Colloid Administration Normalizes Resuscitation Ratio and Ameliorates “Fluid Creep”

Abstract

Although colloid was a component of the original Parkland formula, it has been omitted from standard Parkland resuscitation for over 30 years. However, some burn centers use colloid as "rescue" therapy for patients who exhibit progressively increasing crystalloid requirements, a phenomenon termed "fluid creep." We reviewed our experience with this procedure. With Institutional Review Board approval, we reviewed all adult patients with > or =20%TBSA burns admitted from January 1, 2005, through December 31, 2007, who completed formal resuscitation. Patients were resuscitated using the Parkland formula, adjusted to maintain urine output of 30 to 50 ml/hr. Patients who required greater amounts of fluid than expected were given a combination of 5% albumin and lactated Ringer's until fluid requirements normalized. Results were expressed as an hourly ratio (I/O ratio) of fluid infusion (ml/kg/%TBSA/hr) to urine output (ml/kg/hr). Predicted values for this ratio vary for individual patients but are usually less than 0.5 to 1.0. Fifty-two patients were reviewed, of whom 26 completed resuscitation using crystalloid alone, and the remaining 26 required albumin supplementation (AR). The groups were comparable in age, gender, weight, mortality, and time between injury and admission. AR patients had larger total and full-thickness burns and more inhalation injuries. Patients managed with crystalloid alone maintained mean resuscitation ratios from 0.13 to 0.40, whereas AR patients demonstrated progressively increasing ratios to a maximum mean of 1.97, until albumin was started. Administration of albumin produced a dramatic and precipitous return of ratios to within predicted ranges throughout the remainder of resuscitation. No patient developed abdominal compartment syndrome. Measuring hourly I/O ratios is an effective means of expressing and tracking fluid requirements. The addition of colloid to Parkland resuscitation rapidly reduces hourly fluid requirements, restores normal resuscitation ratios, and ameliorates fluid creep. This practice can be applied selectively as needed using predetermined algorithms.

An overview on fluid resuscitation and resuscitation endpoints in burns: Past, present and future. Part 1 — historical background, resuscitation fluid and adjunctive treatment

“…In 2007, a case-controlled study reported decreased mortality on a multivariate analysis in burn patients receiving albumin during resuscitation [58]. In 2010, Lawrence et al found that the addition of albumin to the Parkland formula resuscitation rapidly reduced hourly fluid requirements, restored normal resuscitation ratios, and ameliorated fluid creep [26].…”

“…This term was coined by Basil Pruitt [20]. There are different hypotheses regarding the phenomenon of fluid creep, although its cause remains uncertain [14][15][16]26].…”

“…Efforts should therefore be made to avoid "futile loading" with excessive amounts of crystalloids along with identifying ways to measure appropriate peripheral perfusion. Moreover, the role of colloids in early resuscitation needs further investigation [26].…”

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

“…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]. Once cardiovascular and perfusion parameters are achieved, the initial aggressive fluid strategy will need to be addressed and re-evaluated.…”

Hydroxyethyl starches in severe burns

“…Others have reported similar results with a variety of colloids, including a lower incidence of renal impairment with the use of colloids. [11,12] A review of fluid resuscitation in patients with severe burns concluded that 'current best evidence supports recommendations to reduce fluidvolume administration through use of colloids or hypertonic saline' , especially if the required volumes would exceed a 'volume ceiling' . [13] Although none of this provides level I evidence for the use of colloids or HES in early burn resuscitation, the scales are starting to tip in favour of the latter.…”