Elsevier

Burns

Volume 36, Issue 2, March 2010, Pages 176-182
Burns

Burn resuscitation: The results of the ISBI/ABA survey

https://doi.org/10.1016/j.burns.2009.09.004Get rights and content

Abstract

Introduction

There are valid concerns that burn shock resuscitation is inadequate; a tendency to over-resuscitate the patient seems to exist which may increase complications such as compartment syndrome. The purpose of this study was to survey members of the ISBI and ABA to determine current practices of burn resuscitation.

Methods

A survey asking for practices of burn shock resuscitation was provided to all participants of a recent ABA meeting. Around the same time, the survey was sent to all members of the ISBI through the internet. The results of the 101 respondents (ABA – 59, ISBI – 42, approximately a 15% response rate) are described.

Results

Surveys were returned from all the continents except Africa. Respondents included directors (48%), staff physicians (19%), nurses (23%) and others. Most programs admitted adults (87%) and children (75%) with a mean of 289 admissions per year. The cut off to initiate resuscitation was 15% TBSA and most preferred peripheral IVs (70%) and central lines (47.5%). The Parkland formula was preferred (69.3%) while others were used: Brooke – 6.9%, Galveston – 8.9%, Warden – 5.9%, and colloid 11.9%. Lactated Ringer's (LR) was the preferred solution (91.9%), followed by normal saline – 5%, hypertonic saline – 4%, albumin – 20.8%. FFP – 13.9%, and LR/NaHCO3 – 12.9%. Approximately half (49.5%) added colloid before 24 h. Urine output is the major indicator of success (94.9%) while 22.7% use other monitors. Most (88.8%) feel their protocols work well with 69.8% feel that it provides the right amount of fluid (24% – too much, 7% – too little). Despite this feeling, they still feel that they give more fluid than the formula in 55.1%, less than formula in 12.4% and the right amount in 32.6%. Approximately 1/3 use an oral resuscitation formula and 81.8% feel that an oral formula works for burns < 15% TBSA.

Conclusion

Large variations exist in resuscitation protocols but the Parkland formula using LR is still the dominant method. Most feel that their resuscitation protocol works well.

Introduction

Burn resuscitation formulas have been used with little change for decades. While most burn units have a formula they use as a protocol, considerable variability is present dependent upon the region of the world that burn unit is located. Several reports indicated a tendency for burn units to “over-resuscitate” patients in the first 24 h after a burn [1], [2], [3], [4]. The term used for this excessive fluid resuscitation is “fluid creep” [2]. Clearly, excessive fluid resuscitation increases the chances for extremity compartment syndromes, abdominal compartment syndrome and acute respiratory distress syndrome (ARDS) [5], [6], [7], [8]. In addition, it was suggested that part of the cause of excessive fluid resuscitation is from excessive narcotic use or “opioid creep” during the first day after the burn [9]. In the recent American Burn Association's State of the Science Meeting many questions arose about burn shock resuscitation [10]. All participants agreed to a tendency to over-resuscitate during burn shock but it was not clear why. Indicators suggested that attention to the actual urine output was ignored and patients frequently produced more than the target amount. It also became obvious that no real consensus was reached on which resuscitation formula was best. Many burn directors admitted to “cheating” when it came to adding albumin to the resuscitation formula. Many centers started with oncotic formulas for the initial fluid. Finally, everyone agreed to no clear endpoints that indicated the adequacy of burn shock resuscitation.

Due to these concerns, a survey was designed as part of the task of the International Society for Burn Injuries (ISBI) Research Committee to determine what burn centers around the world were using for resuscitation policies. This survey was made available to participants at the 39th Annual Meeting of the American Burn Association in San Diego, CA, March 20–23, 2007. In addition, the survey was sent to members of the International Society for Burn Injury during the subsequent year. The results were presented at the 14th Congress of the International Society for Burn Injuries, Montreal, Canada, September 8, 2008 and are reported here.

Section snippets

Methods

As a project for the ISBI Research Committee, a survey evaluating the burn shock resuscitation practices throughout the world was created (see figure). The survey was distributed in two ways: in paper form to participants at the 39th Annual Meeting of the American Burn Association (ABA) in San Diego, CA, March 20–23, 2007; and through e-mail to members of the ISBI. The surveys were supplied within the complementary bag provided to all registrants of the ABA Annual Meeting. Surveys were

Results

Fifty-nine responded from the ABA Meeting and 42 from the ISBI e-mail survey. The location of the respondent was not asked and a large number did not identify the country of origin. Despite that fact, five continents were identified with most being from North America (25 – USA, Canada). Also reporting were South America (3 – Chile, Argentina), Europe (8 – Czech Republic, Romania, Poland, Sweden), Asia (3 – China, India) and Australia (4). The respondents were burn directors (48), staff

Discussion

Despite years of experience with burn shock resuscitation this survey supports that concept that many controversies persist in treating burn patients in the first 24 h after injury. Clearly, many variations exist in resuscitation practices around the world. Such variation suggests that no particular formula or practice works better than another. Despite variations in practice, the Parkland formula which was created four decades ago persists as the favorite formula. In addition, lactated Ringer's

Conclusion

This resuscitation survey indicates that while the Parkland formula still is favored, its dominance is being challenged. The large variance in formulas and fluid choices simply tell us that no protocol is perfect. The use of colloids is increasing so it is time to perform a prospective, randomized trial to determine whether there is a better way to treat burn shock. “Fluid creep” continues to plague resuscitation but the causes are not clear. Simple attention to detail may make a major impact

Conflict of interest

None declared.

Acknowledgement

Supported by the Shriners of North America.

References (21)

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Presented at 14th Congress of the International Society for Burn Injuries, Montreal, Canada, September 8, 2008.

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