Elsevier

Burns

Volume 35, Issue 7, November 2009, Pages 911-920
Burns

Review
Fluid resuscitation in adults with severe burns at risk of secondary abdominal compartment syndrome—An evidence based systematic review

https://doi.org/10.1016/j.burns.2009.03.001Get rights and content

Abstract

Background

Secondary abdominal compartment syndrome (sACS) in adults with severe burns is commonly unsuspected, can be rapidly fatal and seriously compromises the reliability of urine output as an indicator of perfusion and resuscitation status. Current literature lacks an exhaustive, evidence-based review critically appraising all retrieved literature on which clinical decisions may be based.

Methods

The evidence on three inter-related concepts was evaluated: fluid-volume management and its contribution to sACS; the role of urinary bladder pressure monitoring; and awareness of the burns community to sACS. Literature published over the last ten years across the major databases was retrieved, and the search strategy was fully reported to reduce the retrieval bias ubiquitous in previous literature. Each article was individually appraised and classified into a framework of evidence, enabling the formulation of specific, graded recommendations.

Results

Current best evidence supports recommendations to reduce fluid-volume administered through use of colloids or hypertonic saline especially if the projected resuscitation volume surpasses a ‘volume ceiling’. Continuous intra-vesical monitoring is recommended: to guide fluid resuscitation for early diagnosis of sACS; and as a guide to reliability of urine output as indicator of organ perfusion. A priming volume of 75 cm3 or less is recommended.

Conclusion

Fluid resuscitation volume is causative to sACS, especially once a predetermined maxima is reached. Continuous intra-vesical pressure monitoring is a cheap, reliable, user-friendly monitoring method recommended in high-risk patients. Poor awareness among the burns community requires urgent dissemination of evidence based information.

Section snippets

Description of the condition

Secondary abdominal compartment syndrome (sACS) in severely burnt adults is a commonly under-recognized, under-treated and rapidly fatal condition [1], [2]. Although first recognized by Wendt more than 100 years ago [3] only recently was it recognized to occur in burnt patients without abdominal trauma [2]. A consensus definition for ACS was finally formulated by Malbrain et al. as a sustained intra-abdominal pressure (IAP) ≥20 mmHg that is associated to new organ dysfunction or failure;

Literature search

An electronic search was performed across Pubmed; Cochrane Database of Systematic Reviews: ACP Journal Club, Database of Abstracts of Reviews of Effects; Cochrane Central Register of Controlled Trials; Cochrane Methodology Register; Allied and Complementary Medicine; British Nursing Index; CINAHL; EMBASE; Ovid-MEDLINE® In-Process & Other Non-Indexed Citations; The search-construct: ‘Abdominal AND compartment AND syndrome AND burns AND ((Fluid AND resuscitation) OR (monitoring))’ was used in

Management of resuscitation fluid-volume in the severely burnt adult developing secondary abdominal compartment syndrome

O’Mara et al. [7] performed a two-armed RCT on severely burnt patients comparing the effects of fluid-volume (crystalloid and colloid) on intra-abdominal pressure (IAP) and reported a causal relationship. Less volume was required in the colloid arm of their study, resulting in a lower incidence of IAH/ACS enabling colloids to be recommended in this specific scenario. Clear inclusion/exclusion criteria, baseline demographic and clinical details increase applicability of their recommendations.

Discussion

Current best evidence suggests sACS in the severely burnt adult is a common, rapidly fatal and poorly managed syndrome. Such a situation should raise concern among the burns community. Rather than accept current literature at face-value, our contribution aimed to provide an in-depth critical analysis of the robustness of the literature such that each recommendation is underscored by objectively graded evidence. Rigorously applying a hierarchy of evidence model allows an ‘explicit and judicious

Conflict of interest statement

Pertaining to all authors listed on this paper, there are no financial and personal relationships and no conflict of interest.

Acknowledgements

The authors would like to acknowledge Ms S.M. Azzopardi (University of Malta) for her contribution through detailed journal hand-searching; and Mr. Ernesto Azzopardi MPhil (Lond) Pg Dip Res Method, for cross-checking statistical analysis comments.

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    Sources of support: Ernest Azzopardi is an MSc Student at the University of Wales, Cardiff.

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