffectedmusclecompartments.
[59]Weperformtheescharotomiesorfasciotomiesasanemergency.Whileperformingescharotomiesorfasciotomies,acareful
haemostasisisessentialinordertopreventexcessivebloodlosswhichmaycauseanegativeeffectonthefluidmanagementoftheburn
shock.Woundsarecleansedandclosedusingoneofthelocalchemotherapeuticagentssuchassilversulphadiazine,mafenideacetate,or
silverincorporatedamnioticmembrane.Thisprocedureisrepeateduntilallnonviabletissuewasremovedincaseswhereamputationis
required.Woundsarethenclosedwithaskingraftoraflap.Rehabilitationsuchasphysicaltherapyisstartedwhilepatientsare
hospitalisedandcontinuedafterdischarge,ifnecessary.[60]

Fluidmanagementinelectricalburns
Pruittreportedthatpatientswithelectricalburnsrequiredadditionalfluid.[18]Inourpreviousstudyinwhichan11yearexperiencewas
reported,wehavefoundtwomajorcomplicationsofelectricalinjuries:musculoskeletalinvolvementin44%ofpatients,whichrequired

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majoramputationin79%,andacuterenalfailure(ARF)in14.51%ofpatients.Inspiteoftreatmentwithperitonealdialysisor
haemodialysis,themortalityrateforpatientswithrenalfailurewasquitehigh(59%).[61]Inthelightofthesedata,itisclearthatthe
mainthreatintheinitialperiodisthedevelopmentofacutetubularnecrosisandARFrelatedtotheprecipitationofmyoglobinandother
cellularproducts.Myoglobinuriaisacommonfindinginpatientswithelectricalinjuries.Thephenomenonismanifestedashigh
concentratedandpigmentedurine.Thegoalistomaintainaurineoutputof12ml/kg/houruntiltheurineclears.Innonresponding
patients,alkalisationoftheurineandtheuseofosmoticagentsmaypreventdeath.[59]

AcuterenalfailureanddialyticsupportinsevereBurns
ARFisaseverecomplicationofburns,whichoccursin0.530%ofburnpatients.[62]ARFhasbeenfoundtoberelatedtothesizeand
depthofburns.Microalbuminuriaandurinarymalondialdehydeareusefulmarkersforpredictionofrenaloutcomeinsuchgroupof
patients.[63]Burnsizeandsepticaemiaprovedtobetheonlyclinicalparametersthatpredictrenaloutcome.[62,63]Twoformsofacute
renalfailurehavebeendescribedinburnpatients:Thefirstformoccursintheinitialfewhoursafterinjury.Thisformisrelatedto
hypovolemiawithlowcardiacoutput,andsystemicvasoconstrictionduringtheresuscitationperiod.However,thisformofARFbecame
lessfrequentduetotheaggressivefluidresuscitationpolicyattheacutestageoftheburnmanagement.Theotherformoccursinthe
secondweekandisrelatedtosepsisandmultiorganfailure.[62]Fluidshift,stressrelatedhormones,myocardialdepression,inflammatory
mediatorsandnephrotoxicagentsarealsosupposedtobethetriggersoftheARFthatoccursinthesecondweek.[64,65]Dialyticsupport
hastobeinitiatedinsuchcases.InburnpatientswithARF,dialysisisindicatedforfluidoverload,hypercalcaemia,pulmonaryoedema,
unresponsivenesstodiuretics,acidosisanduraemiccomplications.Althoughperitonealdialysisisagoodmethod,ithassome
complicationssuchaslowratesofultrafiltration,respiratoryproblems,increasedintraabdominalpressure,proteinlossesandbacterialor
fungalperitonitis.Inaddition,peritonealdialysisiscontraindicatedinpatientswithabdominalwallburns.Anotherchoicefordialysisis
conventionalintermittenthaemodialysis(CIHD).Althoughhighandstableefficiencyandahighrateofhaemofiltrationareprovidedby
CIHD,postdialyticrebound,difficultyinbalancingthesolutesandcardiacarrhythmiaarethemostcommoncomplications.Additionally,
CIHDisnotsuitableforsevereburnpatientswhoarehypotensive.Inourburnunits,weprefertousethecontinuousvenovenos
haemofiltration(CVVH)fortheburnpatientscomplicatedwithARF.Intheirrecentpreliminarystudy,Sunetal.havealsoadvocated
thatCVVHisanappropriatetoolfortreatingARF,withalowerincidenceofvascularcomplicationsthancontinuousarteriovenous
haemodialysis.[66]

AMERICANBURNASSOCIATIONPRACTICEGUIDELINESFORBURNSHOCKRESUSCITATION
Phametal.reviewedrecentdataintheliteraturetosupportanappropriatefluidmanagementinburnpatients,buttheyfoundthatthere
areinsufficientdataintheliteratureforthispurpose.So,theyrecommendedarationalapproachfortheinitialtreatmentofburnpatients
inthelightoftheirinvestigations.Thefollowingarethepracticeguidelinesforburnshockresuscitation,recommendedbytheAmerican
BurnAssociation.[11]

Guidelines
Adultsandchildrenwithburnsgreaterthan20%TBSAshouldundergoformalfluidresuscitationusingestimatesbasedonbody
sizeandsurfaceareaburned.
Commonformulasusedtoinitiateresuscitationestimateacrystalloidneedfor24ml/kgbodyweight/%TBSAduringthefirst
24hours.
Fluidresuscitation,regardlessofsolutiontypeorestimatedneed,shouldbetitratedtomaintainaurineoutputofapproximately
0.51.0ml/kg/hourinadultsand1.01.5ml/kg/hourinchildren.
Maintenancefluidsshouldbeadministeredtochildreninadditiontotheircalculatedfluidrequirementscausedbyinjury.
Increasedvolumerequirementscanbeanticipatedinpatientswithfullthicknessinjuries,inhalationinjuryandadelayin
resuscitation.

Options
Theadditionofcolloidcontainingfluidfollowingburninjury,especiallyafterthefirst1224hourspostburn,maydecreasethe
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overallfluidrequirements.
Oralresuscitationshouldbeconsideredinawakeandalertpatientswithmoderatelysizedburnsandisworthyoffurtherstudy.
Hypertonicsalineshouldbereservedforprovidersexperiencedinthisapproach.Plasmasodiumconcentrationsshouldbeclosely
monitoredtoavoidexcessivehypernatraemia.
Administrationofhighdoseascorbicacidmaydecreasetheoverallfluidrequirements,andisworthyoffurtherstudy.
Intheabovementionedstudy,Phametal.emphasisedthattheguidelinestheyhaddesignedcouldaidespeciallythephysicianswhowere
responsibleforthetriageandinitialtreatmentofburnpatients.[11]

CONCLUSION
Severalstudieshavesupportedthatpatientswhoreceivelargervolumesofresuscitationfluidareathigherriskforinjurycomplications
anddeath.Inthelightofthisprediction,thechosentypesandratesofthefluidadministrationinmajorburnsareatthefocusof
controversy.Itmustbekeptonmindsthatthesedebateslookforarationalapproachforanadequatefluidresuscitation.Currentlyused
guidelinesarebasedonthevariousexperiencesallovertheworld,andthedevelopingexperienceswillbringanewapproach.So,
cliniciansmustbeawareofthisvastexperienceandongoingliteraturedebatesinordertoimprovethestatusofthispatientgroup.

Footnotes
Source of Support:Nil
Conflict of Interest:Nonedeclared.

Articleinformation
IndianJPlastSurg.2010Sep43(Suppl):S29S36.
doi:10.4103/09700358.70715
PMCID:PMC3038406
MehmetHaberal,A.EbruSakalliogluAbali,andHamdiKarakayali
DepartmentofGeneralSurgeryandBurnandFireDisastersInstitute,Ankara,Turkey
Address for correspondence:Prof.MehmetHaberal,BaskentUniversity,TaskentCaddesi,No:77,Bahcelievler06490,Ankara,Turkey.Email:
rektorluk@baskentank.edu.tr
CopyrightIndianJournalofPlasticSurgery
ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionLicense,whichpermitsunrestricteduse,distribution,and
reproductioninanymedium,providedtheoriginalworkisproperlycited.
ThisarticlehasbeencitedbyotherarticlesinPMC.
ArticlesfromIndianJournalofPlasticSurgery:OfficialPublicationoftheAssociationofPlasticSurgeonsofIndiaareprovidedherecourtesyofMedknow
Publications

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