Fluid Resuscitation In Burn Patients Research Articles

Initial fluid resuscitation guided by the Parkland formula leads to high fluid volumes in the first 72 h, increasing mortality and the risk for kidney injury

BackgroundOur Burn center has used the Parkland formula (4 ml/kg/TBSA%) adjusted by physiological parameters to guide fluid resuscitation in burn patients. Our main objective was to examine fluid resuscitation in patients with major burn injury and its effect on mortality, need for renal replacement therapy (RRT) and the length of stay (LOS) in the Intensive Care Unit (ICU). Further aims were to determine which factors were associated with fluid resuscitation volumes during the first 24 h, and whether these fluid volumes had an association with the volumes infused during the next 48 h. MethodsThis retrospective observational study accrued patients (N = 46) admitted to the Helsinki Burn Center between 2016 and 2018 with burn injuries ≥ 20% TBSA. The national intensive care registry and the electronic patient record system provided data on fluid infusions, urine output, laboratory measurements, presence of inhalation injury, surgical procedures within 72 h from injury, patient demographics, need for renal replacement therapy and mortality. Patients were divided into groups based on infused fluid volumes and univariate regressions were performed to identify factors associated with fluid volumes. Results48% of the patients received fluids more than 6 ml/kg/TBSA% during the first 24 h. 35% of the patients received fluid volumes exceeding the Ivy index (250 ml/kg/d) and was associated with higher TBSA%, SOFA and SAPS scores as well as increased mortality and need for RRT. Higher lactate and lower base excess were associated with higher fluid volumes. Urine output had no association with the resuscitation volumes. Larger resuscitation volumes during the first 24 h were associated with larger fluid volumes given also during the next 48 h. Higher cumulative fluid volume in 0–72 h resulted in increased need of RRT and higher ICU mortality. ConclusionUsing the Parkland formula and adjusting the infusion based on physiological parameters leads to over resuscitation in many of the patients. It seems that the more fluids are given during the initial resuscitation phase, the more fluids are also administered during the subsequent phase. Higher cumulative fluid volumes are associated with RRT requirements and higher mortality. We postulate that starting fluid resuscitation with a lower infusion rate could be beneficial, as it may lead to smaller cumulative fluid volumes during the first 72 h, leading to reduced mortality and kidney injury.

Evolution of hematocrit in burn patients as a marker of early fluid management during acute phase

ObjectiveTo evaluate the value of hematocrit for monitoring fluid resuscitation of burn patients in the acute phase of their care. MethodWe conducted a single-center retrospective study focused on patients admitted with a burn surface of more than 20 % of the total body surface area (TBSA) from 2014 to 2021. We investigated the relationship between the change in hematocrit and the volume administered for patient resuscitation. The change in hematocrit is the difference between an admission hematocrit and a second one taken between the eighth and twenty-fourth hour. ResultsWe included 230 patients with an average burn size of 39.1 ± 20.3 % TBSA, in 94.4 % by a thermal mechanism. The management seems to be in accordance with the current recommendations, with a volume administered during the first 24 h of 4.3 ± 2.5 ml/kg/ % BSA, allowing to obtain an hourly diuresis of 0.9 ± 0.7 ml/kg/h. We did not find any correlation between the pre-hospital volume administration and the hematocrit at admission (p = 0.36). Hematocrit decreased on average to −4.5 ± 8.1 % between admission and a control performed after the 8th hour. This decrease was weakly correlated with the volumes infused between the two samples (r2 =0.13, p < 0.001). A resuscitation above 5.2 ml/kg/ % Burn surface area is an independent factor for excess mortality. ConclusionHematocrit or its variations in our limited data base appears to not reliably detect over-resuscitation, therefore it is possible that it may not be a relevant marker. These conclusions should be clarified in a multi-institutional prospective or real-world analysis to validate the findings and null hypothesis.

The Accuracy of Prehospital Fluid Resuscitation of Burn Patients: A Systematic Review

Early management of burns is an essential component of achieving desirable patient outcomes. One of the earliest points of patient management in the case of burn injuries is in the prehospital setting. Unlike first aid, which can be provided by a non-healthcare worker, fluid resuscitation can be provided in the prehospital setting by emergency medical services personnel. This systematic review aims to investigate whether burn patients are receiving accurate fluid resuscitation in the prehospital setting. In addition, it will investigate if existing inaccuracies could impact patient outcomes negatively. This systematic review was completed in accordance with the guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The search for eligible studies started by searching relevant databases (PubMed, Embase, Medline, and Google Scholar). The selected studies were screened, and data were extracted and analyzed using a narrative synthesis approach. Seven studies met the inclusion criteria of this review, with a total of 961 patients. All seven studies included in this review reported that the volume of fluids for resuscitation purposes received by burn patients in the prehospital setting was inaccurate. However, most reported that the patient outcomes were not affected. Most of the studies were rated as “good,” however, and further high-quality randomized control studies are required before strong recommendations can be made.

Impact of Chronic Alcohol Use on Fluid Resuscitation in Burn Patients.

Acute alcohol intoxication in burn patients has been associated with increased mortality, renal dysfunction, and difficulty with adequate fluid resuscitation. It is less clear how chronic alcohol use, regardless of intoxication status on admission, impacts patient outcomes. In this study, we examine varying levels of alcohol use in burn patients and its impact on both short- and long-term outcomes.

7 Impact of Chronic Alcohol Use on Fluid Resuscitation in Burn Patients

IntroductionAcute alcohol intoxication in burn patients has been associated with increased mortality, renal dysfunction and difficulty with adequate fluid resuscitation. It is less clear how chronic alcohol use, regardless of intoxication status on admission, impacts patient outcomes. In this study, we examine chronic alcohol use and both short- and long-term outcomes in burn patients.MethodsPatients were identified using an institutional burn center registry and linked to clinical data. Adults admitted from 2017 to 2020 with a total body surface area (TBSA) % above 10% and a hospital stay greater than 2 days were eligible for inclusion. A total of 298 patients were enrolled and chart review completed for admission labs and fluid administration. Alcohol use was also examined and patients were staged based on severity and chronicity of alcohol use: none/minimal, early/moderate use, and problem/severe abuse. Renal dysfunction was defined based on Acute Kidney Injury Network criteria. Linear regression was used to assess the association between alcohol use and fluid resuscitation. Multiple logistic regression was used to assess alcohol use and renal dysfunction with adjustment for confounders.ResultsCompared to patients with none/minimal (NM) alcohol use and early/moderate (EM) alcohol use, patients in the problem/severe (PS) alcohol use category were older (NM 45.4 years, EM 44.1 years, PS 52.2 years; p=0.02), had larger mean TBSA burns (NM 18%, EM 14.9%, PS 23.1%; p=0.03), were more likely to have third degree burns (NM 53.8%, EM 36%, PS 72.4%; p=0.02), and more likely to have inhalation injury (NM 7.2%, EM 0%, PS 24.1%; p< 0.001). Patients in the PS category also had a significantly longer hospital length of stay (LOS) (p< 0.001), ICU LOS (p< 0.001), and ventilator days (p=0.005). Mortality was higher for the PS group (21.7%) compared to the NM (6.6%) and EM (0%) groups; p=0.001. These correlated to higher mean hospital costs for patients in the PS category compared to those in the NM category ($394,964 versus $868,126, p< 0.001). After adjusting for TBSA, patients in the PS category required more fluid resuscitation within 48 hours of admission compared to the NM category (p=0.0138), despite a lower mean admission BMI (27.1 vs 30.03, p=0.03). Although there was a trend toward increased rates of acute renal injury within 48 hours of admission in the PS group (32.7%) vs the NM group (21%), this did not reach statistical significance.ConclusionsChronic alcohol use was associated with more severe burn injury, increased morbidity and mortality, and greater resource use. Even after adjustment for comorbidities and TBSA, chronic alcohol use resulted in a need for increased initial fluid resuscitation.

97 Arterial Waveform Variations as Measures of Resuscitation Adequacy in a Porcine Model of Burn Injury

IntroductionOptimized fluid resuscitation of burn patients is a clinical care challenge as both under- and over- resuscitation have deleterious consequences. The gold-standard endpoint guiding burn resuscitation is urinary output (UO), which is known to have limited efficacy. We investigated the potential of the dynamic indices of fluid responsiveness derived from arterial blood pressure (BP) waveforms in conveying information about burn resuscitation. In particular, we investigated pulse pressure variation (PPV) and systolic pressure variation (SPV), which have been shown to be valuable in a number of other indications.MethodsWe conducted a retrospective analysis of arterial BP waveform data acquired from six anesthetized and mechanically-ventilated pigs (33±5 kg weight and 40% total burned surface area) which were instrumented for hemodynamic monitoring for 24 hours. The animals were either under-, over-, or adequately-resuscitated (guided by a burn resuscitation decision support system), with two animals in each group. PPV and SPV were calculated on an hourly basis. Fluid responsiveness thresholds of 15% and 6% were used respectively for PPV and SPV, as per literature.ResultsAll of the animals experienced an immediate rise in PPV and SPV following the injury (PPV and SPV start from large values as seen in Fig. 1 and Fig. 2). In the under-resuscitated group, PPV and SPV increased above the threshold, reaching maximum values in the last eight hours (PPV: 49.8±20%, SPV: 24.7±3.6%), indicating severe hypovolemia. In the over-resuscitated group, PPV and SPV decreased below the threshold, reaching their minimum in the last eight hours (PPV: 8.7±3.6%, SPV: 4.1±1.9%), indicating major hypervolemia. In the adequately-resuscitated group, PPV and SPV maintained closer to the threshold throughout the duration of the experiment, and at the end, PPV was 15.6±4.2% and SPV was 6.2±2.6%.ConclusionsOur initial results suggest that PPV and SPV may help distinguish under-, adequately-, and over-resuscitated burn patients, and potentially complement UO in the hemodynamic assessment of the burn injury patients.

A Fuzzy Inference System Model for Fluid Resuscitation of Burn Patients

A Fuzzy Inference System Model for Fluid Resuscitation of Burn Patients

Early Fluid Resuscitation of Burn Patients Based on High-Precision Weighing System

Correct and continuous weight measurement of a burn patient is important for fluid resuscitation. Generally, a body weight bed uses four sensors to obtain signals. However, owing to signals dynamic characteristics, the air fluidized therapy bed has a large error in this mode, which is difficult to reduce. In this study, we optimized the sensor configuration scheme and developed a set of signal processing and methods to evaluate noise reduction. Additionally, the wavelet neural network was used to improve the weighing accuracy. Furthermore, medical tools are located on different body parts of a patient to acquire weight characteristics to assist with the rehydration of patient. The average error of 183.33g is acceptable from a medical perspective. An average error of 250.21g in dynamic weight after using wavelet de-noising and wavelet neural network methods was obtained.

Let's Escape Didactics: Virtual Escape Room as a Didactic Modality in Residency.

The virtual escape room is a didactic activity for emergency medicine residents (interns, junior residents, senior residents). Residency programs are employing a wide variety of active learning techniques to engage their learners, including large-group discussion, small-group activities, team-based learning, gamification, problem-based learning, role-playing and case studies. In recent years, educators have drawn their attention to educational escape rooms, a new type of learning activity that utilizes collaborative learning activities to foster creating thinking, communication, teamwork and leadership.1-3 There have been a number of cases in medicine, 4,5 but there have been limited works published on the use of virtual educational escape rooms in residency education.Unfortunately, the COVID pandemic has made participation in an escape room more difficult. In lieu of social distancing during the COVID pandemic, participation in a virtual escape room is an effective and flexible learning modality for resident didactics that appears to promote participant satisfaction, competency, learning, and engagement. By the end of the activity, learners should be able to:Identify the hazardous chemicals associated with house firesClassify burn injury according to depth, extent and severity based on established standardsRecall the actions to take in response to fire emergencies (R.A.C.E. and P.A.S.S. acronyms)Recall key laboratory features of cyanide and carbon monoxide poisoningsIdentify appropriate management strategies for smoke inhalation injuriesRecite the treatment for cyanide and carbon monoxide poisoningsDescribe the management of the burn injuriesCommunicate and collaborate as a team to arrive at solutions of problemsDisplay task-switching and leadership skills during exerciseEvaluate virtual escape room experience. Emergent care of burns, a popular and shared topic in both Emergency Medicine and Family Medicine literature, was chosen and educational objectives were developed. The website Deck.Toys was utilized to formulate the escape room along with puzzles around the educational objectives. Students congregated remotely on Zoom, and after instructions, were separated into teams to solve content-specific puzzles in order to escape the room. Teams which solve all the puzzles in the allotted time were considered to have successfully escaped the room. After the allotted time, the faculty led debriefing, and topic discussion occurred. Sixty-three participants composed of residents (24 emergency [EM], 29 family medicine [FM], 4 combined emergency and family medicine [EM/FM]), advanced practice practitioner trainees (2 EM), and faculty member participants (4 FMP) partook in the virtual escape room experience. At the end of the activity, a 17-item survey using Likert-scale questions was embedded in order to obtain feedback regarding satisfaction, engagement, learning, and medical competency in communication, collaboration, task-switching, and leadership skills. Eighteen out of 63 participants filled out the survey. This was the first virtual escape room experience for 94% of the respondents. A majority (88.9%) of respondents enjoyed the virtual escape room, finding it fun, interesting, engaging, and interactive. None of the respondents preferred traditional didactics over the virtual escape room activity, and 72% were either just as or equally as satisfied with virtual compared to in-person escape rooms. Nearly all respondents agreed that the activity encouraged collaboration, communication skills, task-switching, and leadership skills (94.4%, 88.9%, 72.2%, 72.2%, respectively). Participation in a virtual escape room is an effective and flexible learning modality for resident didactics that appears to promote learner satisfaction and engagement. The escape room also promoted important competencies encouraged during residency, such as interpersonal and communication skills and practice-based learning and improvement, and is an effective addition to virtual learning tools. Small group activity, team-building exercise, remote learning, virtual learning, educational games, gamification, medical education, escape room, millennials, student engagement, adult learning theory, emergency medicine residents, family medicine residents, chemicals in house fires, smoke inhalation injuries, burn classification, burn injury management, carbon monoxide poisoning, cyanide poisoning, R.A.C.E. acronym, P.A.S.S. acronym, fluid resuscitation in burn patients, burn referrals.

Fluid resuscitation in burn patients with sepsis

Background. There are several differences between sepsis surgical patients and burn sepsis. The effects of mediators and pathogens lasts for months if burn injury is greater than 30 % TBSA. The purpose is to improve the fluid therapy regimens for burn septicotoxemia and burn sepsis.&#x0D; Materials and methods. The study is based on the observation of 52 patients with burn sepsis treated at the Kyiv City Clinical Hospital No. 2 during 2017–2019. The patients were divided into three groups: first group received Ringer lactate, sodium chloride and other iso-osmolar solutions, second group – Ringer lactate + Reosorbylact at a dose of 10 ml/kg per day, third group – Ringer lactate + Reosorbylact at a dose of 15 ml/kg per day.&#x0D; Result. Patients received plasma to correct the wrapping system, 20 % albumin was administered when total protein level was below 50g/l. Daily use of Reosorbylact at a dose of 10–15 ml/mg helped to reduce the number of leukocytes, leukocyte intoxication index, low molecular weight metabolites (urea and creatinine), as well as the content of MSM in plasma (1.6 times), and reduce the activity of AST and ALT, lowering the level of CRР. During the observation in patients of groups 2 and 3 there was a significantly lower heart rate than in the group of crystalloids (P = 0.002), as well as higher mean blood pressure (P = 0.03), an increase in diuresis. The 24-hour fluid balance in the patients of the study groups was respectively: 64 ml/kg; 60 ml/kg and 52 ml/kg. Septic shock developed in 15.7 %, 11.8 % and 12.5 % patients of the study groups. Patients had a shorter duration of treatment with vasopressors (2.8 ± 1.5 days vs. 4.7 ± 1.4 days).&#x0D; Conclusions:&#x0D; &#x0D; The use of reosorbylact for patients with burn sepsis has led to a decrease in the overall fluid balance during the day.&#x0D; The incidence of septic shock decreased by 3.9 % and 3.2 % in the groups where Reosorbylact was used, the duration of vasopressor treatment decreased by 0.4 and 1.9 days.&#x0D; The detoxication and hemodynamic effect of Reosorbylact has been proved.&#x0D; A dose-dependent effect of Reosorbylact was observed.&#x0D; &#x0D; The study had some limitations. Thus, the conclusion of the study needs further study with more sampling

Influence of inhalation injury on fluid resuscitation of massive burn patients during shock stage

Objective: To explore the influence of inhalation injury on fluid resuscitation of massive burn patients during shock stage. Methods: A total of 74 massive burn patients (65 males and 9 females, aged 21 to 65 years) admitted to the Second Affiliated Hospital of Air Force Medical University (n=57) and Yan'an University Affiliated Hospital (n=17) from May 2009 to December 2019 were enrolled in this retrospective cohort study. Patients were divided into inhalation injury group (n=56) and non-inhalation injury group (n=18) based on clinical symptoms, vital signs, and results of bronchofibroscopy. Then 26 patients in inhalation injury group and 13 patients in non-inhalation injury group were 1∶2 matched by case-control matching based on the difference of total burn surface area. The total fluid replacement coefficient, crystalloid replacement coefficient, colloid replacement coefficient, glucose input volume, ratio of crystalloid to colloid, urine volume, and cumulative ratio of input to output volume during the first 24 h post injury, the second 24 h post injury, and the third 24 h post injury, heart rate, respiratory rate, mean arterial pressure (MAP), and hematocrit (HCT) at post injury hour (PIH) 24, 48, and 72 were recorded and compared between the two groups. Data were statistically analyzed with analysis of variance for repeated measurement and Bonferroni correction, t test, Fisher's exact probability test, and Mann-Whitney U test. Results: (1) After matching, during the first to third 24 h post injury, the total fluid replacement coefficient and glucose input volume of patients in inhalation injury group were significantly higher than those in non-inhalation injury group (F=4.202, 10.671, P<0.05 or P<0.01). During the first, second, and third 24 h post injury, the total fluid replacement coefficient, crystalloid replacement coefficient, colloid replacement coefficient, and ratio of crystalloid to colloid were similar between the patients in two groups(t=-1.336, -1.452, -1.998; -0.148, 0.141, 0.561; 0.916, -0.046, -0.509; -1.024, 0.208, 0.081, P>0.05). During the first, second, and third 24 h post injury, the glucose input volume of patients in inhalation injury group were respectively (2 996±1 176), (2 659±1 030), and (2 680±1 509) mL, which were significantly higher than (2 125±898), (1 790±828), and (1 632±932) mL in non-inhalation injury group (t=-2.334, -2.639, -2.297, P<0.05). (2) After matching, in overall comparison between groups, during the first to third 24 h post injury, the urinary output volumes and cumulative ratios of input to output volume of patients in inhalation injury group were significantly lower or higher than those in non-inhalation injury group, respectively (F=12.158, 9.111, P<0.01). At PIH 24, 48, and 72, heart rate of patients in inhalation injury group were significantly higher than those in non-inhalation injury group (F=4.675, P<0.05). There were no statistically significant differences in heart rate, respiratory rate, MAP, and HCT between patients in the two groups at PIH 24 and 48 (t=-0.039, -1.688, 1.399, 1.299, -1.741, 0.754, -0.677, 0.037, P>0.05). During the first and second 24 h post injury, the urine volume and cumulative ratio of input to output volume of patients in inhalation injury group were respectively significantly lower and higher than those in non-inhalation injury group (t(urine volume)=2.421, 2.876, t(cumulative ratio of input to output volume)=-2.687、-2.943, P<0.05 or P<0.01). At PIH 72, the heart rate and HCT of patients in inhalation injury group ( (114±13) times/min, 0.42±0.06) were significantly higher than those in non-inhalation injury group ( (98±18) times/min, 0.38±0.06, t=-3.182, -2.123, P<0.05 or P<0.01), there were no statistically significant differences in respiratory rate and MAP between the patients in two groups (t=0.359, 1.722, P>0.05). During the third 24 h post injury, there were no statistically significant differences in urine volume and cumulative ratio of input to output volume between the patients in two groups (t=1.664, -1.895, P>0.05). Conclusions: The presence of inhalation injury can lead to increased fluid requirement in massive burn patients during shock stage. An appropriate increase of fluid volume in the fluid resuscitation of burn patients combined with inhalation injury would be beneficial for maintaining ideal urine output.

500 Intracranial Injuries and the Effect of Fluid Resuscitation in Burn Patients

Abstract Introduction Few studies exist that describe the neurologic injuries seen in patients admitted to the burn ICU. Patients who have sustained a severe thermal injury undergo complex metabolic, hemodynamic, and inflammatory changes and require aggressive fluid resuscitation. The neurologic consequences of burn-associated resuscitation may have clinical implications. The purpose of this study was to evaluate the intracranial neurologic injuries and how they relate to volume of burn-related resuscitation fluids administered. Methods We performed a retrospective analysis of all patients admitted to the Burn ICU at a single facility between January 2003 and June 2017. Patients were included if they were admitted within 24 hours of their burn injury and obtained head computed tomography (CT) for any indication in the first 96 hours of hospitalization. Results Of a total 5176 patients admitted, 439 met the inclusion criteria. An acute intracranial process was identified in 41 cases. 27 patients received 0–150 cc/kg of IV fluids, while 11 received &amp;gt;200 cc/kg during the first 24 hours. The most common injuries in the former were hemorrhage (subarachnoid, intraparenchymal) and edema (7/27 for each), while ischemia/infarction (4/11) was the most frequent in those receiving &amp;gt;200 cc/kg. Follow up imaging was more likely to be worse in the &amp;gt;200 cc/kg group (5/11) than in the &amp;lt; 150 cc/kg group (2/27). Conclusions Of patients admitted to the Burn ICU within 24 hours of injury and who received a head CT within the first 96 hours, an acute intracranial abnormality was found in 8% of patients. The most common diagnosis was hemorrhage in those receiving &amp;lt; 150 cc/kg of IV resuscitation, while ischemic/infarction was more common in those receiving &amp;gt;200 cc/kg. Follow up imaging in those receiving more IV fluids was more likely to demonstrate worsening, which could suggest that increased resuscitation leads to worsening intracerebral outcomes. Applicability of Research to Practice Having a high index of suspicion for intracranial complications related to resuscitation improves the multi-disciplinary team’s ability to prevent, identify early and treat appropriately in order to improve patient outcomes.

Resuscitation in Extensive Burn in Pediatrics and Fluid Creep: an Update

Excessive administration of crystalloid and the abandonment of colloid replenishment at certain point of resuscitation are the major contributors to fluid overload, leading to a phenomenon termed fluid creep. Over-resuscitation in burn pediatric patients often results in fluid overload and many complications characterized by anasarca, orbital compartment syndrome, extremity compartment syndrome, bloodstream infections, pneumonia, abdominal compartment syndrome, and pulmonary edema requiring a prolonged and potentially complicated hospital stay. Permissive hypovolemia has been shown to effectively reduce organ dysfunction, when applied a rigorous control of diuresis. More recently, a urine output target of 0.5 to 1 ml/kg/h in the first 48 h of fluid resuscitation has become a trend in the monitoring of pediatric patients. Colloids appear to be an essential component for the resuscitation of severely burned patients. Many strategies were developed to optimize fluid resuscitation in burn patients, and until current days there are controversies regarding the most efficient method to determine the ideal volume of fluid to avoid hypovolemic shock and complications from over resuscitation as well. The success of resuscitation is related to the administration of lower fluid volumes. Some centers have demonstrated that selection of more strict protocols of fluid resuscitation, rigorous diuresis control, moderate use of opioids, and early and regular use of albumin are correlated to positive outcomes and thus may attenuate the urgence of fluid creep.

Tissue Inflammatory Markers and Oxidative Stress in Swine Subjected to a 40% TBSA Burn Injury

Burn injury is well known to induce a robust inflammatory response and hypermetabolic state. Intravenous (IV) crystalloid fluid resuscitation of burn patients is the foundation of modern burn care to improve tissue perfusion and outcomes. However, under military scenarios of far‐forward burn care or under civilian mass casualty situations, the availability of large volumes of such fluids for IV burn resuscitation will be logistically challenging and definitive burn care may be delayed for days. More recently, enteral resuscitation of burns has received renewed attention and some evidence suggests that it may reduce IV fluid requirements to support urine output. The present study investigated the early response of tissue inflammatory markers and evidence for oxidative stress in swine subjected to a 40% burn and resuscitated with enteral fluids compared to no fluids or a standard of care IV fluid regimen. Anesthetized Yorkshire swine (n=6 per group) were subjected to a 40% full thickness total body surface area (TBSA) burn with brass probes heated to 100°C. They were then randomized to 4 groups: 1) no fluid (NF), 2) 15 ml/kg/d WHO oral rehydration solution (ORS) (15‐ORS), 3) 70 ml/kg ORS (70‐ORS) or 4) 2 ml/kg/% burn IV lactated Ringer's (Modified Brooke (MB) formula‐ a standard of care). After 48 h, animals were euthanized and heart, liver, kidney, lung and small intestine collected and analyzed for tissue cytokine levels and indices of oxidative stress. As expected, urine output was higher in the 70‐ORS and MB groups than the NF group (p&lt;0.01). Although plasma creatinine and BUN peaked 6 h after burn, levels returned to baseline by 48 h in all groups except 15‐ORS and NF. In the kidney, levels of IL‐1β, IL‐6 and TNF‐α tended to be higher in the 70‐ORS and MB groups, whereas IL‐10 levels were similar among groups. In liver, heart and jejunum, only IL‐1β levels tended to be higher in MB than the other groups, with a similar trend in IL‐10 concentrations. With regard to oxidant status in kidney, total antioxidant levels, glutathione reductase (GR) and glutathione peroxidase activities were higher in 70‐ORS than the other groups. Mn‐superoxide dismutase (SOD) activity was higher in both 70‐ORS and MB groups, with no differences in catalase activity or nitric oxide levels. In liver, the lowest levels of total antioxidants, SOD, GR and catalase activities were observed in the NF groups compared to the others. No significant differences in indices of antioxidant status were observed in jejunum, heart or lung among groups. Typically, these variables in 15‐ORS were similar to the NF group in all tissues. The results of this study indicate that enteral fluids may be as effective as a standard of care IV fluid regimen in maintaining antioxidant status in vital organs without major changes in pro‐inflammatory cytokines. As such, this oral resuscitation may prove lifesaving in resource poor environments and reduce potential IVfluid‐related complications until definitive clinical care is available.Support or Funding InformationFunded by US Army MRMCThis abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

203 Vasopressor Use During Acute Fluid Resuscitation in Burn Patients

It is not known why some burn patients require vasopressor (VP) drugs during the acute fluid resuscitation phase. The purpose of this study was to evaluate factors that predict VP administration during acute burn resuscitation. Retrospective analysis of patients with burns ≥ 20% TBSA admitted within 24 hours post burn (PB) to an adult regional ABA-verified burn center between 11/15/15 and 7/1/17. Patients that received a VP in the 1st 48 hours (PRESS) were compared to those who did not (NOPRESS). Values are shown as the mean ± SD or median (1st, 3rd quartiles) as appropriate. There were 49 patients that met inclusion criteria. Following exclusion for VP administration prior to arrival at the BC (n=3) or provision of comfort measures ≤ 24 hours PB (n=9), a study population of 37 subjects remained. This population’s characteristics were age 47 ± 16 yrs, 35% female, with %TBSA burn 32 (24.5,49.2) and % full thickness burn 20.5 (3.3,39.8), and 32% with inhalation injury (INH). In the PRESS group, VPs were initiated at 24.3 ± 13 h PB, and were continued for 13.9 ± 10.5 h during the 1st 48 h PB period. The total amount of resuscitation fluid administered up to the initiation of VPs was 4.1 ± 2.2 mL/kg/%TBSA burn, and at the start of VPs, 119.6 ± 55.1 % of predicted resuscitation fluid had been infused. The 1st VP was norepinephrine in all cases. Vasopressin was added in two cases and epinephrine was added in 4 cases. PRESS and NOPRESS are compared in the table. There were no differences between the groups in % of predicted resuscitation fluid administered at 6,12, and 24 h PB, urine output, use of propofol for sedation, or the dose of opioids and benzodiazepines at 24 and 48 hours PB. High dose vitamin C had been used in 47% of PRESS resuscitations and in 23% of NOPRESS resuscitations (p=0.127). Only age was a significant predictor of need for VPs [OR 1.17 (95%CI: 1.01–1.36)]. Advanced age appears to be the main predictor of the need to initiate VPs during acute fluid resuscitation after burns. However, this study is limited by a small sample size and other factors may be contributory. VPs may be required in older patients despite acceptable fluid provision, during acute burn resuscitation.

The impact of patient weight on burn resuscitation.

Optimal fluid resuscitation of burn patients with burns greater than 20% total body surface area is critical to prevent burn shock during the initial 24 hours to 48 hours postburn. Currently, most resuscitation formulas incorporate the patient's weight when estimating 24-hour fluid requirements. The objective of this study was to determine the impact of weight on fluid resuscitation requirements and outcomes during the initial 24 hours after admission. We performed a retrospective review of patients admitted to our burn intensive care unit from December 2007 to April 2013, resuscitated with a computerized decision support system. We classified patients into body mass index (BMI) categories of underweight (BMI: <18.5), normal (BMI: 18.5-24.9), overweight (BMI: 25.0-29.9), or obese (BMI: >30.0). We also calculated the percent difference from ideal body weight (IBW) and compared 24-hour fluid volumes received. Patients with missing weight and/or height values were excluded from the study, resulting in a final cohort of 161 patients for analysis. Mean total body surface area was 42 ± 20% with a full thickness burn of 18 ± 23%. Mean age, weight, and height were 47 ± 19 years, 83 ± 19 kg, and 68 ± 4 inches, respectively. IBW for this cohort was 68 ± 11 kg with a BMI of 28 ± 6. Univariate analysis showed significant differences in 24-hour resuscitation volumes (mL/kg) between normal and obese patients (p < 0.05). Further analysis revealed that increasing percent difference from IBW was associated with lower fluid volumes. Although obesity was not associated with inhalation injury or renal replacement therapy, it was correlated to an increased risk for mortality (p < 0.05). This analysis showed that increasing weight was associated with lower fluid resuscitation volume requirements and a higher mortality rate, despite the low incidence of inhalation injury and renal replacement therapy in our obese patients. The use of actual body weight to drive resuscitation volumes may result in overresuscitation of obese patients, depending on the resuscitation formula. Further studies are needed to better explain the relationship between mortality and obesity in burn patients. Therapeutic/care management, level IV.

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Introduction: Fluid resuscitation of burn patients is critical during the initial 48 hours post burn. Inappropriate fluid management of the burn patient may result in over or under resuscitation leading to serious complications and death. Hypothesis: The use of a computerized decision support system (CDSS) for fluid resuscitation of burn patients is able to maintain patients within appropriate resuscitation targets. Methods: We performed a retrospective cohort review of 207 patients admitted to our burn intensive care unit (BICU) from December 2007 to June 2012. Inclusion criteria included requirement for active fluid resuscitation as defined by a total body surface area (TBSA) greater than 20%. Patients were resuscitated using a custom CDSS. The system provides crystalloid recommendations every hour post admission based on a target urinary output (UOP) of 30 to 50 ml/hr, and providers are free override the system’s recommendations at any time. Average crystalloid volume of fluid infused per hour was analyzed and compared to predicted volumes based on the Modified Brooke (MB) resuscitation formula (2 ml/kg/TBSA) and Parkland (PK) resuscitation formula (4 ml/kg/TBSA) during the initial 24 hours post burn. UOP was also analyzed for meeting target rates during the resuscitation period. Results: Mean cohort age was 44 ± 21 years with an average weight of 89 ± 61 kg. Mean TBSA burn was 41 ± 19% including an average of 17 ± 22% full thickness. Average total fluid administered during the initial 24 hours (11.1 ± 6.4 L) was significantly higher than MB (7.1 ± 4.6 L, p<0.01) and lower than PK (14.2 ± 9.1 L, p<0.01) with a normalized volume of 3.49 ± 1.95 ml/kg/TBSA. Total resuscitation volume during the initial 8 hours was not significantly different from the expected MB volume (3.4 ± 2.7 L vs. 3.5 ± 2.3 L, p=0.40) but was significantly lower than the expected PK volume (3.4 ± 2.7 L vs. 7.1 ± 4.6 L, p<0.01). Total volume during the second 16 hours (7.7 ± 4.8 L) was significantly higher than MB (3.5 ± 2.2 L, p<0.01), but was not different from the expected PK volume (7.1 ± 4.6 L, p=0.13). Mean UOP for the initial 24 hours was 55 ± 28 ml/hr with a median value of 49 ml/hr and mean rate of 0.66 ± 36 ml/hr/kg. Quartile analysis resulted in 50% of UOP values occurring between 36 ml/hr and 68 ml/hr. Conclusions: Use of our CDSS resulted in average crystalloid volumes bounded between the lower MB and the upper PK formulas while maintaining appropriate UOP values. This analysis shows that implementation of a CDSS can be an effective tool for care of patients in the critical care environment.

A review of emergency department fluid resuscitation of burn patients transferred to a regional, verified burn center.

The purpose of this study was to examine the adequacy of burn patient fluid resuscitation in relationship to the American Burn Association formula before arrival at a regional burn center. Further substratification of the data was undertaken to compare total burn surface area and fluid volume resuscitation as evaluated from the primary hospital's emergency department staff vs. the burn intensive care unit staff. The charts of all patients admitted to the burn center during 1 year were reviewed retrospectively. Data were compiled to calculate the time of injury, time of arrival in the referring emergency room, time in transit to the burn unit, and time of arrival in the burn unit. The total number of patients evaluated in the study was 41. Patients who were not referred from outside hospitals or who had incomplete charts were excluded. The average time from initial burn to transfer to the burn intensive care unit was 6.26 hours (range, 0.5-96 hours). The average total body surface area (TBSA) evaluated by the referring emergency department staff was 23.9% (range, 5-70%) compared with the burn intensive care unit staff evaluation average of 17.8% (range, 2-55%). Using the referring emergency department staff TBSA percentage, evaluation of the data revealed that only 23% of patients fell within the accepted range using the American Burn Association formula. Furthermore, 30% of patients were overresuscitated whereas 47% were underresuscitated. Of the overresuscitated patients, 1 patient was critically overresuscitated. In the group of underresuscitated patients, five were critically underresuscitated. Thirty-three percent of the patients' TBSA had a more than 50% discrepancy between the burn unit and the emergency department calculations. The authors conclude that better educating providers referring patients to regional burn centers can make a marked improvement in the overall care of burn patients. More important, early communication with the referring burn staff has been encouraged. Early communication permits review of estimated TBSA burn evaluations and permits cooperative calculations and optimal delivery of early fluid resuscitation. Burn center practitioners can improve care of patients before arrival by appropriately guiding the referring physician.

The Rational of Colloid Requirements in Burn Patients : Literature Reviews

Backgrounds: For decades, fluid resuscitation in burn patients has been done as a routine process; most clinicians continue to adjust volume requirements using Parkland formula for the initial 24- hour period. In a variety of situations, there is increasing recognition of using significantly greater volumes than anticipated by the Parkland formula; clinicians tend to escalate volume requirements to drive the urine output to the higher end of any desired range. This excessive fluid could result in numerous edema-related complications, which currently coined as “fluid creep” phenomenon. Besides optimizing titration of fluid infusion rate, there have been studies of earlier and more liberal use of colloids, and even the use of hypertonic saline. The overall goal is to reduce the resuscitation volume requirements and subsequently, early edema formation.Conclusion: Current research in fluid resuscitation now concentrates on approaches to minimize fluid creep, including tighter control of fluid infusion rate. The single most important principle in using the Parkland formula, however, is that it should be used only as a guideline. The resuscitation rate and volume must be continually adjusted based on the response of the patient. Studies have been demonstrated to compare the use of crystalloids with early colloid in the first 24 hours post burn. At present, there are still wide variations in the timing of colloid resuscitation. However, use of 5% albumin in the second 24 hours seems to be an acceptable alternative.