fluid resuscitation in burn - harsh amin (plastic & cosmetic surgeon)

Fluid resuscitation in Burn

Dr. HARSH AMIN

Introduction

Before 1940s hypovolemic shock was the leading cause of death after burn injury

Now the mortality due to hypovolemic shock is decreased after use of various fluid resuscitation formulas.

But still 50% burn deaths occurring in first 10 days are mainly due to inadequate and inappropriate fluid resuscitation management.

Phases of management of burn injury

Burns shock -patho-physiology

Burns shock resuscitation -standard resuscitation methods -problems and complications with

resuscitation

Burn Resuscitation

Burn shock

Mechanism is still not clear

NORMAL BLOOD CAPILLARY

POSTBURN BLOOD CAPILLARY

Water molecule

Water is the smallest molecule that can pass through the capillary pores.

Protein molecule

Permeability is increased, which allows large molecules such as proteins to pass through the capillary pores easily.

Patho-physiology

Resuscitation

It begins with arrival of patient

Secure I.V. Line

Weight of Patient

Estimation of Size of Burn

Start Resuscitation

Secure an IV Line

A challenging task in burns patient

Difficult to Secure IV Line

Maximal Sterile Barriers

Peripheral Line

Peripherally inserted central catheter

Cental Venous Line

Venous Cut-Down

Estimation of Size of Burn

Overestimated in inexperienced hand

Other Formulas

Fluid Resuscitation Protocol

Goal: Restore and Preserve tissue perfusion to avoid ischemia

Resuscitation Solutions

Crystalloids- RL, d5%, NS, Hypertonic Saline

Colloids- Albumin, Dextran, Hetastarch

Most Preferred Solution

Most Preferred Fluid → Ringer Lactate( RL )

Na+ conc most free of converted

130mEq/L physiological Glucose to HCO3

CRYSTALLOID

COLLOID HYPERTONIC SALINE

DEXTRAN

Parkland Evan’s Monafo Demling

Modified Brooke Brooke Warden

Slater

Resuscitation Formulas

None is absolute — ultimate resuscitation is conditional

Most Preferred Formula

fluid requirements for children averaged 5.8 cc/kg/% burn.

Which equals parkland formula + maintenance

fluid 4 mL/ kg × % TBSA burn + 1500 cc/m2 BSA

for 24 h

Fluid Resuscitation in Pediatric Patient

Formula For Pediatric Burn

In massive burns , child and inhalational injury cases combination of fluid is used to “minimize edema”

Where- calculate by parkland formula and --->

1st 8 hr RL + 50 mEq NaHCO3

hypertonic

2nd 8 hr RL -

3rd 8 hr RL+ 5% albumin

hyperosmolar

Monitoring

No resuscitation formula is a license to put the burns patient on AUTO PILOT

Cardiovascular- B.P./ECG/heart rate

Renal- urine output

U.O.-Adult- 30-50 ml/hr - child(<30kg)-0.5-1 ml/kg/hr

When does resuscitation complete ???

When No more accumulation of edema fluid (18 – 30 hrs post burn)

Resuscitation fluid require till Volume required to maintain U.O. at 30-50

ml/hr equals Maintenance volume

Most common disadvantage with parkland’s

formula

Sequelae: Skin edema Compartment syndrome Pulmonary & Cerebral edema ARDS / MOD ↑ costs, ↑mortality

“Fluid Creep”-over resuscitation

Avoid early over resuscitation (accurate initial

burn estimation)

Early institution of colloid ( colloid rescue )

Changing Resuscitation protocols

Avoiding “the creep”

Failure of Resuscitation

Extreme age

Extensive burns

Major electrical injury

Major inhalational injury

Initial delay in initializing fluid

Underlying disease that limits metabolic or cardiac reserve

Innovations

Innovations

Thank you

for your attentio

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