SCCM Resource Library-Pro/Con: Burn Resuscitation: How Much to Pour and With What?

Video Transcription

I would love to start by telling you all thank you for your interest in this topic and for allowing Dr. Cancio and I to speak with all of you today.  My name is Amalia Cochran and I am here to talk to you about PRO in terms of being more aggressive with burn shock resuscitation with the idea being to turn the faucet on that  more is better, although I will also tell you in the interest of equanimity I did put a question mark after more is better.  To give you all the overall objectives of what's going to happen here is there will be a description of the complications of inappropriate burn shock resuscitation.  You'll get Dr. Cancio's side in terms of less is better and you'll get mine that I am taking in terms of more is better.  He has also included some information in his talk about appropriately utilizing fluids other than lactated ringers for burn shock resuscitation and I'm going to talk a little  bit about effectively monitoring burn shock resuscitation in a variety of environments.  I'm going to give you kind of low tech, intermediate tech, and high tech options that are available out there. So if some is good, more must be better, right?  And I say that a little bit flippantly because of the fact that there are definitely consequences  to over resuscitating and Dr. Cancio has all sorts of wonderful illustrations of that in his talk and there are also dangers to under resuscitating and I think that we have to  be thoughtful in our approach because of that. Major burns, burns that are more than 20% total body surface area do require a formal resuscitation.  I'm not saying that burns smaller than that don't require resuscitation but burns of that size or larger absolutely unequivocally require resuscitation.  Burn shock is a complex process of circulatory and micro circulatory dysfunction. It's not entirely remedied by fluid resuscitation although fluid resuscitation is sort of our  equivalent of sticking our finger in the proverbial dam and it's really a result of tissue damage or loss and inflammatory mediators so it's a really complex interaction.  The goals of burn shock resuscitation are to restore and maintain adequate intravascular volume as well as to provide adequate organ perfusion and I think that the small letters  at the bottom of this are really the important point and that is simply that left untreated patients in burn shock will die.  I did want to bring up an important quote from my esteemed colleague who is on the con side of this.  Inadequate or delayed fluid resuscitation causes organ failure or death and this obviously would have been a whole lot more fun in person to be able to quote this since I'm taking  the side of well less is not good. There are a few factors that will increase fluid requirements in patients who have burn  shock and it's important to realize that any resuscitation formula is really only a starting point.  All burn injuries are different and the inflammatory response that affects the patient's response to resuscitation is highly variable.  This list includes a lot of features that are associated with increased volumes of fluid that are required by burn patients so you have a delayed resuscitation that can occur  which has a risk of ischemia reperfusion injury. You can have smoke inhalation injury which can increase fluid requirements by up to 50% over what you might estimate them to be.  There's an increased burden of inflammatory response and therefore the need for fluid resuscitation for patients with third degree aka full thickness burn injuries.  High voltage electrical injury, I tell everyone it's always a lie because what you see is not actually what you have going on in terms of damage to the underlying tissue.  There are certainly associated soft tissue injuries if you have a burn and trauma patient that's a combined patient, they're infinitely more complex.  And then methamphetamine use, I spent years practicing in the Mountain West and this was really something that we saw commonly and it made our resuscitations a great deal harder  and the group out at UC Davis actually did some really nice studies demonstrating this as did the group at Iowa.  Bad things do happen without formal burn shock resuscitation and these are some physiologic bad things that happen. So first of all you do have a reduced venous return to the heart.  You have reduced intravascular volume because people get leaky. This is associated with a reduced end systolic volume and it results in a reduced cardiac  output and more specifically if you want to think about the consequences of reduced cardiac  output that is often associated with non-occlusive mesenteric ischemia and nobody likes dealing with dead gut, let's be honest about that.  There are the real possibility of increased oxygen demands and damaged tissues. Thank you leukocytes, sometimes you're our friends, in this case you're not and so there's  compensation through tachycardia that's somewhat limited to that increased oxygen demand.  Superfusion can become compromised and this ultimately results in end organ damage and failure and so these are just sort of a quick overview of the bad things that happen.  I think it's important also to understand that restrictive resuscitation may lead to acute kidney injury.  This is a very nice study and the QR code on any of my slides that you see will actually link you to a website where you can access these studies but these were factors associated  with acute kidney injury and you see that the p-value is 0.02 for the patients in the restrictive fluid resuscitation group and a three times increased odds ratio for AKI  with a restrictive resuscitation strategy. Let's be honest, this slide really highlights the fact that everyone is giving more volume than we like to think that we're giving.  This is data gleaned from the abrupt trial which was a retrospective multi-center study looking at how much volume was being given for burn shock resuscitation and what it really  demonstrates is that we are all resuscitating in excess of Parkland. Here in this table that I'm sharing with you are the fluid resuscitation characteristics  for the entire cohort and what you notice is that for the whole cohort, the total fluid in mLs per kg per percent TVSA was 4.6 plus or minus 2.2 and remember that Parkland is  4.0 in the first 24 hours. Crystalloid group was a little bit below that four benchmark although with your standard  deviation it's close and then the albumin group was higher although I'm also going to tell you that because I was at the center at Utah that contributed data to this study  and we always used albumin as rescue for people who were failing on crystalloid that there's a little bit of a mitigating factor in terms of this does not account for the fact that  these may have been patients that were failing resuscitation on a different protocol. I'm going to move away from the discussion about more versus less and which is better  and which is worse because my hope is that by the end of this session you will have an understanding that Dr. Canciano and I may agree to some extent with each other's viewpoints  that we have taken for this and that really what we want you to understand is that fluid resuscitation needs to be individualized to the patient and so while we've talked about  the complications of inappropriate resuscitation we really want you to walk away with an understanding  of the fact that there are alternative fluids to crystalloid that can and should be used at times and also that there are a variety of ways that we can monitor burn shock and  this really gets to the heart of being able to individualize therapy for patients. This again gets to this whole question of the burn resuscitation pendulum which Dr.  Canciano goes into much more depth about where we've got all of these different formulas that are floating around out there none of which seems to get it exactly right.  Current recommendations from the American Burn Association are the use of the consensus formula for the initiation of burn fluid resuscitation. So what are our low-tech options?  Let's say that you're in a place where you just don't have access to a lot of sophisticated things or you're just not a fancy person which is totally okay.  So you can just use simple physiologic parameters so heart rate, blood pressure, if you're able to access the central venous pressure you could consider that and then urine output  is also another option. Here are the issues though, heart rate and blood pressure or mean arterial pressure are notoriously unreliable in burn patients.  They can be impacted by so many other things besides where they are with their volume resuscitation  and to be honest central venous pressure doesn't really change much in the first hours of burn resuscitation nor does it predict fluid responsiveness.  Use of urine output is definitely user dependent and it needs to be both observed and acted upon and it alone is not a reliable predictor of hypovolemia.  It has proven time and again to be the most effective monitor of burn shock resuscitation. There are a few lab values that are not super fancy lab values that can be used for sort  of low tech monitoring. Hematocrit you can certainly tell if someone's hemoconcentrated. Base deficit and serum lactate have also been looked at in some detail.  Using lactate and base deficit for goal directed resuscitation has really only shown that patients  get more fluid but that resuscitating to those goals doesn't actually improve clinical outcomes. What about medium tech?  Well there's echocardiography and ultrasound which is an option. Unfortunately this hasn't really been shown to maximize cardiac function and intravascular  volume but it also perhaps has not received adequate evaluation because no studies have been done to date that use echo to guide resuscitation decisions.  So this may be an area that's actually ripe for further investigation as could you consider  doing trans thoracic ultrasound slash echocardiography guided burn shock resuscitation. I think it's possible.  Volumetric parameters are out there and there's something that there's been increasing discussion around.  Use of non-invasive or minimally invasive really hemodynamic monitoring to look at either pulse pressure variation or stroke volume variation.  Interestingly pulse pressure variation has better accuracy than mean arterial pressure for predicting fluid responsiveness.  However it's the most accurate when the tidal volumes that a patient is taking exceed eight  milliliters per kilogram which is not consistent with a lung protective strategy and when the driving pressure is more than 20 centimeters.  So clearly these have to be people that are on very high ventilator pressure support sorts of situations. What about high tech? Well there's invasive hemodynamic monitoring.  This is almost an area that's ripe for the is the swan dead discussion that I think kind of rears its head every once in a while. Pulmonary artery catheters.  I will tell you if you're looking at PACs versus transpulmonary thermodilution neither of these methods has an obvious use in burns at this point in time.  They do accurately detect hypovolemia in the acute post burn period but they may also lead to over resuscitation.  Transpulmonary thermodilution may show hypovolemia earlier but should not be used alone to guide resuscitations.  If you want the too long didn't read version of looking at this and the data that's sitting there looking at specifically at transpulmonary thermodilution.  Invasive monitoring at this time does not show a clear benefit in terms of clinical outcomes from burn shock resuscitation though it may result in less fluid being given than  what the Parkland formula or the Baxter formula would project. Nurses versus navigators. I actually think this is a really fun area and there are a couple of articles that I  have you linked to here. Nurses have been shown in multiple evaluations of nurse driven research resuscitation protocols  to be able to accurately adjust fluids for burn shock resuscitation. I think that's an important point to make because several of those studies including  ones that I've participated in were really initiated because there were folks in the burn world that were very adamant about well our nurses can't reliably make these changes.  And what several centers, my own prior center at Utah included, where I have been able to  demonstrate is that indeed nurses can be reliable arbiters of what needs to happen using a nursing driven protocol.  Computerized decision support seems to work well and has been adopted by some centers. The ISR in San Antonio has been an early creator and adopter and seems to have been fairly  successful with this. What I would really say is that the jury is still out in this space. We need validation in bigger trials because with the navigators that first trial from  ISR was encouraging and showed decreased total volumes with increased percent of time at target urine output and decreased spent days in ICU stay, but it worked well in one center  and how much of that was a Hawthorne effect. I truthfully don't know. I like to think that I have equipoise around this question and I would love to see us continue  to pursue this in the burn world. So what's my take home message for you? What are our take home messages for you?  Well I think the first one really is the key one and that is that resuscitation should be approached judiciously.  Resuscitation is an individualized experience for each patient, their burn injury, their concomitant morbidities, and any other parts of their injury situation.  And over resuscitation and under resuscitation are both problematic at the end of the day.  Colloids can certainly be part of that individualized resuscitation strategy and can be helpful for reducing the volume that's given.  And the real key lies in the monitoring options. There are a lot of monitoring options available to help you individualize therapy, but no  single method out of these has yet proven to be consistently reliable. As a burn critical care surgeon, I will tell you that I use a combination of the low and  intermediate tech strategies that I talked with you about. I don't use the high tech options that are out there. At some point I may adopt navigators, but I'm not there yet.  And so I will use a smorgasbord of heart rate, blood pressure, urine output, lactates, occasionally  throwing an ultrasound probe on someone's chest to look at what their filling looks like and what their squeeze looks like.  And so I think that what I really want to highlight for you is that even when we feel like we're pretty good at this, we do not have this completely figured out yet.  It is still a work in progress. We're really appreciative of your interest in the topic of burn resuscitation and thank you for your time listening to us today.  Hello, my name is Dr. Lee Cancio. I'm a surgeon and I work at the U.S. Army Burn Center in San Antonio, Texas. Today I will be discussing burn resuscitation.  I will be taking the point of view that we should slow down and that less is better. I have one conflict of interest to mention.  I was a co-inventor of the burn resuscitation decision support system called Burn Navigator. I have assigned my rights to the Army.  Burn shock occupies the first 24 to 48 hours post burn in patients with burns in excess of 10 to 20 percent of the total  body surface area. The physiology of burn shock changes dramatically throughout this period and we must adjust therapy in response. Early there is increased  microvascular permeability which results in rapid loss of fluid similar to plasma from the intravascular space into the interstitium. Thus burn shock is first  and foremost hypovolemic shock. Meanwhile massive catecholamine release causes intense vasoconstriction. There is also a variable degree of myocardial dysfunction.  During the latter half of the first day microvascular permeability begins to be repaired. Most importantly rapid attempts to restore plasma volume through boluses  or aggressive volume loading are bound to fail. Rather permissive hypovolemia should be the goal of burn shock resuscitation. Consistent with this  concept of permissive hypovolemia throughout his career Dr. Basil Pruitt argued in favor of avoiding over resuscitation. For example in 1979 he  stated that the goal of resuscitation is to maintain a vital organ function at the least immediate or delayed physiologic cost. Various formulas have  been developed to help guide burn shock resuscitation and to strike a balance between over and under resuscitation. In most cases these formulas were  empirically derived by clinicians taking care of patients. For example COPE in 1943 noted that the reason for a formula that provided half plasma and half  normal saline was the fact that during the response to the Coconut Grove nightclub fire of 1942 plasma came up from the blood bank mixed half and half  with normal saline. Looking at this list one notes that there was a gradual trend away from plasma and towards crystalloid based formulas. In 1968 Charles Baxter of  the Parkland Burn Center in Dallas along with G. Tom Shires applied the concept of an extracellular sodium deficit to burn shock. They reasoned that  faster restoration of this deficit reduced multiple system organ failure. This led to a doubling of the predicted fluid resuscitation dose from 2 ml to 4  ml per kilogram per percent burn. The subsequent history of the Parkland formula will be discussed below. Over the three decades which followed the  publication of the Parkland formula there appeared increasing reports of what became known as fluid creep. Here Dr. Pruitt commented in an editorial about  post-burn abdominal compartment syndrome that adequate resuscitation has been replaced by fluid creep in the apparent belief that if some fluid is good lots  of fluid will be even better. The consequences of too much fluid can be life-threatening. Indeed the abdominal compartment syndrome as shown here is  perhaps the most devastating example of what Dr. Stephen Wolff has called resuscitation morbidity. Other examples include extremity and orbital compartment  syndromes, cerebral edema, pulmonary and airway edema, gastrointestinal dysfunction, wound progression and delayed healing, and impaired function  especially in the hands. Ivy and colleagues published the first paper about ACS in burn patients. Based on their series and subsequent confirmatory  studies, input of more than the IV index of 250 ml per kilogram during the first 24 hours post burn is thought to confer increased risk of ACS and all efforts  must be made to avoid exceeding this amount. Among other things this is because an open abdomen in a patient with a large burn size is a recipe for  disaster. It becomes very difficult to de-resuscitate these patients and loss of abdominal domain is followed by peritonitis, multiple system organ  failure, and death. Patients with circumferential burns of the extremities are subject to what I call the extremity eschar syndrome. This is not a  true extremity compartment syndrome. In the case of eschar, impaired limb perfusion is solved by an incision through the eschar or an escharotomy. But  in the case of a true extremity compartment syndrome, the problem of limb ischemia is caused by edema within a muscle compartment and impaired limb  perfusion requires an incision through the investing fascia or a fasciotomy. Burn patients can develop a true extremity compartment syndrome as first  described by Sheridan and colleagues. High volume resuscitation is one possible etiology and if not detected and treated acutely it can cause  intramuscular infection and of course limb loss. To underscore the fact that eschar and compartment syndromes are distinct, we documented the occurrence of  extremity compartment syndrome in unburned legs in seven patients with large volume fluid resuscitation and no other injuries to the extremities. None  of these patients emerged unscathed from this complication and two died.  Orbital compartment syndrome may be caused by large volume fluid resuscitation. It is diagnosed by intraocular pressure measurement and is  treated at the bedside by urgent lateral canthotomy and cantholysis as shown here. We have also found that OCS can occur within hours of injury in patients with  deep periorbital burns even before or in the absence of large volume fluid resuscitation, which is one reason we consult ophthalmology early in these  patients. There are many long-term neurological and psychological sequelae of extensive thermal injury and these phenomena are not fully understood, but  there is reason to believe that cerebral edema that develops during burn shock may play a role. These authors inserted intracranial pressure monitors into 32  patients with burn size of over 60% and without concomitant head injury. They found a peak intracranial pressure of 31.4 and a nadir cerebral perfusion  pressure of 41, both of which occurred on average on day two. Low ICP and high CPP were associated with survival. Meanwhile, there are multiple animal studies which  point to disruption of the blood-brain barrier by pro-inflammatory mediators during burn shock. This again is reason to be cautious about over-resuscitation.  Zach and colleagues studied pediatric scald patients. They found that some of these patients required endotracheal intubation during burn shock despite  having no direct injury to the airway. Those who were intubated were younger, had larger burns, and received more fluid during the first 24 hours post burn. They  also had higher mortality. Likely, higher fluid resuscitation requirements superimposed on the small caliber of the airway of younger patients explains  these findings. Of course, patients with burns of the upper airway, to include the face and mouth, are particularly likely to require endotracheal intubation.  Over-resuscitation can only increase the risk that these patients will need to be intubated and, perhaps more importantly, that they will stay intubated longer.  Having recognized some of the consequences of over-resuscitation, what factors contribute to the problem? Human factors no doubt play a role to include  lack of situational awareness and a cognitive bias in favor of not de- escalating fluid infusion rates. The choice of resuscitation formula, that is,  preferring the 4 ml over the 2 ml formula, probably plays a role. There probably is a vicious cycle of endothelial glycocalyx damage, where an  infusion of massive volumes of crystalloid leads to glycocalyx injury, which in turn accelerates volume loss across the microvasculature. Finally,  opioid creep refers to the increased use of narcotics, which in turn has been associated with increased resuscitation volumes. We lack prospective studies of  clinician decision-making during burn resuscitation, but we did find evidence that the team is more likely to increase fluid input in the setting of low urine  output than it is to decrease fluid input in the setting of high urine output. This signifies, I believe, a cognitive bias against de-escalation.  There is no randomized controlled trial of the various burn formulas. However, Chung and colleagues analyzed data from the recent wars in which the clinical  practice guidelines stated that providers could use either the 2 ml or the 4 ml formula, with no specific guidance regarding when to prefer one  formula over the other. The authors found that both groups of patients received more than the formulas predicted, but that the volume of fluid expressed as  milliliters per kilogram or as ml per kilogram per percent burn was higher in the 4 ml group than in the 2 ml group.  These findings are consistent with many reports on actual experience with burn resuscitation, most of which show that more fluid is given than the formulas  predict. For example, this study of patients resuscitated with the 4 ml formula found that over half received in excess of what the Parkland formula  predicted, in comparison with only 12% of patients in the original paper by Baxter. An improved understanding of endothelial anatomy and physiology has  underscored the importance of the glycocalyx. Multiple factors can damage the glycocalyx, to include several which are present in burn shock. There are some  data to suggest that over resuscitation may contribute to endothelial glycocalyx damage. This study found that syndicin-1, a glycocalyx  constituent, was associated with both resuscitation volumes and the occurrence of compartment syndromes.  Shupp and colleagues demonstrated in a rat model that plasma, in comparison to lactated ringers, decreased TNF alpha expression and Evans blue dye  extravasation. This, along with several other studies, indicates that plasma may play a protective role in shock resuscitation in comparison with  crystalloid, but it also points to the potential adverse effect of large volume crystalloid resuscitation on glycocalyx integrity. The concept of opioid creep  makes sense to those who have observed the hypotensive effects of narcotics and sedative medications in hypovolemic burn shock patients. Here, the group from  Seattle documented a large increase in both opioid equivalents and in fluid resuscitation volumes, comparing the mid-1970s to the year 2000 at their  center. What can we do to reduce fluid resuscitation volumes? First, as pointed out by Chung and colleagues, we should start low using the 2ml formula and we  should go slow, avoiding boluses or aggressive volume loading, if at all possible. When patients get to the 8th or 12th hour post burn and are on course  for a large volume resuscitation, which we define as a predicted 24-hour volume in excess of the IV index of 250 ml per kilogram, it is time to consider early  initiation of albumin or plasma at a dose such as 0.5 ml per kilogram per percent burn per day. Decision support or other ways of increasing situational  awareness can help the team figure out if the patient is on course for a large volume resuscitation. If necessary, we have to be prepared to accept oliguria  and we need to consider other endpoints such as the lactate, presser needs, an echocardiographic estimation of volume status, and of cardiac function. Early use  of continuous renal replacement therapy can buy time by correcting metabolic derangements and may help clear pro-inflammatory cytokines. Judicious  use of pressers to support blood pressure is okay as long as we are paying attention to global indices of perfusion. If possible, narcotics,  propofol, and benzodiazepines should be limited during burn shock. High dose vitamin C and hypertonic saline may have a role to play. Early use of  colloids is defined as initiation of a continuous infusion during the first post burn day. In the Parkland and modified Brook formulas, that is the 4 ml  and 2 ml formulas in common use today, colloids in the form of 5% albumin are given at a dose of about 0.5 ml per kilogram per percent burn at a  continuous rate during hours 25 through 48, that is during the second day only. But when a patient is on course for a large volume resuscitation, it may be  effective to start colloids at this same rate sometime after the 8th post burn hour. Saffel and colleagues have described a practical approach to  identifying when to provide such colloid rescue. Situational awareness and communication can be enhanced by simple tools such as the standardized burn  resuscitation flow sheet, which was introduced by the US Army during the recent conflicts with an associated improvement in documentation and a  reduction in the combined endpoint of mortality and abdominal compartment syndrome. A computerized decision support system was developed at the US Army Burn  Center with similar goals in mind. Use of this system was associated with decreased fluid resuscitation volumes measured in ml's per kilogram per  percent burn or in ml's per kilogram. This system is now part of our standard care. In conclusion, over resuscitation can and must be avoided. Certainly  successful resuscitation requires careful navigation between over and under resuscitation, but during the first 24 hours post burn, a sweet spot of  permissive hypovolemia should be targeted. Thank you very much for the opportunity to present to the Society of Critical Care Medicine.

Video Summary

The video transcript discusses different approaches to burn shock resuscitation and the debate between using more aggressive or more conservative strategies. The speaker explains that burn shock is a complex process of circulatory and microcirculatory dysfunction that requires fluid resuscitation to restore and maintain adequate intravascular volume and organ perfusion. However, there are risks associated with both over-resuscitation and under-resuscitation.<br /><br />The speaker mentions complications of inappropriate resuscitation, including reduced venous return, reduced intravascular volume, reduced cardiac output, increased oxygen demands, compromised perfusion, and end-organ damage. They highlight the importance of individualized therapy, as fluid requirements can vary depending on multiple factors such as burn size, smoke inhalation injury, underlying tissue damage, and associated injuries.<br /><br />The speaker discusses different monitoring options for burn shock resuscitation, including low-tech options like heart rate, blood pressure, and urine output, as well as intermediate and high-tech options such as echocardiography and invasive hemodynamic monitoring. They acknowledge that no single method has proven to be consistently reliable and emphasize the need for individualized therapy based on the patient's condition.<br /><br />The speaker also addresses the issue of fluid creep, where patients receive more fluid than what the formulas predict. They discuss the potential consequences of over-resuscitation, including abdominal compartment syndrome, extremity and orbital compartment syndromes, cerebral edema, pulmonary edema, gastrointestinal dysfunction, wound progression, and delayed healing.<br /><br />Finally, the speaker suggests strategies to reduce fluid resuscitation volumes, such as starting with a lower fluid resuscitation formula, using intraoperative decision support systems, considering early initiation of albumin or plasma, and monitoring other endpoints like lactate, pressor needs, and echocardiographic estimation of volume status. They also mention the potential roles of high-dose vitamin C, hypertonic saline, and colloids in burn shock resuscitation.<br /><br />Overall, the video transcript highlights the need for careful and individualized management of burn shock resuscitation to avoid both under and over-resuscitation and reduce the risk of complications.

Asset Subtitle

Trauma, Integument, 2022

Asset Caption

Fluid resuscitation remains a cornerstone of burn care but there also remains some controversy in how best to resuscitate burn patients. We have seen both underresuscitation and overresuscitation and the complications that come with them. Speakers will discuss traditional burn resuscitation, complication of burn resuscitation, the use of decision support systems in burn resuscitation, and the use of fluids other than lactated Ringer solution in burn patients.

Learning Objectives:
-Review traditional burn resuscitation
-Recognize fluid creep and complications of overresuscitation and describe computerized decision support systems for burn resuscitation
-Describe other modalities of burn resuscitation such as hypertonic saline, fresh frozen plasma, and vitamin C

Meta Tag

Content Type Presentation

Knowledge Area Trauma

Knowledge Area Integument

Knowledge Level Intermediate

Knowledge Level Advanced

Learning Pathway Emergency Medicine and EMS Care

Membership Level Select

Tag Burns

Tag Fluids Resuscitation Management

Tag Abdominal Compartment Syndrome

Year 2022

Keywords

burn shock resuscitation

fluid resuscitation

complications

individualized therapy

monitoring options

over-resuscitation consequences

management

Emergency Medicine and EMS Care

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