What is the superior fluid resuscitation strategy for burn patients?

From the Guidelines

The superior fluid resuscitation for burn victims involves the use of lactated Ringer's solution, administered according to the Parkland formula, with the consideration of albumin administration after the first 6 hours for patients with a total burned body surface area of over 30%. This approach is based on the most recent and highest quality evidence, which suggests that albumin administration can significantly reduce mortality and abdominal compartment syndrome in severe burns patients 1. The Parkland formula, which calculates the fluid requirement as 4 mL × patient's weight in kg × percentage of total body surface area burned, should be used to guide the initial fluid resuscitation, with half of the calculated volume given in the first 8 hours and the remaining half administered over the next 16 hours.

Key considerations in fluid resuscitation for burn victims include:

• Early administration of crystalloids, such as lactated Ringer's solution, to address hypovolaemic shock and restore cardiac output 1
• Use of the Parkland formula to calculate initial fluid requirements
• Adjustment of fluid administration based on urine output, targeting 0.5-1 mL/kg/hour in adults
• Consideration of albumin administration after the first 6 hours for patients with a total burned body surface area of over 30% to reduce mortality and abdominal compartment syndrome 1
• Continuous monitoring of vital signs, urine output, and electrolytes to guide therapy and prevent complications like under-resuscitation or fluid overload

The use of albumin in burn resuscitation is supported by recent studies, which have shown that it can reduce mortality and morbidity in severe burns patients 1. However, the optimal timing and dosage of albumin administration are still debated, and further research is needed to fully understand its role in burn resuscitation. Nevertheless, the current evidence suggests that albumin administration after the first 6 hours can be beneficial for patients with severe burns, and it should be considered as part of a comprehensive fluid resuscitation strategy.

From the FDA Drug Label

Burn Therapy An optimal therapeutic regimen with respect to the administration of colloids, crystalloids, and water following extensive burns has not been established. During the first 24 hours after sustaining thermal injury, large volumes of crystalloids are infused to restore the depleted extracellular fluid volume Beyond 24 hours Plasbumin-25 can be used to maintain plasma colloid osmotic pressure. Burns—After a burn injury (usually beyond 24 hours) there is a close correlation between the amount of albumin infused and the resultant increase in plasma colloid osmotic pressure. The aim should be to maintain the plasma albumin concentration in the region of 2. 5 ± 0.5 g per 100 mL with a plasma oncotic pressure of 20 mm Hg (equivalent to a total plasma protein concentration of 5.2 g per 100 mL). (2) This is best achieved by the intravenous administration of Plasbumin-25.

The superior fluid resuscitation for burn victims is not explicitly stated in the FDA drug label. However, it is mentioned that large volumes of crystalloids are infused during the first 24 hours after sustaining thermal injury to restore the depleted extracellular fluid volume. Beyond 24 hours, Plasbumin-25 (albumin) can be used to maintain plasma colloid osmotic pressure 2 2.

• The goal is to maintain the plasma albumin concentration in the region of 2.5 ± 0.5 g per 100 mL with a plasma oncotic pressure of 20 mm Hg.
• The use of Plasbumin-25 is recommended beyond 24 hours after the burn injury.

From the Research

Fluid Resuscitation for Burn Victims

The optimal fluid resuscitation strategy for burn victims is a topic of ongoing debate. Several studies have investigated different approaches to fluid resuscitation, including the use of crystalloids, colloids, and hypertonic solutions.

Comparison of Fluid Resuscitation Strategies

• A study published in the Journal of Burn Care & Research found that the addition of colloid to Parkland resuscitation rapidly reduces hourly fluid requirements, restores normal resuscitation ratios, and ameliorates "fluid creep" 3.
• A survey of burn resuscitation practices published in Burns found that the Parkland formula using lactated Ringer's solution is still the dominant method, but there is significant variation in resuscitation protocols 4.
• A study published in The American Journal of Emergency Medicine compared hypertonic and isotonic fluids during resuscitation of severely burned patients and found that hypertonic resuscitation consists of giving a higher fluid and sodium load in the first hour of therapy, which is accompanied by a decrease in fluid requirements and fluid accumulation for the first 24 hours of burn shock 5.
• A study published in Emergency Medicine Journal found that the use of Parkland fluid resuscitation tables can improve the accuracy and ease of calculation of fluid resuscitation requirements 6.

Key Findings

• The use of colloid supplementation can help to reduce fluid requirements and ameliorate "fluid creep" in burn patients 3.
• Hypertonic resuscitation may be beneficial in reducing fluid requirements and fluid accumulation in the first 24 hours of burn shock 5.
• The Parkland formula using lactated Ringer's solution is still the dominant method of fluid resuscitation, but there is significant variation in resuscitation protocols 4.
• The use of resuscitation tables can improve the accuracy and ease of calculation of fluid resuscitation requirements 6.