Invited Critique: Fluid Creep

Abstract

Dr. Jeffrey Saffle is to be complemented for this scholarly review of the factors, which lead to the administration of more fluid given intravenously than is needed to complete complication free resuscitation of patients with burns.1 However, codifying the term “fluid creep,” which has no scientific value, into the culture of burn care is a disservice. In the Section “Strategies for Prevention and Treatment of Fluid Creep” and specifically in Subsection 2, “Consider Routine Colloid or ‘Colloid Rescue’,” the article falls short of emphasizing a root cause of the administration of the excess amount of fluid given in the acute resuscitation of patients with burns, that is, hypoproteinemia.2 The pathophysiologic cause of hypoproteinemia in burns starts with the loss of the semipermeable membrane that separates the intravascular from the interstitial fluid space which occurs in heat injured but not heat obliterated blood vessels.3 This results in the sequestration of virtually all the noncellular elements of the blood into the tissues immediately subjacent to the burned tissues and with superficial burns, the formation of blisters. Arturson4 cites that molecules as large as 350 angstroms move across the vascular wall into the interstitial space. As a result of this extravascular sequestration of what is essentially plasma and the administration of crystalloid alone to replace it, hypoproteinemia occurs. All hypoproteinemic states result in anasarca. If the hypoproteinemia is not repaired and excessive amounts of crystalloid are given, troubling edema related complications occur, for example, pleural effusion, pulmonary edema, acites, intraabdominal hypertension, and pathological elevation of tissue pressure, even in areas of the body free of burn injury. The process of losing intravascular protein is arrested when the injured blood vessels clot off.5 Among those with large surface area burns and because of the sequestration of plasma clotting factors into the extravascular space, a coagulopathy occurs perpetuating the problem.