Weight-based vs body surface area-based fluid resuscitation predictions in pediatric burn patients

Treatment for pediatric burns includes fluid resuscitation with formulas estimating fluid requirements based on weight and/or body surface area (BSA) with percent total body surface area burn (%TBSA burn). This study evaluates the risk of complications using weight-based resuscitation in children following burn injuries and compares fluid estimates with those that incorporate BSA. A retrospective review was conducted on 110 children admitted to an ABA-verified urban pediatric burn center over 12 years. Patients had ≥ 15% TBSA burn and were resuscitated with the weight-based Parkland formula. BSA-based Galveston and BSA-incorporated Cincinnati formula predictions were calculated. Complications were collected throughout hospital stay. Patients were classified into weight groups based on percentile. This study included 11 underweight, 60 normal weight, 18 overweight, and 21 obese children. Total fluid administered was higher as percentile increased; however, overweight children received more fluid than the obese (p = 0.023). The Galveston formula underpredicted fluid given over the first 24 h post-injury (p = 0.042); the Parkland and Cincinnati formula predictions did not significantly differ from fluids given. Further research is needed to determine the value of weight-based vs BSA-based or incorporated formulas in reducing risk of complications.     

Fluid resuscitation of pediatric burn victims: a critical appraisal

The objectives of fluid therapy in the burned child can be simply stated and defined, and they should represent the basis for the resuscitation process. During the first 24 h after the burn, the ultimate goal is restoration of the patient's volume and electrolyte homeostasis. All efforts should be directed at monitoring or restoring organ function while simultaneously minimizing edema formation. Only the minimum amount of fluids and other nutrients needed to restore cell function should be provided. Electrolyte deficits and lactic acidosis must be promptly corrected and every attempt should be made to prevent further derangement in body homeostasis by replacing concurrent losses and anticipating maintenance fluid and electrolyte requirements. Restoration and maintenance of perfusion pressures should lead to maximal oxygenation of injured and noninjured tissues, which promotes spontaneous healing, minimizes wound conversion, decreases bacterial colonization and prepares the injured areas for early excision and grafting. It must be emphasized, however, that restoration of fluid and electrolyte balance and organ function does not necessarily imply a return to normal of all physiological variables. The cardiac output, for example, may not return to preburn levels for 24–48 h post injury, even when the intravascular volume has been completely replenished. Likewise, oliguria may persist for 48–72 h, or even longer, after the burn, as a result of excessive secretion of antidiuretic hormone stimulated by the stress of the injury rather than its effect of fluid balance. Thus, while the objectives can be easily enumerated and defined, they are difficult to meet.     

Adoption of rescue colloid during burn resuscitation decreases fluid administered and restores end-organ perfusion

IntroductionTraditionally, lactated Ringer’s solution (LR) has been utilized for the resuscitation of thermally injured patients via the Parkland or Brooke formulas. Both of these formulas include colloid supplementation after 24 h of resuscitation. Recently, the addition of albumin within the initial resuscitation has been reported to decrease fluid creep and hourly fluids given. Our institution has previously advocated for a crystalloid-driven resuscitation. Given reports of improved outcomes with albumin, we pragmatically adjusted these practices and present our findings for doing so.MethodsOur burn registry, consisting of prospectively collected patient data, was queried for those at least 18 years of age who, between July 2017 and December 2018, sustained a thermal injury and completed a formal resuscitation (24 h). At the attending physician’s discretion, rescue colloid was administered using 25% albumin for those failing to respond to traditional resuscitation (patients with sustained urine output of <0.5 mL/kg over 2–3 h, or unstable vital signs and ongoing fluid administration). We compared the total volume of the crystalloid-only and rescue colloid resuscitation fluids given to patients. We also examined the in/out fluid balances during resuscitation. Statistical analysis was performed using Stata software.ResultsA total of 91 patients with thermal injuries were included: the median age was 40 (IQR 31–57), 73% were male, and 30 patients received rescue albumin. The percentage of total body surface area burned (%TBSA) was greater in those who received rescue albumin (40.3% vs. 34%; p = 0.047). Despite a higher %TBSA in the albumin group, the total LR given during resuscitation was not significantly different between groups (15,914.43 mL vs. 11,828.71 mL; p = 0.129) even when normalized for TBSA and weight (ml LR/kg/%TBSA: 4.31 vs. 3.66; p = 0.129. The average in/out fluid ratio for the rescue group was higher than for the crystalloid group (0.83 ± 0.05 vs. 0.59 ± 0.11; p = 0.06) and returned to normal after colloid administration.ConclusionRescue albumin administration decreases the amount of fluid administered per %TBSA during resuscitation, and also increases end organ function as evidenced by increased urinary output. These effects occurred in patients who sustained larger burns and failed to respond to traditional crystalloid resuscitation. Our findings led us to modify our current protocol and a related prospective study of clinical outcomes.     

成批烧伤患者休克期补液治疗体会

目的　总结成批烧伤患者早期补液复苏经验。　方法　对 1批 2 5例烧伤中 11例危重患者的现场救护和休克期的补液复苏治疗及效果进行分析总结。　结果　 11例危重患者均平稳度过休克期 ,全部治愈。　结论　医护人员快速前伸至事故现场救援 ,及时实施正确的补液复苏治疗 ,能有效地预防休克的发生。     

烧伤病人血流变学动态改变与体液复苏的关系

目的探讨烧伤病人血流变学的变化特点及其与体液复苏的关系以及严重烧伤后贫血的防治措施。方法将238例烧伤住院患者按轻重程度及体液复苏方案不同,分为四组观测。结果烧伤后24～48h 内及时补充新鲜血并结合中药治疗,可明显改善血流变学的异常指标,对有效减少烧伤后输血量是十分有益的。结论血液流变学的动态观测是监测烧伤休克和指导体液复苏的最佳指标之一,严重烧伤后早期补充新鲜血并给予中药治疗是改善血流变学的异常指标,防治贫血的有效措施。     

Characteristics of 1494 pediatric burn patients in Shanghai

To analyze the epidemiological characteristics of pediatric burn patients in Shanghai and to determine the targets for a pediatric burn prevention program, a retrospective review of all medical records of acute pediatric burn patients (age相似文献   

Arterial thermodilution in burn patients suggests a more rapid fluid administration during early resuscitation

Background: A number of target points have been used for fluid replacement in severely burned patients. The aim of our prospective randomized study was to compare the effect of two different types of fluid resuscitation regimes on the multiple organ dysfunction score (MODS) and central venous oxygen saturation (ScvO₂) in the first 3 days after injury.
Methods: Twenty-four patients admitted to the critical care unit of a university hospital with the presence of burn injury affecting more than 15% of the body surface area and in-hospital fluid resuscitation started within 3 h after burn injury were included. Patients were randomized into two groups. Fluid resuscitation was guided by the hourly urine output (HUO Group, n =12) or by the intrathoracic blood volume index (ITBVI Group, n =12). Invasive transpulmonary hemodynamic measurements utilizing pulse contour analysis with a single dilution technique and continuous ScvO₂ measurements were performed in both groups.
Results: The mean ScvO₂ was significantly lower in the HUO Group than in the ITBVI Group ( P =0.024) for the first 24 h. MODS was significantly higher in the HUO Group than in the ITBVI group 48 h ( P =0.024) and 72 h after injury ( P =0.014). The two main outcome parameters, i.e., MODS calculated at 48 and 72 h after injury and ScvO₂ were negatively correlated on day 1 ( r =−0.684, P =0.004, r =−0.677, P =0.003). There were no statistical differences in clinical outcome parameters.
Conclusion: Our data suggest that ITBVI may be a better target parameter than HOU in the fluid resuscitation of severely burned patients after injury.     

Albumin administration for fluid resuscitation in burn patients: A systematic review and meta-analysis

Objective

The objective was to systematically review the literature summarizing the effect on mortality of albumin compared to non-albumin solutions during the fluid resuscitation phase of burn injured patients.

烧伤休克延迟补液后氧自由基对心肌的损伤

采用大鼠25%TBSA Ⅲ度烧伤模型,动态观察了大鼠心肌在不补液,立即补液,延迟补液三种复苏条件下的超氧阴离子O_2~-、丙二醛(MDA)含量、乳酸脱氢酶同工酶(LDH_1)和肌酸磷酸激酶(CPK-MB)的活力,结果表明烧伤早期心肌中可产生多量的O_2~-,并可发生脂质过氧化反应,尤其在延迟补液组,不但MDA含量增加,且LDH_1和CPK-MB活力也明显增加。提示烧伤后立即补液对心肌仅有一定保护作用,故严重烧伤后的液体复苏中应辅以新的内容。     

烧伤休克延迟补液后氧自由基对心肌的损伤

采用大鼠２５％ＴＢＳＡＩＩＩ度烧伤模型，动态观察了大鼠心肌在不补液，立即补液，延迟补液三种复苏条件下的超氧阴离子Ｏ２－、丙二醛（ＭＤＡ）含量、乳酸脱氢酶同工酶（ＬＤＨ１）和肌酸磷酸激酶（ＣＰＫ－ＭＢ）的活力，结果表明烧伤早期心肌中，可产生多量的Ｏ２－，并可发生脂质过氧化反应，尤其在延迟补液组，不但ＭＤＡ含量增加，且ＬＤＨ１和ＣＰＫ－ＭＢ活力也明显增加。提示烧伤后立即补液对心肌仅有一定保护作用，故严重烧伤后的液体复苏中应辅以新的内容。     

高张及平衡盐溶液分别复苏烧伤休克大鼠的实验研究

我们采用２０％Ⅲ度烧伤大鼠模型，分对照组、平衡盐溶液组和高张盐溶液组。后两组均按Ｎａ＋·ｍｍｏｌ（－１）·ｋｇ（－１）／ＢＳＡ％分别计算伤后２４ｈ液体复苏量。动物均于伤后２４ｈ活杀，分别测定全血粘度、组织含水量，用电镜观察肾小球微循环的变化。实验发现，复苏后组织含水量均增加，平衡盐溶液组尤为明显（Ｐ＜０．０５）。血粘度均明显下降，高渗组尤甚（Ｐ＜０．０１）。电镜发现，对照组肾毛细血管扩张，ＲＢＣ凝聚，内皮细胞水肿裂隙增大。平衡盐溶液组微血管通畅。高渗组微循环未见明显改善，微血栓充塞血管腔。我们认为高张盐能改善体循环，但如何进一步改善微循环尚值得深入研究。     

高张及平衡盐溶液分别复苏烧伤休克大鼠的实验研究

我们采用20%Ⅲ度烧伤大鼠模型,分对照组、平衡盐溶液组和高张盐溶液组。后两组均按Na~ ·mmol~(-1)·kg~(-1)/BSA%分别计算伤后24h 液体复苏量。动物均于伤后24h 活杀,分别测定全血粘度、组织含水量,用电镜观察肾小球微循环的变化。实验发现,复苏后组织含水量均增加,平衡盐溶液组尤为明显(P<0.05)。血粘度均明显下降,高渗组尤甚(P<0.01)。电镜发现,对照组肾毛细血管扩张,RBC 凝聚,内皮细胞水肿裂隙增大。平衡盐溶液组微血管通畅。高渗组微循环未见明显改善,微血栓充塞血管腔。我们认为高张盐能改善体循环,但如何进一步改善微循环尚值得深入研究。     

Mathematical model of volume kinetics and renal function after burn injury and resuscitation

This paper presents a mathematical model of blood volume kinetics and renal function in response to burn injury and resuscitation, which is applicable to the development and non-clinical testing of burn resuscitation protocols and algorithms. Prior mathematical models of burn injury and resuscitation are not ideally suited to such applications due to their limited credibility in predicting blood volume and urinary output observed in wide-ranging burn patients as well as in incorporating contemporary knowledge of burn pathophysiology. Our mathematical model consists of an established multi-compartmental model of blood volume kinetics, a hybrid mechanistic-phenomenological model of renal function, and novel lumped-parameter models of burn-induced perturbations in volume kinetics and renal function equipped with contemporary knowledge on burn-related physiology and pathophysiology. Using the dataset collected from 16 sheep, we showed that our mathematical model can be characterized with physiologically plausible parameter values to accurately predict blood volume kinetic and renal function responses to burn injury and resuscitation on an individual basis against a wide range of pathophysiological variability. Pending validation in humans, our mathematical model may serve as an effective basis for in-depth understanding of complex burn-induced volume kinetic and renal function responses as well as development and non-clinical testing of burn resuscitation protocols and algorithms.     

Evaluation of arterial waveform derived variables for an assessment of volume resuscitation in mechanically ventilated burn patients

Objective

The purpose of this study was to assess the usefulness of stroke volume variations to monitor the early fluid resuscitation in mechanically ventilated burn ICU patients.

Methods and results

Data of 29 burn patients (APACHE II – 9.8 ± 3.6, SAPS II – 29 ± 5, TBSA – 39.5 ± 14) were prospectively included in this observational study. Hemodynamic parameters were determined using arterial pressure wave analysis for up to 36 h after burn. Statistically significant changes in cardiac index (CI), systemic vascular resistance index (SVRI), stroke volume variation (SVV) were recorded during the observation period. There were significant correlations between CI and SVV (r = −0.454, p = 0.03), SVV and SVRI (r = 0.482, p = 0.02) at 16 h postburn; CI and SVV (r = −0.513, p = 0.012), SVV and SVRI (r = 0.480, p = 0.02) at 24 h postburn, CI and SVV at 36 h postburn (r = −0.478, p = 0.021). Significant changes in CI (1.9 ± 1 vs. 3.4 ± 0.9), p = 0.02 and in SVV (24.9 ± 3 vs. 14.6 ± 2, p = 0.01) were observed in patients with low cardiac output state after administration of 10 ml/kg of Ringer lactate.

Conclusion

Our results suggest that measurement of stroke volume variations by arterial pulse contour analysis is valuable in monitoring volume administration and in predicting volume responsiveness during the early postburn period.     

烧伤病人血流变学动态改变与体液复苏的关系

目的探讨烧伤病人血流变学的变化特点及其与体液复苏的关系以及严重烧伤后贫血的防治措施。方法将２３８例烧伤住院患者按轻重程度及体液复苏方案不同，分为四组观测。结果烧伤后２４～４８ｈ内及时补充新鲜血并结合中药治疗，可明显改善血流变学的异常指标，对有效减少烧伤后输血量是十分有益的。结论血液流变学的动态观测是监测烧伤休克和指导体液复苏的最佳指标之一，严重烧伤后早期补充新鲜血并给予中药治疗是改善血流变学的异常指标，防治贫血的有效措施。     

A comparison of two different fluid resuscitation management protocols for pediatric burn patients: A retrospective study

Objective

Pediatric burn patients are more susceptible to burn shock than adults, and an effective fluid management protocol is critical to successful resuscitation. Our research aim was to investigate the safety and efficacy of two protocols for pediatric burn patients for use within the first 24 h.

液体复苏加山莨菪碱对烧伤兔心肌功能的影响

目的探讨山莨菪碱对烧伤兔心肌功能的影响。方法采用新西兰兔25％Ⅲ度烫伤模型,分别于伤前,伤后即刻,1,3,5,7小时测定左心室内压峰值、左心室内压最大变化速率,并观察严重烧伤休克期液体复苏加山莨菪碱对上述指标的影响。结果严重烧伤后早期即发生心肌的收缩功能和舒张功能障碍,并呈进行性减退。单纯给予山莨菪碱或单纯输液治疗对兔严重烧伤后的心功能在短期内有支持作用,但治疗效果欠佳,且单纯山莨菪碱治疗组心功能下降早于单纯补液组。而在给予山莨菪碱同时进行液体复苏。可使心肌收缩性和舒张性在伤后7小时维持在同时相点的假烫组同一水平。结论提示在液体复苏的同时应用山茛菪碱可改善心肌功能,并有利于休克的恢复。     

Incidence and risk factors for deep vein thrombosis among pediatric burn patients

BackgroundPatients with major burns covering a large total body surface area (%TBSA) fulfill all the criteria of Virchow’s triad, as a sequela of their injury. This places these patients at increased risk for developing deep vein thrombosis (DVT). However, data regarding the incidence of DVT in burn patients are minimal, especially in the pediatric age group. Therefore, the aim of this study is to determine the incidence of DVT in pediatric burn patients, identify possible risk factors for developing DVT, and explore the need for prophylactic treatment.MethodsA retrospective chart review of 95 patients admitted to our Burn Unit was conducted. We included all pediatric patients with second- and third-degree burns admitted to the unit. Exclusion criteria were adult patients, those with first-degree burns and admitted to the unit for <72 h, patients discharged against medical advice, those admitted for elective reconstructive surgery, secondary admissions for non-healing/infected burns, and patients with trauma-induced skin loss. A data collection sheet was utilized.ResultsThe total incidence of thrombosis in our population was 4.2% (DVT, 3.1%; arterial thrombosis, 1.1%). Factors significantly associated with DVT included length of hospitalization (p = 0.012), central venous catheter placement (p = 0.013), and %TBSA (p = 0.004). Unlike adult patients, weight for age (percentile) and body mass index were not significant risk factors for DVT in our patients.ConclusionBurns are a major risk factor for DVT, especially when covering large surface areas (≥40% TBSA) and combined with other factors (i.e., prolonged hospitalization and central lines). Thus, investigations for DVT and prophylactic anticoagulation should be considered for pediatric burn patients with these risk factors, even if they are asymptomatic.     

Controversies in fluid resuscitation for burn management: literature review and our experience

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.     

液体复苏加山莨菪碱对烧伤兔心肌功能的影响

目的探讨山莨菪碱对烧伤兔心肌功能的影响。方法采用新西兰兔２５％Ⅲ度烫伤模型，分别于伤前，伤后即刻，１，３，５，７小时测定左心室内压峰值、左心室内压最大变化速率，并观察严重烧伤休克期液体复苏加山莨菪碱对上述指标的影响。结果严重烧伤后早期即发生心肌的收缩功能和舒张功能障碍，并呈进行性减退。单纯给予山莨菪碱或单纯输液治疗对兔严重烧伤后的心功能在短期内有支持作用，但治疗效果欠佳，且单纯山莨菪碱治疗组心功能下降早于单纯补液组。而在给予山莨菪碱同时进行液体复苏，可使心肌收缩性和舒张性在伤后７小时维持在同时相点的假烫组同一水平。结论提示在液体复苏的同时应用山莨菪碱可改善心肌功能，并有利于休克的恢复。