Fluid Resuscitation in Major Burns

dr. Aditya Wardhana, SpBP – RE (K)

Burn Unit RSCM
Plastic, Recostructive & Aesthetic Surgery Division
February 2013
REGIONAL
BACKGROUNDS
OF BURN INJURIES
Referring Hospital (JABODETABEK)

12 Government
Hospital
31 Private (27 Patients) 3 Clinic
Hospital
(3 Patients)
(45 Patients)

RSCM
 Problems in RSCM
USA* Indonesia**
(Hagstrom et al, 2003) (Handini NS,
Wardhana A, 2011)

Under resuscitated 47% 84%

Adequately resuscitated 23% 6%

Over resuscitated 30% 10%

%TBSA discrepancy 33% 34%

*University of California Irvine Medical Center Burn Center, St. Francis Memorial Hospital, San Francisco
**Burn Unit, Cipto Mangunkusumo Hospital, Jakarta
 Patients Demographics and
Initial Evaluation
Characteristic Average Range

Age (yr) 26.12 1-64

Weight (kg) 45.49 8-80

TBSA by referral (%) 33.09 5-99

TBSA by burn unit (%) 33.43 6-95

Time of injury until arrival at burn unit (hours) 37.91 1.5-456

Fluids given (mL) 1142 0-7500

Early Resuscitation and
Outcome Evaluation

Outcome Early Resuscitation Status Total

Over Adequate Under

Died 2 - 22 24

Survived 3 3 20 26

Total 5 (10%) 3 (6%) 42 (84%) 50

Characteristic of Our Patient

TBSA discrepancy

Delayed resuscitation

Under resuscitation
 Consequences

 How much is enough? (not too big or little)

 Which formula?

 What kind of fluid?

 When do we give?

 How do we monitor ?

 Do we have the equipment for accurate resuscitation?

 Controversies

 The Current consensus : there is no consencus

 Colloid vs crystaloid : an age-old debate

 Endpoints of resuscitation
 Our Policies

 Guidelines : Univ of Utah (Parkland Based Formula)

 Type of fluid : Lactate Ringer (crystaloid), albumin 5%,

Plasma Protein Solution, Gelofusin (colloid).
 Monitor : Clinical Feature, Urine Output, Laboratories
exam.
 Invasive monitoring.
Burn Patient Characteristic and Outcomes Following Resuscitation with Albumin. Elseveir. Burns 33:2007;25-30:1
Burn Patient Characteristic and Outcomes Following Resuscitation with Albumin. Elseveir. Burns 33:2007;25-30:1
Burn Patient Characteristic and Outcomes Following Resuscitation with Albumin. Elseveir. Burns 33:2007;25-30:1
 FLUID CREEP CHARTS

RSCM, JAKARTA
TORONTO, CANADA
FLUID CREEP CHARTS

RSCM, JAKARTA
TORONTO, CANADA
 Endpoints of fluid resuscitation

 Physiological parameters and resuscitation end points

 Urine out put 0,5 – 1cc/kg/hour

 Pulse, BP, SpO2.

 Arterial pH, base deficit, serum lactate, cvp, mixed venous

 Cardiac output, pcwp.

Diver. The evolution of burn fluid resuscitation. International journal of

surgery 2008;6:345-350.
Questions ?

 Parkland tends to “over resuscitate”

 Is it suitable for our patients ( Indonesia)?

 There is TMMU protocol published in Burns 35 (

2009) 1118-1123. Was developed in 1960. Now
widely use in China. More feasible.
 Need further multi-center trials.
 Top 5 topics for investigation
(ISBI / ABA Survey)

 Define the endpoints of burn shock resuscitation.

 Develop a better understanding of pathophysiology of burn
shock edema.
 Determine the cause of “fluid creep”.
 Develop oral resuscitation protocol
 Perform a multicenter trial with an agent that reduces the
capillary leak of burn shock.

Greenhalgh.Burn resuscitation:the result of ISBI/ABA survey.Burns 2010;36:176-82

 Conclusion
 No protocol is perfect

 Quickly, smoothly and reliably tailor the resuscitation

to the individual patient.
 Delay and co-morbidity can complicate the
resuscitation process.
 Multi-center trials to address these issues would be
the best way to resolve resuscitation problems.
Greenhalgh.Letter to editor.Burns 2010;36:1316-1321.
Thank You