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Fluid Resuscitation

Fluid Resuscitation. Naiem S Moiemen Study Day - 29 October 2010. LD50. Skin Regeneration. Early Total Excision . Skin substitutes. 90%. Tangential excision. Cultured Skin. Topical antimicrobials. Nutrition. 70%. Fluid Therapy. 50%. Antibiotics. 30%. 1940s. 1950s.

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Fluid Resuscitation

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  1. Fluid Resuscitation Naiem S Moiemen Study Day - 29 October 2010

  2. LD50 Skin Regeneration Early Total Excision Skin substitutes 90% Tangential excision Cultured Skin Topical antimicrobials Nutrition 70% Fluid Therapy 50% Antibiotics 30% 1940s 1950s 1960s 1970s 1980s 1990s 2000s

  3. HISTORICAL REVIEW • 1800s, Bleeding • 1921, Rialto theatre Fire Frank P Underhill • 1942, Coconut Grove Fire Cope and Moore • 1952, Basinstoke Evans • 1950s, Brooke Army Pruitt,Mason and Moncrief • 1968, Parkland Baxter

  4. Thermal injury Local response SIRS >20% TBSA Systemic response Cell membrane Capillary permeability

  5. Up to 350,000 dalton Arturson G. Acta Physiol Scand (Suppl) 463:111,1979

  6. Na+ Intra cellular Extra cellular K+ Baxter CR. Fliud volume and elctrolyte changes in the early post- burn period. Clin plast Surg. 1074; 1:693- 703.

  7. K+ H2O H2O Na+ Na+ Na+ H2O K+ Na+ Na+ K+ Na+ H2O Na+ H2O Na+ K+ K+ Na+ Na+ Damaged collagen Na+ H2O Na+ Arturson G. Acta Physiol Scand (Suppl) 463:111,1979

  8. Losses Na H2O Proteins

  9. Who to resuscitate? • Adult Burns >15% TBSA • 20% TBSA in some US centres • Paediatric Burns/Scalds >10% TBSA • Calculation ?! • If in doubt… resuscitate

  10. Thermal injury Local response 15- 20% TBSA SIRS Systemic response Cell membrane Capillary permeability

  11. Estimating TBSA Burn

  12. Which Fluid? • Albumin (Plasma Protein Solution) • Plasma Substitutes (Dextrans, Starches) • Hypertonic Saline • Compound Sodium Lactate Solution (Hartmann’s)

  13. First 8 hours

  14. After 8 hours

  15. MW Na+ mmol Cl - Normal Saline 150 150 Hartmann’s 131 111 HAS 4.5% 75,000 100-160 100-160 Hespan 6% 450,000 150 150 Pentaspan 6% 250,000 150 150 Voluven 6% 130,000 154 154 Volulyte 6% 130,000 137 110 Haemacel 30,000 150 150 Gelofusine 30,000 150 150

  16. Muir & Barclay 1962 • 6 periods • TBSA(%) x Wt(Kg) 2 volume for first 4 hrs

  17. Parkland 1968 Hartmann’s: 1st Period = 8 hrs • %TBSA x Wt (Kg) x 2 = Total • 1/2 that for the 1st 4 hrs: (% x Kg x 1)- fluid given in A&E.

  18. Crystalloids “Parkland” 0 - 8 hrs 8 –16 hrs Parkland (Baxter)

  19. Crystalloids “Parkland” 0 - 8 hrs 8 –16 hrs Parkland (Baxter) 0.25 ml/hr 0.125 ml/hr

  20. Maintenance Parkland (Children only) (Adults 20mls/ Kg) Children 100 mls/Kg for the 1st 10 Kg 50 mls/Kg for the 2nd 10 Kg 20 mls/Kg for over 20 Kg

  21. Urine Output Children ml/ kg/ hr Adults ml/ kg/ hr

  22. Urine Output Children 1- 2 ml/ kg/ hr Adults 0.5- 1 ml/ kg/ hr

  23. Fluid Replacement Following Resuscitation Basal Requirement + Extra evaporative loss 1500 ml/ m2 + (25 + % burn) x m2 x 24 Example Adult 70 kg, 25% burn : 2550 + 2040 = 4590ml/24h

  24. Vol (ml/kg)/%burn/hr Maintenance 24 h 8 h Time post burn Warden GD, Burn shock resuscitation. World J Surg 1992;16:16-23

  25. Resuscitation Endpoints • Urine Output: 0.5-1 ml/kg/hr 1-2 mls/kg/hr for inhalation injury or haemo-/ myoglobinuria. • Heart Rate: <120 bpm (unreliable in the elderly) • MAP: >60 mmHg (according to TBSA) • Base excess & Hct improvement.

  26. The Problem with Resuscitation • The Parkland formula under-estimates fluid requirement in ~ 50% of cases. Engrav et al 2000, Cartotto et al 2002, Inoue et al 2002 Friedrich et al 2004 • Resultant “fluid creep” from fluid overload Cancio et al 2004

  27. Interstitial Oedema • Pulmonary oedema, ARDS • Abdominal & limb compartment syndromes Renal impairment • Burn progression

  28. Infusion Adjustments In ideal 75Kg adult Urine output is 30-50mls/hr: • Increase infusion rate when <20 mls/hr • Decrease “ “ “ >60 mls/hr

  29. Resort to colloids Colloid “Fluid challenge” required when: • Urine output fails to respond to requirement adjustment, by increasing the crystalloid rate or • Patient haemodynamically unstable Ideally with 200mls of HES

  30. Pitfalls • The CVP almost never exceeds 3 in the first 48 hrs! (Baxter ) • The MAP is secondary in the presence of an adequate urine output providing: • the urine is concentrated (good osmolality) • the patient is not diabetic, intoxicated or on diuretics.

  31. Burns Resuscitation Following the Shock Phase

  32. Fluid Requirements • Basal: 1500 mls x m2 / 24hrs ideally as NG or Dex.Saline • Evaporative losses: (25 + % Burn) x m2 /hr ideally as Hartmann’s (Na-rich loss)

  33. Urine output requirement • 1 ml/Kg/hr To account for: • Respiratory water losses • ADH derangement • Osmotic diuresis secondary to: • increased glucose intolerance • high protein feed

  34. Crucial • Constant re-evaluation of a dynamic situation! • Avoid treating numbers, treat the patient!

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