A History of Fluid Management—From “One Size Fits All” to an Individualized Fluid Therapy in Burn Resuscitation

Abstract

Fluid management is a cornerstone in the treatment of burns and, thus, many different formulas were tested for their ability to match the fluid requirements for an adequate resuscitation. Thereof, the Parkland-Baxter formula, first introduced in 1968, is still widely used since then. Though using nearly the same formula to start off, the definition of normovolemia and how to determine the volume status of burn patients has changed dramatically over years. In first instance, the invention of the transpulmonary thermodilution (TTD) enabled an early goal directed fluid therapy with acceptable invasiveness. Furthermore, the introduction of point of care ultrasound (POCUS) has triggered more individualized schemes of fluid therapy. This article explores the historical developments in the field of burn resuscitation, presenting different options to determine the fluid requirements without missing the red flags for hyper- or hypovolemia. Furthermore, the increasing rate of co-morbidities in burn patients calls for a more sophisticated fluid management adjusting the fluid therapy to the actual necessities very closely. Therefore, formulas might be used as a starting point, but further fluid therapy should be adjusted to the actual need of every single patient. Taking the developments in the field of individualized therapies in intensive care in general into account, fluid management in burn resuscitation will also be individualized in the near future.

State of the Art: An Update on Adult Burn Resuscitation

“…There are several formulas to predict fluid resuscitation needs; the key is that these are estimates and that the infusion rate must be adjusted hourly based on individual responses. The modified Brooke formula predicts a conservative volume of 2 mL/kg/%TBSA of lactated Ringer's solution (LR) over the first 24 h, with 50% of the total amount programmed for delivery during the first 8 h. The most frequently used is the Parkland formula, which estimates 4 mL/kg/%TBSA [2,[30][31][32][33][34]. The original rationale for the higher dose prescribed by the Parkland formula was the theory that more rapid correction of a patient's extracellular sodium deficit during shock would result in better outcomes.…”

“…Complementary methods of monitoring hemodynamic status and perfusion should be considered for all patients, particularly those with comorbidities including renal, hepatic, or cardiovascular disease, the elderly, and in difficult resuscitations [35,[52][53][54][55]. A variety of measurements have also been evaluated as alternatives to UOP, without identification of consistently superior performance [33,[54][55][56].…”

“…Base excess and lactate, as well as the correction rate thereof, are reliable predictors of mortality [57][58][59]. However, these variables are not specific to burn shock alone, and lactate may remain elevated despite adequate resuscitation due to impaired hepatic or renal clearance, cyanide toxicity, or the infusion of epinephrine [33,35,[60][61][62].…”

“…Interestingly, this appears to be a relatively recent phenomenon. Earlier literature reports that the Parkland formula accurately predicts total resuscitation volume, while more recent data reflect Parkland as almost always underestimating total volumes [24,33,35,37,52,54,95]. Possible mechanisms include increasing use of opioids and sedatives that counter the stress response and promote vasodilation, increasing proportion of patients with large burns, more intravenous fluids in the prehospital setting, decreased use of colloids, overestimation of burn size and depth, higher rates of comorbidities, and use of alternate endpoints that require higher volumes to normalize.…”

Sepsis in Burns—Lessons Learnt from Developments in the Management of Septic Shock

“…In the history of burn care there have always been two challenges that accounted for the majority of mortality in burn patients. Resuscitation and the acute phase of the first three days after burn trauma as the first critical situation have been optimized in the past and further developments are still increasing the survival rate even for severely burned patients [1]. Sepsis however, being the second significant challenge in burn care, is still the major cause of death after the first 24 h after trauma.…”