ReviewBurn resuscitation
Introduction
Resuscitation after severe burn, specifically in the first 24 h after injury, has been and remains a taxing assignment for all burn care providers, regardless of level of training. Accepted guidelines (Parkland and modified Brooke formulas) provide a foundation for focused resuscitation boundaries, and remain the mainstay of what is taught about initial resuscitation around the world, from first responders to intensivists and trauma surgeons. The large difference in recommended total fluid between these accepted formulas of resuscitation, exemplifies the ongoing controversies that exist in applying appropriate therapy [1], [2], [3]. Many studies exist that examine alterations or adjustments in resuscitation protocols that may lead to improved outcomes, however, none are definitive nor have replaced the tried and true standards. The fact remains that these guidelines, even if followed closely, do not always insure a smooth resuscitation, and under-resuscitation and over-resuscitation after severe burn and associated morbidity continue to plague providers and patients despite any advances in therapy [4], [5], [6], [7], [8]. This can be related, to some extent, to the difficulty in implementing the Parkland or Brooke formulas during signs of physiologic decompensation such as hypotension or systemic acidosis. Often, this leads to high infusion rates in an attempt to augment cardiac preload that may or may not be effective, or in fact may be harmful. Also, this notion leads to a high rate of non-compliance with these formulas by many inexperienced providers.
Many very important advances in burn resuscitation were made over the last 60 years, although very little of significance has developed since the 1960s and 1970s when Baxter and Pruitt focused research efforts in burn resuscitation and proposed the Parkland and modified Brooke formulas, respectively [9]. Many questions remain unanswered and future considerations are plentiful in this difficult arena. The goal of this article is to review burn resuscitation evolution, understand how we have arrived at today's guidelines, and reiterate the questions that continue to befuddle and should be addressed in future studies.
Section snippets
History
Burn resuscitation studies date back to the early 20th century with Haldor Sneve's description of burn treatments in the Journal of the American Medical Association (JAMA) in 1905 [10]. Sneve proposed methods of preventing shock after severe burn by the administration of salt solutions to severely burned patients by various modalities. These included solution administration through oral ingestion, clysis, enemas, and intravenous infusion. He also described many important concepts regarding skin
The Parkland formula
The development of the Parkland formula in 1968, a crystalloid only formula by Baxter and Shires, stemmed from elucidation of important concepts in burn physiology from their studies on fluid shifts between compartments seen after severe burn [33]. Although these data originated the most widely used burn resuscitation formula today, issues arise after careful review of the landmark article proposing the Parkland formula. The publication describes several elegant experiments, beginning with a
The modified Brooke formula
The original Brooke formula proposed by Dr. Artz at the Army Burn Center was composed of both crystalloid and colloid fluids, as this was felt to be important for the adequate resuscitation of burn patients at that time [21]. As Moyer in the 1960s questioned the role of colloids in resuscitation regiments, he realized that patients tolerated infusions of lactated Ringers’ alone at doses sufficient to keep urine output greater than 50 cm3/h [22]. Importantly he realized that the volumes his
Muir–Barclay formula
In 1974, two British surgeons, Muir and Barclay, published their experiences and recommendations regarding appropriate burn treatment. In their review of resuscitation guidelines from across the globe, they took issue with the most recent recommendations of their time as deficient in addressing the constant need for re-evaluation of the fluid resuscitation protocol in burned patients in order to prevent shock and maintain normal end organ blood flow [39]. Muir and Barclay described how
Other considerations for effective resuscitation
As is seen, absolute consensus on resuscitation formulae has not been reached. The inherent challenges faced by providers caring for severely burned casualties during the initial resuscitation period have been described previously. In November 2005, the USAISR implemented a military-wide burn resuscitation guideline that was developed along with a burn flow sheet, which required the documentation of the initial 24 h resuscitation for all severely burned casualties [40]. We found that a lower
Current effectiveness of accepted guidelines
In most places, two formulas are accepted as guidelines for the resuscitation of severely burned patients, the Parkland and modified Brooke formulas. Burn care providers of all specialties are trained in the use of these formulas in order to help prevent the onset of burn shock prior to the patient's arrival in a burn centre with experienced burn staff. Unfortunately, in the “heat of the moment”, inexperienced first responders as well as many higher level emergency care physicians fail to have
Future considerations
The reality of burn resuscitation evolution is that our guidelines have been in place for 40 years with no significant changes despite the findings of continued complications during resuscitation [9]. Complications remain possibly as result of overzealous over-resuscitation, irresponsible under-resuscitation, or simply the lack of recall for complex formulas. The formula developed in the 1960s and 1970s was designed for the technology and monitoring of the time. Urine output was generally not
Summation
The resuscitation of severely burned patients has clearly evolved over the last century, with a lull in significant progress since the 1970s, at the expense of the patient in our opinion. The guidelines used today were developed 40 years ago, yet remain the mainstay of current initial fluid therapy despite ongoing research. Preventing complications of over- or under-resuscitation still confounds burn providers as no recent advances have been made in this arena as well. As we continue to
Conflict of interest
None.
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