Effectiveness of hypertonic saline-dextran 70 for initial fluid resuscitation of major burns.

Small-volume resuscitation (4 ml/kg) with hypertonic saline-dextran (HSD) has been shown effective in hemorrhagic shock. In the present study the effectiveness of an initial 4 ml/kg bolus infusion of HSD on cardiovascular function and fluid resuscitation requirements after a major burn injury was evaluated in anesthetized sheep following a 40% BSA scald burn. One hour after injury resuscitation was initiated by a rapid intravenous bolus infusion (4 ml/kg) of either hypertonic saline-dextran (7.5% NaCl in 6% dextran 70) (HSD) or the same volume of normal (isotonic) saline (NS). Lactated Ringer's was later infused as needed to maintain cardiac output at 90% of baseline. HSD rapidly and effectively restored cardiac output and mean arterial pressure significantly better than the same volume of NS. Hemodynamic improvement by HSD was short lived, and need for further fluid therapy was only marginally delayed (HSD 38 +/- 8 min, NS 20 +/- 3 min; p = 0.06) (mean +/- SEM). The total requirements for fluid therapy during the first 6 hr postburn were not reduced by the initial HSD bolus (HSD 3,145 +/- 605 ml, NS 2,905 +/- 495 ml; n.s.), nor was skin edema formation reduced. We conclude that in anesthetized sheep HSD resuscitation was only transiently effective in treating burn shock. This may be attributed to the sustained increase in vascular permeability and continued plasma leak following thermal injury.     

Effectiveness of Parkland formula in the estimation of resuscitation fluid volume in adult thermal burns

Purpose: Acute burn resuscitation in initial 24 h remains a challenge to plastic surgeons. Though various formulae for fluid infusion are available but consensus is still lacking, resulting in under resuscitation or over resuscitation. Parkland formula is widely used but recently its adequacy is questioned in studies. This study was conducted to see how closely the actual volume of fluid given in our center matches with that of calculated volume by Parkland formula. Methods: All patients admitted with more than 20% flame burn injury and within 8 h of incident were included in this study. Crystalloid solution for infusion was calculated as per Parkland formula; however, it was titrated according to the urine output. Data on fluid infusion were collected from patient''s inpatient records and analyzed. Results: The study included a total of 90 patients, about 86.7% (n ¼ 78) of the patients received fluid less than the calculated Parkland formula. Rate of fluid administered over 24 h in our study was 3.149 mL/kg/h. Mean hourly urine output was found to be 0.993 mL/kg/h. The mean difference between fluid administered and fluid calculated by Parkland formula was 3431.825 mL which was significant (p < 0.001). Conclusion: The study showed a significant difference in the fluid infused based on urine output and the fluid calculated by Parkland formula. This probably is because fluid infused based on end point of resuscitation was more physiological than fluid calculated based on formulae.     

Fluid resuscitation in major burns

BACKGROUND: The Parkland formula is established as the "gold standard" for initial fluid resuscitation for major burns. The purpose of this study was to review our fluid resuscitation practice for major burns to determine whether anecdotal observations of significant variations from the Parkland formula were wide spread and whether any difference could be used as a basis for a revision of fluid resuscitation in major burns. METHODS: A retrospective review of 127 presentations to The Alfred Burns Unit with total body surface area (TBSA) affected > or =15% was conducted. A retrospective review of the resuscitation data from these patients was compared with the Parkland formula as well as other studies. RESULTS: A total of 49 patients with complete data on fluid administration and uncomplicated burns were included in the analysis. Significantly larger volumes of fluid (5.58 mL/kg per %TBSA) were given to these patients in the first 24 h than predicted by the Parkland formula. Mean arterial pressure, pulse rate and urine output were at satisfactory levels. Clinically evident complications from fluid administration were minimal. Mortality was similar to that in other centres. CONCLUSION: Fluid resuscitation volumes significantly higher than those predicted by the Parkland formula were given, without adverse consequences. This retrospective review supports a prospective, multicentre, randomized, controlled study comparing this study with the Parkland formula, resulting in a better guide to initial fluid resuscitation in major burns.     

The study of hemodynamic changes in resuscitation of burns with two types of fluid regimens

In dogs inflicted third-degree burns of 25% TBSA the hemodynamic changes were observed with resuscitation with whole blood (group A) or balanced saline solution (group B). The results showed that there were significant differences in time and degree of recovery between two groups. In group A, the recovery of cardiac index (CI) began after 18 hr of resuscitation, and it was delayed to 22 hr; in group B, 24 hr after the injury. Two groups showed significant differences in CI. The recovery in CI related mainly to stroke index. Moreover, group B animals showed higher pulmonary arterial pressure after injury. There was significant difference between the level at 48 hr and the pre-injury level. It could be concluded that resuscitation with whole blood did give more satisfactory resuscitation than pure crystalloid.     

Monitoring tissue oxygenation during resuscitation of major burns

BACKGROUND: Because subcutaneous and splanchnic oxygenation indices are sensitive indicators of evolving hemorrhagic shock and adequacy of resuscitation, we postulated that these indices might have an equivalent role in the monitoring of severely burned patients. This observational study was undertaken to examine changes in tissue oxygenation indices during burn resuscitation. METHODS: Seven patients with major burns (54 +/- 21% total body surface area) were studied during the first 36 hours of fluid resuscitation. Silastic tubing was placed in the subcutaneous tissue just beneath both normal skin and deep partial thickness burn. Fiberoptic sensors inserted into the tubing measured subcutaneous oxygen and carbon dioxide tensions in the burnt skin (PO2scb and PCO2scb) and normal skin (PO2scn and PCO2scn) continuously. Gastric intramucosal pH (pHi) and the mucosal CO2 (PCO2m) gap were calculated using gastric tonometers. Mean arterial pressure, arterial pH, lactate, and pHi measurements were obtained for 36 hours. RESULTS: There were no significant differences in mean arterial pressure, arterial pH, or lactate concentrations throughout the study period, whereas indices of tissue oxygenation showed deterioration: pHi decreased from 7.2 +/- 0.1 to 6.7 +/- 0.3 (p = 0.06), the PCO2m gap increased from 12 +/- 17 to 108 +/- 123 mm Hg (p < 0.01), PO2scn decreased from 112 +/- 18 to 50 +/- 11 mm Hg (p < 0.01), PO2scb decreased from 62 +/- 23 to 29 +/- 16 mm Hg (p < 0.01), PCO2scn increased from 42 +/- 4 to 46 +/- 10 mm Hg (p = 0.2), and PCO2scb increased from 42 +/- 10 to 52 +/- 5 mm Hg (p = 0.05). CONCLUSION: Despite adequate global indices of tissue perfusion after 36 hours of resuscitation, tissue monitoring indicated significant deterioration in the splanchnic circulation and in the normal and burnt skin.     

Colloid or crystalloid for resuscitation of major burns

There is continuing debate over the merits of colloid versus crystalloids for the resuscitation of major burns. This article reviews fluids used in burn resuscitation and discusses potential advantages and disadvantages of colloid and crystalloid.     

Current attitudes to burns resuscitation in the UK

In recent years, much discussion has occurred regarding the efficacy and safety of using albumin as part of burns resuscitation regimes. The discussion was fuelled in 1998 by the publication of the findings of the Cochrane Injuries Group Albumin Reviewers, Br Med J 1998; 317: 235-240. The current usage of human albumin solutions as part of the burn resuscitation regimes of burns units in the UK was assessed by telephone questionnaire by contacting medical staff from all the burns units in the UK that admit burn patients for resuscitation. Knowledge of the albumin controversy, details of their current resuscitation regimes and recent or planned changes were included in the questionnaire, Most individuals were aware of the albumin controversy. A total of eight units had made changes to their resuscitation regimes since July 1998, although five were still using albumin. Four more were considering making changes, while 13 units that had been using albumin prior to the controversy had made no changes at all. Only three units had stopped using albumin-based colloid altogether. Only one unit was not using albumin prior to the controversy. The implications of these results and possible ways forward are discussed.     

Acromio-clavicular repair using two different techniques

Acromio-clavicular joint (ACJ) injuries represent nearly half of all athletic shoulder injuries. Stability of this joint depends on the integrity of the acromio-clavicular and coracoclavicular ligaments. Although the traumatic acromioclavicular joint separation is a well-known topic, there are different classifications, diagnostic procedures, concepts of intervention, and a great variety of implants. In this paper, we present an overview of the recent literature about this issue and the results of a retrospective non-randomized study with 2 different techniques. At the first Orthopedic Department of University of Pisa, a retrospective study was performed starting from January 2007 to February 2011 in our electronic database. We selected patient treated with two different techniques (tight-rope^® system and hook plate) by the same senior surgeon with experience in shoulder surgery. The mean Costant score was 90 for the tight-rope^® system group and 75 for the hook plate group. At the final follow-up, most of the patients had returned to their preinjury level of activity. Two patients had a breakage of the fixating system. The above-mentioned techniques provided satisfactory results with no loss of reduction except in two cases. The use of the hook plate is useful in fracture-dislocation of ACJ, but this requires another surgery to remove it. On the contrary, the use of the tight-rope^® system does not require a new surgery or use of expensive synthetic graft or a graft harvested from a distant donor site.     

A comparison of two smartphone applications and the validation of smartphone applications as tools for fluid calculation for burns resuscitation

We conducted a randomised, blinded study to compare the accuracy and perceived usability of two smartphone apps (uBurn^© and MerseyBurns^©) and a general purpose electronic calculator for calculating fluid requirements using the Parkland formula. Bespoke software randomly generated simulated clinical data; randomly allocated the sequence of calculation methods; recorded participants’ responses and response times; and calculated error magnitude. Participants calculated fluid requirements for nine scenarios (three for each: calculator, uBurn^©, MerseyBurns^©); then rated ease of use (VAS) and preference (ranking), and made written comments. Data were analysed using ANOVA and qualitative methods. The sample population consisted of 34 volunteers who performed a total of 306 calculations. The three methods showed no significant difference in incidence or magnitude of errors. Mean (SD) response time in seconds for the calculator was 86.7 (50.7), compared to 71.7 (42.9) for uBurn^© and 69.0 (35.6) for MerseyBurns^©. Both apps were significantly faster than the calculator (p = 0.013 and p = 0.017 respectively, ANOVA: Tukey's HSD test). All methods showed a learning effect (p < 0.001). The participants rated ease of use on a VAS scale with a higher score indicating greater ease of use. The calculator was easiest to use with a mean score (SD) of 12.3 (2.1), followed by MerseyBurns^© with 11.8 (2.7) and then uBurn^© with 11.3 (2.7). The differences were not found to be significant at the p = 0.05 level after using paired samples t-test and a multiple correction was applied manually. Preference ranking followed a similar trend with mean rankings (SD) of 1.85 (0.17), 1.94 (0.74) and 2.18 (0.90) for the calculator, MerseyBurns^© and uBurn^© respectively. Again, none of these differences were significant at the p = 0.05 level.