The Phenomenon of “Fluid Creep” in Acute Burn Resuscitation

Abstract

Several reports have documented that modern burn patients receive far more resuscitation fluid than predicted by the Parkland formula-a phenomenon termed "fluid creep." This article reviews the incidence, consequences, and possible etiologies of fluid creep in modern practice and uses this information to propose some therapeutic strategies to reduce or eliminate excessive fluid resuscitation in burn care. A literature review was performed of historical references that form the foundation of modern fluid resuscitation, as well as reports of fluid creep and its consequences. The original Parkland formula required a 24-hour volume of 4 ml/kg/%TBSA lactated Ringer's solution followed by an infusion of 0.3-0.5 ml/kg/ %TBSA plasma. Modern iterations of this formula have omitted the colloid bolus. Numerous exceptions to the formula have been noted, most consistently patients with inhalation injuries. In contrast, recent reports document greatly increased fluid requirements in unselected patients, which seems to consist largely of progressive edema formation in unburned areas, increasing after the first 8 hours post-burn. This has been linked to occurrence of the abdominal compartment syndrome and other serious complications. Strategies to reduce fluid creep include the avoidance of early overresuscitation, use of colloid as a routine component of resuscitation or for "rescue," and adherence to protocols for fluid resuscitation. Fluid creep is a significant problem in modern burn care. Review of original investigations of burn shock, coupled with modern reports of fluid creep, suggests several mechanisms by which this problem can be controlled. Prospective trials of these therapies are needed to confirm their effectiveness.

Joint Theater Trauma System Implementation of Burn Resuscitation Guidelines Improves Outcomes in Severely Burned Military Casualties

“…1 To prevent organ failure and death, optimal resuscitation while avoiding over-resuscitation morbidity is critical in the first 24 hours to 48 hours postburn. 1,2 The United States Army Institute of Surgical Research Burn Center is the sole burn treatment facility in the Department of Defense serving active duty personnel in addition to its role as the regional burn center for South Texas. Since the beginning of 2003, our burn center has admitted nearly 600 military casualties sustaining burns in Iraq and Afghanistan.…”

Incidence and prognosis of intra-abdominal hypertension and abdominal compartment syndrome in severely burned patients: Pilot study and review of the literature

“…The results from this study support the idea that fluid restriction is not beneficial, and in fact more fluid than the Consensus Formula suggests is often administered. This phenomenon of fluid creep has emerged over the past few decades [53,54], attributed by one author to an opioid creep [55]. It is yet to be established if the volume of fluid administered could be reduced by a combination of colloid and balanced salt solutions [56].…”

Implementation of a Nurse-Driven Burn Resuscitation Protocol: A Quality Improvement Project

“…16 Fluid creep is described as clinical practice in which more resuscitation fluid is administered than is recommended by the Parkland formula. 7,19 This phenomenon has also been termed "supraBaxter resuscitation." 20 Complications associated with overresuscitation include pulmonary edema, ARDS, acute lung injury, abdominal hypertension, abdominal compartment syndrome, longer duration of mechanical ventilation, and longer ICU stays.…”

“…2,7 Many formulas exist to guide fluid resuscitation in burn patients; however, a definitive consensus on best practice has not been achieved. 2,[6][7][8][9][10] Best practice in burn resuscitation is imperative because effective fluid resuscitation will decrease burn shock, tissue loss, and organ damage and will reduce morbidity and mortality.…”

“…15 Recently, a trend in overresuscitation has been reported. 7,[16][17][18] "Fluid creep" is an adverse consequence of overresuscitation, a term originally coined by Pruitt. 16 Fluid creep is described as clinical practice in which more resuscitation fluid is administered than is recommended by the Parkland formula.…”