Protection from Excessive Resuscitation: “Pushing the Pendulum Back”

Pruitt, Basil A.

doi:10.1097/00005373-200009000-00030

Cited by 276 publications

(124 citation statements)

References 8 publications

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“…Moreover, urine output was unable to identify fluid responders after a fluid challenge. Other studies also suggest the inaccuracy of urine output as a resuscitation target [40,41], perhaps even contributing to the phenomenon of fluid creep.…”

Section: Urine Outputmentioning

confidence: 99%

An overview on fluid resuscitation and resuscitation endpoints in burns: Past, present and future. Part 2 — avoiding complications by using the right endpoints with a new personalized protocolized approach

Peeters

Lebeer

Wise³

et al. 2015

Anaesthesiol Intensive Ther

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While organ hypoperfusion caused by inadequate resuscitation has become rare in clinical practice due to the better understanding of burn shock pathophysiology, there is growing concern that increased morbidity and mortality related to over-resuscitation induced by late 20 th century resuscitation strategies based on urine output, is occurring more frequently in burn care. In order to reduce complications related to this concept of "fluid creep", such as respiratory failure and compartment syndromes, efforts should be made to resuscitate with the least amount of fluid to provide adequate organ perfusion. In this second part of a concise review, the different targets and endpoints used to guide fluid resuscitation are discussed. Special reference is made to the role of intra-abdominal hypertension in burn care and adjunctive treatments modulating the inflammatory response. Finally, as urine output has been recognized as a poor resuscitation target, a new personalized stepwise resuscitation protocol is suggested which includes targets and endpoints that can be obtained with modern, less invasive hemodynamic monitoring devices like transpulmonary thermodilution.Key words: burns; fluid resuscitation; monitoring; treatment; resuscitation endpoint/target; de-resuscitation; abdominal pressure; abdominal hypertension; abdominal compartment syndrome; personalized care; protocol; algorith Anaesthesiology Intensive Therapy 2015, vol. 47, s15-s26 As discussed in the first part of this review, following a severe burn injury, an overwhelming systemic inflammatory response, with an associated capillary leak syndrome, occurs. Due to fluid shifts that reach a maximum at 12 to 24 hours post injury, the severely burned patient experiences profound intravascular hypovolemia. During this initial "ebb" phase with profound intravascular underfilling, fluid resuscitation is of paramount importance. Moreover, the fluid needs can be enormous due to plasma and proteins leaking into the extravascular compartment. This results in a positive (daily and cumulative) fluid balance associated with well-known complications related to fluid-creep like renal and respiratory failure, gastro-intestinal dysfunction, abdominal hypertension and compartment syndromes [1].As the systemic inflammatory response diminishes, a polyuric or "flow" phase is entered, where a negative fluid balance is seen, reflecting the loss of the initial resuscitation fluids [1].Despite the fact that numerous articles regarding burn resuscitation have been published over recent decades, there is still no universal consensus on the optimal resuscitation fluid and how to achieve adequate resuscitation whilst avoiding the adverse effects of fluid overload. Thus, it is necessary to develop a dynamic fluid strategy, including an active de-resuscitation therapeutic protocol based on newly available physiologic parameters via transpulmonary thermodilution such as extravascular lung water (EVLW), pulmonary vascular permeability index (PVPI), in combination with capillary le...

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Section: Urine Outputmentioning

confidence: 99%

An overview on fluid resuscitation and resuscitation endpoints in burns: Past, present and future. Part 2 — avoiding complications by using the right endpoints with a new personalized protocolized approach

Peeters

Lebeer

Wise³

et al. 2015

Anaesthesiol Intensive Ther

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“…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. 7,19 This phenomenon has also been termed "supraBaxter resuscitation."…”

Section: Introductionmentioning

confidence: 99%

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

Fahlstrom

Boyle

Makic

2013

Critical Care Nurse

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Background Burn resuscitation, including titration of fluids and administration of colloids, is often driven by physicians’ orders. Inconsistencies in burn resuscitation cause overresuscitation, which has adverse consequences. Methods Retrospective chart reviews were completed to evaluate fluid resuscitation and complications for 12 months before and after development and implementation of a nurse-driven burn resuscitation protocol. Results Before implementation of the protocol, results at 24 hours after injury indicated that 58% of patients were overresuscitated, had a serum level of lactate of at least 2 mmol/L (100%), and had complications (pulmonary edema 20%, abdominal compartment syndrome 7%, acute lung injury/acute respiratory distress syndrome 30%) within the first 5 days. Two outcomes differed from before to after implementation of the protocol: serum level of lactate at 24 hours (t37.8 =2.38, P =.007) and central venous pressure at 48 hours (t31 =2.27, P =.03). After implementation of the protocol, no patients had abdominal compartment syndrome develop. Conclusions Implementation of the nurse-driven burn resuscitation protocol improved nurses’ awareness and assessment of fluid status during resuscitation and improved patients’ outcomes.

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“…This is usually caused by delayed or inadequate fluid resuscitation but may also result from substantial muscle breakdown or haemolysis and it is usually reversible. 5 Very few researchers have reported various Histo-pathological changes in renal tissue following an episode of flame burn. [6][7][8][9][10][11][12] Renal failure is associated with high mortality rate hence understanding its pathophysiology at cellular level is essential to anticipate and prevent such complications.…”

mentioning

confidence: 99%

Histo-pathological changes in kidneys in autopsies of flame burns at a tertiary care center in North Western India: an autopsy based study at SMS medical college Jaipur (2015-2016)

Mangare¹,

Punia²

2017

Int J Res Med Sci

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Background: Burn injury is associated with an intricate patho-physiological response with rapid involvement of various organ systems and which in turn impact the patient with multisystem disruption. These damages can be attributed to the alteration occurring at the tissue and cellular level leading to the histological changes in the renal tissue.Methods: The main aim of this study was to document the histo-pathological changes in kidneys of fatal cases of flame burns. This study was hospital based observational descriptive study carried out at mortuary of SMS medical college and attached hospitals, Jaipur, Rajasthan, India to study and document the histo-pathological changes in the fatal cases due to flame burns.Results: In this study, most common histo-pathological finding in kidneys was cloudy degeneration followed by congestion. Acute tubular necrosis of proximal convoluted necrosis was most commonly observed during 3 to 7 days of mortality (18 cases) followed by mortality during 0 to 48 hours. Acute tubular necrosis of distal convoluted tubules was most commonly observed during 3 to 7 days followed by mortality during 0 to 48 hours.Conclusions: This study revealed that cloudy degeneration and acute tubular necrosis were the hallmark changes in burn patients which were most prominent at 3-7 days after sustaining burn injuries. This reflects the role of immediate management provided to the patient during this period with timely and effective fluid restoration and it possibly will change the prognosis of patients.

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Protection from Excessive Resuscitation: “Pushing the Pendulum Back”

Cited by 276 publications

References 8 publications

An overview on fluid resuscitation and resuscitation endpoints in burns: Past, present and future. Part 2 — avoiding complications by using the right endpoints with a new personalized protocolized approach

An overview on fluid resuscitation and resuscitation endpoints in burns: Past, present and future. Part 2 — avoiding complications by using the right endpoints with a new personalized protocolized approach

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

Histo-pathological changes in kidneys in autopsies of flame burns at a tertiary care center in North Western India: an autopsy based study at SMS medical college Jaipur (2015-2016)

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