Resuscitation fluid volume and abdominal compartment syndrome in patients with major burns

doi:10.1016/j.burns.2005.08.011

Burns

Volume 32, Issue 2, March 2006, Pages 151-154

https://doi.org/10.1016/j.burns.2005.08.011 Get rights and content

Abstract

Abdominal compartment syndrome (ACS) is rarely reported as a complication of severe burn. This study clarified the risk of burned patients with and without ACS, especially regarding the resuscitation fluid volume. Extensively burned patients admitted to our burn unit from January 2003, through to June 2004, were examined. Vital signs, blood gas analysis, bladder pressure to estimate intra-abdominal pressure (IAP), peak inspiratory pressure (PIP), resuscitation fluid volume, and urine output (UO) were analyzed. Intra-abdominal hypertension (IAH) was defined as an IAP of more than 30 cm of H₂O. Eight of 48 patients suffering from a more than 30% total burn surface area developed ACS in 18.3 ± 4.9 h. In these patients, IAP (49 ± 12 cm H₂O), PIP (50 ± 16 cm H₂O), heart rate (115 ± 8/min), and PaCO₂ (54.6 ± 10.1 mmHg) were higher than normal, and their resuscitation volume was 0.40 ± 0.11 L/kg. Also, a significant correlation between the IBP, PIP and resuscitation volume was observed. Most patients with severe burns required more than 300 mL/kg of resuscitation fluid for the first 24 h after injury that led to ACS and had higher HR, IBP, PIP and PaCO₂ despite arterial pressure showing no significant difference.

Introduction

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) can occur after major abdominal trauma or major surgery [1]. ACS can become fatal since the acute elevation of intra-abdominal pressure (IAP) causes a syndrome consisting of multiple organ dysfunction characterized by decreased cardiac output, pulmonary dysfunction, splanchnic ischemia, elevated intracranial pressure, and acute renal failure if IAH is not appropriately treated. Previous investigators established that these adverse physiological effects are associated with clinical ACS [1], [2] which was confirmed using a laboratory model [3], [4]. Extensively burned patients develop secondary ACS induced by massive resuscitation volumes. To date, in burned patients several case reports [5], [6], [7], [8], survival rate [9], changes in their IAP induced by escharotomy [10], and a correlation between their IAP and total fluid volume [11] have been reported. This study describes the characteristics of ACS in patients suffering from extensive burns with a focus on intravenous fluid volume of the first 24 h after injury. We also compare parameters including hemodynamics, and of blood gas analysis with and without ACS.

Section snippets

Patients and method

Approval for this study was obtained from the Chukyo Hospital Investigational Review Board. Between January 2003 to June 2004, 51 patients were admitted to our burn unit with burns affecting more than 30% of their total body surface area (TBSA). Three patients who were younger than 12-years-old, or had active withdrawal of care during their initial burn resuscitation were excluded from this study. The subjects consisted of 12 women and 36 men between the ages of 17 and 91 years with a mean age

Results

Eight patients developed signs of ACS within a mean time of 18.3 h from burn injury (Table 1).

Hemodynamic parameters including IAP and HR were higher in patients with ACS than in those without 24 h after injury (49 ± 12 cm H₂O, 115 ± 8 bpm versus 9 ± 8 cm H₂O, 102 ± 11 bpm).

PIP and PaCO₂ were remarkably higher in patients with ACS than in those without (50 ± 16 cm H₂O, 54.6 ± 10.1 mmHg versus 25 ± 6 cm H₂O, 37.1 ± 3.9 mmHg), and these results were compatible with the development of IAH.

These patients underwent escharotomy

Discussion

ACS without abdominal injury or surgery was described as secondary ACS by Maxwell et al. [14]. Patients with severe burns are at risk for developing ACS due to the large volume of resuscitation fluid that is infused, abdominal wall compliance, capillary leakage due to increased permeability, bowel edema, intra-abdominal fluid and other factors. For patients with extensive burns, ACS may occur during the resuscitation period [7], [8], [9], [11], [15] with endothelial leaking requiring massive

References (19)

R.R. Ivatury et al.
Intra-abdominal hypertension and the abdominal compartment syndrome
Surg Clin North Am
(1997)
M.D. Wilson et al.
Severe gastrointestinal haemorrhage and ischaemic necrosis of the small bowel in a child with 70% full-thickness burns: a case report
Burns
(2001)
J.B. Friedrich et al.
Is supra-Baxter resuscitation in burn patients a new phenomenon?
Burns
(2004)
G.L. Bloomfield et al.
Treatment of increasing intracranial pressure secondary to the acute abdominal compartment syndrome in a patient with combined abdominal and head trauma
J Trauma
(1995)
J. Oda et al.
Amplified cytokine response and lung injury by sequential hemorrhagic shock and abdominal compartment syndrome in a laboratory model of ischemia-reperfusion
J Trauma
(2002)
J.M. Doty et al.
The effects of hemodynamic shock and increased intra-abdominal pressure on bacterial translocation
J Trauma
(2002)
M.E. Ivy et al.
Abdominal compartment syndrome in patients with burns
J Burn Care Rehabil
(1999)
D.G. Greenhalgh et al.
The importance of intra-abdominal pressure measurements in burned children
J Trauma
(1994)
A.C. Corcos et al.
Percutaneous treatment of secondary abdominal compartment syndrome
J Trauma
(2001)

There are more references available in the full text version of this article.

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Intra-abdominal compartment syndrome (ACS) is a devastating complication in burn patients with a high mortality. Apart from high-volume resuscitation as known risk factor, also mechanical ventilation seems to influence the development of ACS.
The TIRIFIC trial is a retrospective, matched-pair analysis. Thirty-eight burn patients with ACS were matched for burned total body surface area (TBSA), age and mechanical ventilation (MV). In contrast to the already published part I addressing fluid resuscitation as a risk factor, the parameters analyzed in part II were maximum and average PEEP and peak pressure levels as well as serum lactate levels and prokinetic therapy. For subgroup-analysis the ACS-group was split up into an early-onset and late-onset ACS-group according to the median time between burn trauma and ACS. The groups were analyzed with a two-sided Mann–Whitney-U-test with significance set at p < 0.05.
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The TIRIFIC trial showed significantly increased ventilation pressures in the ACS group in general as a surrogate parameter to support early diagnostics. Especially, maximum PEEP levels and peak pressures are significantly increased in both, early- and late-onset ACS. As an addition to the actual WSACS guidelines we suggest IAP measurement in mechanically ventilated burn patients if ventilating pressures are rising continuously without a clear pulmonary or otherwise identifiable reason.
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Protein C circulates in human plasma to regulate inflammation and coagulation. It has shown a crucial role in wound healing in animals, and low plasma levels predict the presence of a wound in diabetic patients. However, no detailed study has measured protein C levels in patients with severe burns over the course of a hospital admission. A severe burn is associated with dysfunction of inflammation and coagulation as well as a significant risk of morbidity and mortality. The current methods of burn assessment have shortcomings in reliability and have limited prognostic value. The discovery of a biomarker that estimates burn severity and predicts clinical events with greater accuracy than current methods may improve management, resource allocation and patient counseling. This is the first study to assess the potential role of protein C as a biomarker of burn severity.
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Various surgical complications can occur in burn patients resulting from pathologic progression of the burn injury itself or from iatrogenic etiologies. Burn patients are at risk for potential surgical complications involving multiple organ systems. Complications requiring operative management in the setting of a burn injury are relatively common and can compound an already overwhelming physiological response. These complications are often unavoidable, and clinicians must be thorough in the evaluation of patients with a significant burn injury. This chapter reviews the frequently encountered nonthermal surgical complications in burn patients with respect to diagnosis and management.

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^☆: Oral presentation at the 12th Congress of the International Society for Burn Injuries, Yokohama, Japan, August, 2004.

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Resuscitation fluid volume and abdominal compartment syndrome in patients with major burns☆

Abstract

Introduction

Section snippets

Patients and method

Results

Discussion

Surg Clin North Am

Burns

Burns

Treatment of increasing intracranial pressure secondary to the acute abdominal compartment syndrome in a patient with combined abdominal and head trauma

J Trauma

Amplified cytokine response and lung injury by sequential hemorrhagic shock and abdominal compartment syndrome in a laboratory model of ischemia-reperfusion

J Trauma

The effects of hemodynamic shock and increased intra-abdominal pressure on bacterial translocation

J Trauma

Abdominal compartment syndrome in patients with burns

J Burn Care Rehabil

The importance of intra-abdominal pressure measurements in burned children

J Trauma

Percutaneous treatment of secondary abdominal compartment syndrome

J Trauma