What is the recommended fluid resuscitation strategy for a patient with a split thickness skin graft?

Fluid Resuscitation for Patients with Split Thickness Skin Grafts

For patients with split thickness skin grafts, fluid resuscitation should be guided by clinical and hemodynamic parameters, with crystalloids as the first-choice fluid and targeting a urine output of 0.5-1 mL/kg/h. 1

Initial Fluid Management

• Crystalloids (Ringer's or Hartmann's solutions) are recommended as the first-choice fluid for resuscitation in patients with split thickness skin grafts 1
• For patients with significant fluid needs, an initial fluid bolus of at least 30 mL/kg of crystalloid solution should be administered within the first 3 hours 2, 3
• Either balanced crystalloids or normal saline can be used, though balanced solutions may be preferred due to concerns about hyperchloremic metabolic acidosis with normal saline 2
• Albumin may be considered in addition to crystalloids when patients require substantial amounts of crystalloids 1, 2

Monitoring and Adjustment of Fluid Therapy

• The easiest and fastest way to adjust fluid resuscitation rates is based on hourly urine output, targeting 0.5-1 mL/kg/h in adults 1
• Additional parameters to guide fluid therapy include:
  • Clinical indicators: capillary refill time, absence of skin mottling, warm and dry extremities, well-felt peripheral pulses, return to baseline mental status 1
  • Laboratory values: arterial lactate concentration 1
  • Advanced monitoring: echocardiography, cardiac output monitoring, and central venous pressure measurements (particularly valuable in patients with hemodynamic instability and/or persistent oliguria despite resuscitation) 1

Special Considerations for Split Thickness Skin Grafts

• Adequate fluid resuscitation is critical for graft survival as it ensures proper tissue perfusion and prevents graft failure 1, 4
• Over-resuscitation ("fluid creep") should be avoided as it is associated with increased morbidity and can compromise graft take 1
• Under-resuscitation can lead to poor tissue perfusion and increased risk of graft failure 1, 4
• Negative pressure wound therapy (NPWT) is often used as a bolster for split thickness skin grafts and has shown improved outcomes compared to alternative bolstering techniques, especially in diabetic foot wounds 4

Vascular Access Considerations

• Intraosseous route is recommended when vascular access is difficult 1
• Central femoral venous access should be considered as a last resort 1
• If intravascular access devices are a possible source of infection, they should be removed promptly after other vascular access has been established 1

Pitfalls and Caveats

• Avoid relying solely on static measures like central venous pressure to guide fluid therapy; dynamic measures of fluid responsiveness are preferred 2, 3
• Be vigilant for signs of fluid overload, which can delay wound healing and compromise graft take 3
• For patients with cardiac dysfunction, consider smaller fluid boluses with more frequent reassessment 3
• Hydroxyethyl starches should be avoided due to increased risk of acute kidney injury and mortality 2, 3
• Timing of skin grafting is important - studies suggest that early grafting (less than 14 days after wound preparation) is associated with higher graft failure rates 5

By following these guidelines for fluid resuscitation in patients with split thickness skin grafts, clinicians can optimize graft survival while minimizing complications associated with both under- and over-resuscitation.