Burn Fluid Resuscitation Key Issuespptx.pptx

Describes some of the most important aspects and principles of burn resuscitation. Includes a discussion about Fluid Creep, and examples of methods of calcualating %TBSA

1. Key Issues in Burn Resuscitation Adults with Burns >15% TBSA Children with Burns >10% TBSA Children are resuscitated at lower TBSA because they have a larger surface area relative to plasma volume

2. Fluid Loss in Burns Burns patient lose plasma into the interstitial space of the body because massive wound inflammation causes Systemic Inflammatory Response Syndrome (SIRS), with generalised capillary lea. They also lose some fluid directly through their wounds, but most of it is lost into the interstitial space of the body causing severe oedema

3. Systemic Inflammatory Response The systemic inflammatory response in Burns is unusual in that it persists for many weeks. Giving excess IV Fluid in Burns produces severe, persistent oedema

4. Early systemic changes in burns Water molecule Albumin molecule NORMAL CAPILLARY LEAKY CAPILLARY IN MAJOR BURN If excessive IV Fluid and Salt is given, it effectively just pours out into the interstitial tissue space.

5. Increased Capillary Permeability If we persist in giving excess IV Fluid in Burns, severe persistent oedema develops The key is to give enough but not too much

6. The Parkland Formula was described by Dr Charlie Baxter and colleagues at Parkland Hospital Dallas, USA This excellent formula is an approximate guide It requires close monitoring of urine output as the key resuscitation end-point Volume administered should be adjusted according to urine output International Standard of Care for Burn Resuscitation

7. Some advocate Children 3ml x %BSA x Weight kg Generally for Children 4 x %BSA x Wt Kg Plus maintenance Gives a bit much

8. Important: Burn Resuscitation Target is adequate urine output 0.5 to 1ml/kg/hour in adult 1 to 1.5ml/kg/hour in children International Society for Burn Injuries Guideline

9. Resuscitation must be with a Sodium rich solution usually either Ringer’s Lactate or Normal Saline Using Dextrose-only to resuscitate causes fatal oedema

10. Fluid Management Why do we use Hartmann’s/Ringer’s lactate? Because it is similar in content to Plasma, and avoids risk of hyperchloraemic acidosis with Normal Saline An iso-osmolar Sodium solution for resuscitation is essential to normal cardiac and brain function

11. For Children, Add Maintainance Fluid, with mix Dextrose and Saline 100mls/kg/day for the first 10kg 50mls/kg/day for the second 10kg 20mls/kg/day thereafter Or 4ml/kg/ hr First 0-10kg 2ml/kg/ hr 10 -20kg 1ml/kg/ hr >20kg Type of maintenance fluids varies: -typically 0.45% NaCL / 5% Dextrose --maintenance fluids can also be given via NG tube

12. Make sure fluid administration is calculated from time of injury Other Key Points

13. If delayed resuscitation, don’t rush to catch up the fluid rate too quickly However, give a safe bolus of fluid to start catch-up process Other Key Points

14. If Urine output over 1ml/kg/hour in adult for two hours, reduce the fluid administration rate Similarly for child over with U.O. over 1.5ml/kg/hour Other Key Points

15. If urine output low, assess other parameters eg : Other Key Points Tachycardia suggests fluid depletion High Haematocrit , High serum Urea suggests fluid depletion Poor peripheral perfusion suggests fluid depletion Tachypnoea may indicate fluid excess Relative Hypoxia may indicate fluid excess However, this is a complex situation and there is no substitute for considered clinical observation and ideally, clinical experience in assessing these situations

16. “Fluid Creep” In the last 20 years, it is notorious that doctors have tended to over-resuscitate burn patients

17. The term “Fluid Creep” was coined to describe High-urine output resuscitation end points/targets which cause severe oedema This causes: Poor Healing Pulmonary oedema/ARDS Abdominal Compartment Syndrome

18. Fluid Creep “the idea that because enough urine output is good, therefore more urine output is better ---- is just plain wrong” The late Dr BASIL PRUITT AVOID excessive resuscitation Aim for between 0.5 - 1.0 (adult) and 1.0 -1.5 (children) ml/kg/hour

19. Summary We are learning from the mistakes of recent generations of clinicians Avoid over-resuscitation of burn patients Use careful observation of clinical parameters to plan and adjust fluid administration

20. We Calculate TBSA to Decide how much fluid to give Methods to calculate TBSA Rule of Nines Lund and Browder chart Palm Method (patient’s palm including fingers) Using Phone Apps

21. LUND and BROWDER Chart

22. Palm Method Use patient’s palm to estimate %TBSA For adults, one palm is approx. 1%TBSA For children, it is approx. 1.25% TBSA

23. Burn Calculator Apps Simple way to calculate TBSA and resus

24. Fluid Management The fluid infusion rate calculated by the Parkland Formula should be adjusted depending on urine output Other useful simple test is Haematocrit > if raised, then more fluid may be needed

25. LUND and BROWDER Chart

26. Adult suitable for Rule of nines