Journal Review in Burn Surgery: Fluid Resuscitation

Welcome to Behind the Knife. Today we're doing a journal review in Burn Fluid Resuscitation. This is our first burn dedicated episode with our new burn team, and we're excited. So you're on call at a level one trauma center and you get called that you're receiving a large TBSA burn patient. You're not working at a burn center. You remember hearing about some controversy surrounding burn resuscitation. Was it the Parkland formula? Consensus formula? You think you remember that AbSci asked about the modified brook formula? So join Dr. Kathleen Romanowski, Dr. Laura Johnson, myself and Dr. Lauren Soff to discuss modern burn fluid resuscitation. So welcome ladies. I thought we'd get started today with this case. You have a 30 5-year-old male who presents to the trauma bay of your level one trauma center after a welding accident during

which is clothing caught fire, EMS reports, the patient has sustained a 40 to 60% TBSA burn total body surface area. Vital signs are heart rate of one 30, blood pressure one 50 over 96, sat of 92% on two liters nasal cannula. Dr. Nosov, what are your first thoughts? So I have a lot of first thoughts, but the first thing I really want to know is, was there associated trauma? Was he an enclosed space? Why do you ask? Well, whether or not the patient has associated trauma totally changes my course of management. I. Trauma's always going to come first. Burn patients are first a trauma patient. And I'm not just saying that 'cause we're not in a burn center. I always tell the residents that very few people on fire stand still okay, but if no known trauma, I'm worried about the airway next. So following a TLS guidelines.

The patient is on two liters, nasal cannula on the monitor. His sat is 98%. There's no slit in the mouth. He's speaking in full sentences. There's no strider. He has no central facial burns. Okay, well that's reassuring. And b, breathing. Do I have clear and equal breath sounds? Yes you do. Dr. Romanowski what next? Well, next we move on to C is for cookie. Wait, no. And this is where burns get interesting. How so Burns are always interesting. Very true. Well, so burn patients don't always have the best places to put IVs. And every burn patient with a significant burn requires two large bore IVs. So can you place those IVs through burn injured skin? And what if your nurses can't get IV access? So I always say place an IV wherever you

have to place an iv. If it goes through a burn, that's just fine. Will it stay through the burn once it gets to the burn center? Probably not. But it could save someone's life in the transport process. And if you can't get an IV in, go for either an IO or a central line. Anything else foresee that you're worried about? Of course, I'm a burn surgeon, so, I always worry about circumferential injuries burns that are third degree and go all the way around an extremity could lead to compartment syndrome. And then I also wanna start thinking about how we're gonna start our initial fluid rate for resuscitation. So the patient has no circumferential third degree extremity burns. No Escar, otomy needed. The radial and penal pulses are palpable and equal bilaterally. Now what do you mean by initial fluid rate? So burn surgeons love math. But we usually have to pace

ourself with initiating that math after we've already finished the primary survey. So advanced burn life support guidelines put out by the A BA recommend that the initial fluid rate in adult patients be started at 500 ccs an hour burn. Patients don't do really well with boluses, so we need an initial fluid rate that we can start a patient on so that we don't have to play too much catch up after we've started the fun math. So why lr? You mentioned lr. Why lr? What about normal saline, plasma light, other isotonic fluids? That's a great question. So it's really actually goes back to basic chemistry. Our burn patients get tons of fluid over the course of their early resuscitation. So the problem with normal saline is that it isn't really normal, it's acidic, and if they get a large volume of resuscitation with it, they'll end, patients will end up with a hyperchloremic metabolic acidosis. In addition to any other acidosis they might

have from their burn shock, unfortunately, some of the other resuscitation fluids on the market, plasma light for example, haven't really been extensively studied. So we can't say for sure that they're any better or worse than lr. And so recommendations are still lactated ringers. Dr. Romanowski, you take care of a lot of pediatric patients at Shriners. Would you start the pediatric patients on 500 an hour of LR also? No, I mean, as, as we all learned on our pediatric rotation kids are not just little adults. So you would start teenagers on that. So kids who are 13 and older would get 500 an hour school aged children get two 50 an hour of LR and younger kids get 125 milliliters per hour of lr. All right, just making sure anything else for C guys? So don't forget, we definitely need to start a Foley catheter to monitor hourly urine output. It is the gold standard of burn resuscitation.

Oh, pun intended. I love it. Okay. Your nurse places the Foley catheter successfully. Now, since we finished C, I'm guessing D. Yes, d we need to assess the motor and sensory components of our patient's extremities and determine a GCS, which is actually extra important when we have patients coming in after electrical injuries because the risk for spinal trauma is definitely a component of their overall trauma complex. So GCS is 15 motor sensory intact in all four extremities. Then it's time to expose them e for exposure. We need to see every part of the patient evaluate the size of the burn, remove any jewelry or clothing that could cause circumferential, tourniquet effect if as they swell over the first couple days. As, as we do this, we're gonna make sure to roll our patient and protect the spine because we haven't finished our trauma workup yet. And then after we're done exposing them, we need to depose

them and cover them back up. Warm burn patients are happy burn patients, and if you have the opportunity to preheat your trauma bay, if you know a big burn's coming in, that would be amazing. Certainly we try and get our individual patient rooms in the burn unit heated up as hot as we can tolerate for our patients when they are coming up to the ICU. Okay, so you evaluate the burns and you note that the entire torso was burned. The central posterior torso is burned, so entire anterior torso burned. The central posterior torso is burned, the posterior right thigh and leg, the anterior left thigh and leg, the posterior left arm, the anterior right arm, and the neck, and I won't try to trick you. These are all second and third degree burns. As we know, first degree burns are not included in our total body surface area calculation. Oh, you're gonna make this difficult for me. This is what I get for saying burn surgeons love math. Huh? So we're gonna do the rule of

nines. That's how I usually start for a rough estimate to calculate the burn size in an adult. Dr. Miles, you may have a calculator 'cause I do not have one in front of me. I'll calculate for you. Love it. So the anterior torso is gonna be nine plus nine for the chest wall and then the abdomen combined, so that should be 18. The central posterior torso we'll say, is about seven. The posterior lower extremity, right thigh and leg in combination is gonna be nine. And so is the anterior of the opposite leg. Anterior thigh and leg will be nine. The anterior of the left upper extremity is gonna be half, four and a half. Arms have less surface area overall than lower extremities, so they get. No more than nine total. And the same for the posterior of the other arm. And then the neck, we're gonna say about 2%. And you said the face was not involved, so I think that's where the math stops. Face not involved. So from your math, we're at

54%. I will say there's also an app for that. It's free. I use it to quickly calculate burn size and the trauma bay, it's called burn area. And no, I don't get paid for saying that in smaller burns. You could also use the Palmer Method, though I teach it as the hander method. Your hand is your 1%. A six year old's hand is their 1%, not your hand. So you can either march out what is burned or in larger burns you can march out, what isn't. So you do all of this math and then what? Dr. Romanowski, a 54% burn. So now it's time to calculate their adjusted fluid rate. The A BA has a consensus formula and it's what also is taught in A BLS which recommends two milliliters per kilogram, per percent total body surface area burned for adults. And this is to be given over 24 hours. You give the first half over eight hours in theory, and the second half

over the next 16 hours. So how much does this patient weigh? Let's just say a hundred kilos. Oh, good. More math. As Dr. Johnson said, burn surgeons do love math. So two times, a hundred times 54 divided by two, and then divided by eight for, we'll give you our initial adjusted fluid rate. All right, so our adjusted fluid rate is 675 ccs per hour of lr. Sounds right to me. Wait a second. You and I have had this conversation before. Is that what you guys really do with Davis? Well, no. Actually we use the Parkland formula, however, for the sake of the AB site and for A BLS this is the answer. In 2008, the American Burn Association set published a set of practice guidelines that laid the ground look for how we

were gonna manage burn shock resuscitation today. This patient emphasized that while formulas like Parkland Consensus modified Brooke help estimate initial fluid needs resuscitation is a very dynamic process. It's not like I tell my residents, it's not like an oven. You don't set it at a temperature and leave it there. You change it continuously. So in the authors of this paper, advocated for ongoing hourly titration based on physiologic endpoints and in particular what they used as urine output. The goal was to avoid both under resuscitation and the dreaded fluid creep of over resuscitation. They also stress the importance of early IV access. Using lactated ringers as your crystal and cautions against and cautioned against excessive bolusing. The bottom line, these are guidelines, right? And this pushed burn care towards individualized responsive fluid management. Not a particular, particular for formulaic math equation, right? So

no perfect formula for every patient. Dr. Johnson and I use two from the consensus formula. What about you, Dr. Miles? Two also. Yeah. So as you can see here, as we all know, there's a lot of controversy around burn resuscitation formulas. At the end of the day, the adjusted fluid rate is just a starting point. You just look at it for that first hour. I don't think anyone in any burn unit across the country is not titrating fluids hourly. We should record the urine output for the next hour, and if we overshoot our urine output goal. We decrease the fluids by 10%. If we overshoot, we increase by 10%. And if you've overshot or undershot by a lot, you can sometimes go up or down by 20%. I. A recent 2023 study by Rizzo looked at how the initial formula choice affects total fluid volume over the first 24 hours after a severe burn. They found that patients resuscitated with higher volume formulas like four ccs per kg

TBSA. The Parkland formula ended up receiving significantly more fluid than those treated with more conservative formulas like the ABAs two ccs per kg per percent. TBSA. Really the take home message was the higher you start, the more you give regardless of whether the patient actually needs it per se. This supports the shift towards lower initial volumes and more aggressive hourly titration, reinforcing the idea that the formula is just a starting point, not a destination. So with that, what is your urine output goal? So that I think we all agree on. Although I will say I think burn surgeons, the only thing we like more than math is arguing basic concepts. But we're gonna say 0.5 ccs per kilo per hour in adults and one cc per kilo per hour in our pediatric patients, greater than one cc per kilo per hour in adults with electrical injury. I, I think we all do agree though that bolusing

the patient is not the answer. Agree? Yep. Yep. Yep. So you only use the urine output to titrate your fluids? Nope. Nope, I didn't think so. So what else do you use? So there are a lot of different things you can use. Many surgeons use serial laboratory values, such as lactate or base deficit, but you can also use vital signs and physical exam to inform your decision making. Sounds reasonable, but I think for the purpose of this podcast, we would say urine output is the gold standard. Oh, you did it again. Agreed. Both that urine output is a gold standard and a great pun. Sadly there haven't really been large studies looking at other methods, so we're still waiting to see if something will surpass the gold standard. All right, so you're turn miles. The last time, two

hours, your interns have called you and said the patient made less than 10 ccs of urine for each hour. So what are you gonna do? So I would consider the CS of resuscitation failure enlighten me. Okay, so I have to give Dr. Steve Kahn at MUSC and my burn director in New Orleans, Dr. Jeff Carter. The credit for these, although I have added a few, I initially learned the CS in an advanced burn provider course when I was a PGY two in Miami at the Southern Region Burn Conference. I. So the first CS refer to complications of inhalation injury, carbon monoxide, or cyanide toxicity. So you're considering an inhalation injury. Next, concomitant trauma. So sometimes I do a fast, repeat, fast or review the patient's initial scans was their missed trauma. I consider comorbid conditions. Does the patient have a known CHF or CKD or end stage renal disease? I'll scour epic

under care everywhere. Calculation error. That's pretty self-explanatory. Compartment syndrome, sometimes a missed need for sclerotomy or an incomplete Romy can cause low urine output. And then now for the two, I've added, the patient can't pee, is the Foley clogged? Again, consider a KI end stage renal disease. CKD. We now know that with ano kit administration, especially two doses, we can see early and severe a KI in some patients. And then lastly, cocaine or other drugs, especially methamphetamine. So I review the tox screen. I love these. I think this beautifully encapsulates all the problems we potentially run across in that early phase of burden patient management. But your patient is still not making any urine, so what's next? So now we're gonna go real controversial. I would, I would add

fresh, frozen plasma. At our institution, we order immediate release four units of FFP, but where I trained in fellowship at Parkland Hospital, we used 5% albumin. We would start LR for the next hour at 50% of our goal rate and 5% albumin at 50% of our goal rate. We know burn patients are losing protein as the endothelium is no longer intact. FFP can be magic for burn patients. In some STA studies show that it restores the glycocalyx. Are you guys FFP or 5% albumin users? I know there's a head-to-head trial going on right now regarding this topic. No right answer. Right. So Dr. Johnson and I use FFP at Grady. Though we do consider albumin if we think the patient has known liver dysfunction. And at Davis and at Shriners, we use 5% albumin. However, we don't usually start it until patients are at least eight hours out from their injury.

So Colloid product protocols obviously differ. Even more than burn re resuscitation protocols and, and research is ongoing, but I think the burn surgeon community is in agreement that colloid, whether it be 5% albumin or FFP, is the rescue in burn patients failing resuscitation now. I have another one for you and, and this one's realistic. We faced this this year actually A major IV fluid plant suffers damage from a hurricane, and your hospital does not have access to IV fluids. What do you do whether you're in the US or in austere environments? Yeah, this was a really scary situation as we really thought to think about what we were going to do if we ran out of IV fluids entirely and even start to think about, which patients would get them. But one thing that's being looked at now is oral rehydration formulas for larger burn sizes. Maybe not the massive ones, but definitely larger than what we would normally consider Orally

fluid. Orally fluid, or Hy hydrating someone. There are World Health Organization published guidelines that help account for these scenarios. I know at our institution we're enrolling patients in Dr. Jeffrey shop's trial out of MedStar that's looking at outcomes and resuscitating non massive TBSA burn patients with an oral rehydration solution. So I think overall more to come, but certainly this year highlighted for us in the burn world the need to investigate alternatives. And don't forget, there have been some other interventions studied over the years to. Decrease the amount of crystal patients get. Those include vitamin C plasmapheresis out of the Washington group and early CRRT again to try and address the inflammatory burden in these patients. And these may also offer alternatives, though, maybe less in austere environments than in the us. More things to argue about in the future. Wait, so I

think we're out of time, but I, I wanna thank you, you all for tuning into this episode of Behind the Knife with your new Burn team. We've had a lot of fun putting this episode together for you and look forward to producing more High Yield Burn podcast for you in the future. Please feel free to send any topic ideas our way, and with that, go resuscitate those burn patients and dominate the.