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British Journal of Anaesthesia Fluid Resuscitation Management in Patients With Burns: Update P. Guilabert; G. Usúa; N. Martín; L. Abarca; J. P. Barret; M. J. Colomina Disclosures Br J Anaesth. 2016;117(3):284-296. Abstract Since 1968, when Baxter and Shires developed the Parkland formula, little progress has been made in the field of fluid therapy for burn resuscitation, despite advances in haemodynamic monitoring, establishment of the 'goal-directed therapy' concept, and the development of n
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    British Journal of Anaesthesia Fluid Resuscitation Management in Patients With Burns: Update P. Guilabert; G. Usúa; N. Martín; L. Abarca; J. P. Barret; M. J. Colomina Disclosures   Br J Anaesth. 2016;117(3):284-296.  Abstract Since 1968, when Baxter and Shires developed the Parkland formula, little progress has been made in the field of fluid therapy for burn resuscitation, despite advances in haemodynamic monitoring, establishment of the 'goal-directed therapy' concept, and the development of new colloid and crystalloid solutions. Burn patients receive a larger amount of fluids in the first hours than any other trauma patients. Initial resuscitation is based on crystalloids because of the increased capillary permeability occurring during the first 24 h. After that time, some colloids, but not all, are accepted. Since the emergence of the Pharmacovigilance Risk Assessment Committee alert from the European Medicines Agency concerning hydroxyethyl starches, solutions containing this component are not recommended for burns. But the question is: what do we really know about fluid resuscitation in burns? To provide an answer, we carried out a non-systematic review to clarify how to quantify the amount of fluids needed, what the current evidence says about the available solutions, and which solution is the most appropriate for burn patients based on the available knowledge. Introduction Fluid and electrolyte treatment for burn resuscitation began in 1921 when Underhill [1]  studied the victims of the Rialto Theatre fire in New Haven and found that blister fluid has a composition similar to plasma. In 1942, Cope and Moore [2]  developed the burn oedema concept and introduced the body-weight burn budget formula. Other charts were then developed: the Wallace rule of nines, [3]  the rule of the hand, and the one currently considered the most exact, the Lund and Browder Chart. [4]  Finally, in 1968, Baxter and Shires [5,6]  developed the Parkland formula, the one most widely used today for initial fluid resuscitation in burn patients. [7]  In accordance with the indications of the Advanced Burn Life Support programme of the American Burn Association, this formula now stipulates 2  – 4 ml of Ringer's lactate (RL) solution per kilogram of weight per percentage of burned body    surface area in adults. It is intended to be adapted to vascular permeability changes to avoid fluid excess (the phenomenon known as 'fluid creep'), [8  – 10]  and the amount has to be corrected according to the urinary output, [5,8,11]  which ultimately leads to substantial variability in the quantity of fluids administered. Sometimes this process is imprecise because the body surface area calculations are not always reliable (e.g. in obese patients).  After all these years of studying burn patient pathophysiology and outcomes, it is now clear that prompt fluid resuscitation is essential for survival in these patients. [12] Since the implementation of efficient, dynamic fluid replacement, fewer patients die in the first 24  – 48 h. [13]  It is a priority to maintain intravascular volume and organ perfusion despite the oedema caused by intense fluid resuscitation. [13,14]  When resuscitation is suboptimal, burn depth increases and the shock period is longer, leading to greater mortality. [12]  However, can we be sure that resuscitation is done properly? We found it surprising that despite advances in haemodynamic monitoring and establishment of the 'goal-directed fluid therapy' concept, many burn units still base their resuscitation practice on a formula created 40 yr ago. [7,15]  In 1991, Dries and Waxman [16]  had already suggested that resuscitation based only on the urinary output and vital signs might be suboptimal. It is also surprising that after the recent emergence of studies on hydroxyethyl starches (HES), burn patients have been included alongside septic patients as those in whom starch administration should be avoided, even though none of the studies on which these recommendations were based included patients with major burns. These considerations prompted us to undertake the present review. The aim of this review concerning initial fluid resuscitation in burn patients was to provide an overview of the current data regarding two key questions: what is the best way to determine the amount of fluids a burn patient needs, and what are the optimal fluids to use in this patient population? The reasons why burn patients require large amounts of fluids in the initial resuscitation is not a subject of this review, because the pathophysiological changes occurring are extensive and would require a review in themselves. Methods To provide answers to the proposed questions, we carried out a two-phase bibliographic search of articles published since 2000, the time when the scientific community focused renewed interest on fluid therapy, new concepts such as goal-    directed therapy appeared, some products such as the previous generation starches were no longer available, and the Boldt retraction occurred. [17,18]  First, we identified related clinical practice guidelines, systematic reviews, and other critical syntheses of documents in the scientific literature, such as health technology evaluation reports. In this first phase, we consulted the electronic database MEDLINE, using PubMed and the Cochrane Database of Systematic Reviews. The search strategy included the following terms: burn, burn resuscitation, fluid therapy, colloids, gelatins, crystalloids, hydroxyethyl starch, albumin, isotonic and hypertonic solutions, saline, Ringer's solution, Ringer's lactate, Ringer's acetate (RA), monitoring, haemodynamic monitoring, goal-directed therapy, lactate, base deficit, burn metabolic parameters, lactate clearance, systematic, review, randomized controlled trial, controlled clinical trial, and meta-analysis. In the second phase, we specifically searched individual studies, prioritizing randomized controlled trials, but also including observational studies, retrieved from MEDLINE. Only studies carried out in adults and reported in articles written in English, French, or Spanish were selected. The research was carried out in November 2014, and articles retracted up to that date were excluded. The GRADE criteria [19]  were used to evaluate the scientific quality of the studies selected. During the period reviewed, 13 studies were published on goal-directed therapy in burn patients, and 11 of them are included in this review. [15,20  – 29]  One study performed in paediatric patients and another written in a language other than the three specified above were excluded. Regarding crystalloids, we reviewed 42 articles, two of which were included. [30,31]  The remaining articles were excluded for the following reasons: 17 did not meet the search criteria, four were reviews, eight were written in other languages, five were protocols, guidelines, descriptions of daily clinical practice, or surveys, two were carried out in paediatric patients, and four were experimental animal studies. In relation to hydroxyethyl starches, we first analysed the studies carried out with last-generation starches that later prompted the recommendations not to use these substances in burn patients, [32  – 35] and then performed a search on HES use for burn resuscitation. Two articles investigating HES in burn patients were included, [36,37]  whereas seven non-systematic reviews, nine articles that did not meet the search criteria, three that included critically ill patients, and four in other languages were excluded.    Eighteen articles were found on albumin use in burn patients, and four were included in the present review. [38  – 41]  We excluded three non-systematic reviews, two articles focusing on hypoalbuminaemia that did not deal with initial replacement therapy, one in paediatric patients, one in animals, one experimental study, four that were protocols, guidelines, or descriptions of daily clinical practice, and one deemed to have a high risk of bias. This last study [42]  was based on information from a database in which albumin administration was recorded as a 'special procedure'. The study assumed that patients who were not given albumin had received only crystalloids; the potential use of other colloids was not considered. Furthermore, fluid therapy did not seem to follow an established protocol; hence, it is likely that the more severely ill patients who did not respond to crystalloids were those given albumin treatment. Fluid Therapy for Burns Determining the Initial Amount of Fluid Therapy a Burn Patient Needs Burn patients receive a larger amount of fluids in the first 24 h than any other trauma patients because of the pathophysiological mechanisms occurring in the injury. Burn shock is a combination of hypovolaemic shock and cell shock, characterized by specific microvascular and haemodynamic changes. In addition to the local lesion, the burn stimulates the release of inflammatory mediators that induce an intense systemic inflammatory response, producing an increase in vascular permeability in both the healthy and the affected tissue. The increased permeability provokes an outpouring of fluids from the intravascular space to the interstitial space, giving rise to oedema, hypovolaemia, and haemoconcentration. These changes, together with increased vascular resistance and the decreased cardiac contractility produced by tumour necrosis factor and interleukin-1 release, can trigger a state of shock, depending on the magnitude of the lesions. The amount of inhalation injury also has an effect on the clinical course, fluid requirements, and the patient's prognosis (Fig. 1). The main objective of fluid administration in thermal trauma is to preserve and restore tissue perfusion and prevent ischaemia, but resuscitation is complicated by the oedema and transvascular displacement of fluids characteristic of this condition. [12  – 14]
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