The Impact of Opioid Administration on Resuscitation Volumes in Thermally Injured Patients

Abstract

Administration of resuscitation volumes far beyond the estimates established by burn-body weight resuscitation formulas has been well documented. The reasons behind this increase are not clear. We sought to determine if our resuscitation volumes had increased and, if so, what factors were related to their increase. A retrospective chart review identified 154 patients admitted with burns greater than 20% of their BSA during the years of 1975-1976 (period 1), 1990-1991 (period 2), and 2006-2007 (period 3). Charts were reviewed for total fluids (crystalloid, colloid, and blood products) and opioids given before admission, during the first 8 hours of treatment, the next 16 hours of treatment, and the following 24 hours of treatment. Opioids were converted to opioid equivalents (OE). Multiple regression analysis was performed to determine the effects of variables of interest and control for confounders. Significance was assumed at the P < .05 level. Resuscitation fluid volumes increased significantly among adults from 3.97 ml/kg/%BSA during the first period to 6.40 ml/kg/%BSA during the third period (P < .01). The same trend in children <30 kg was not seen (P = .72). Fluid administered during the first 24 hours was significantly associated with age, BSA, intubation, latter two study periods, and opioid administration. Fluid administration was consistently associated with opioid administration at all measured time points. At 24 hours postburn, patients who received 2 to 4 OE/kg required an average of additional 3,650 +/- 1,704 ml of fluid, those receiving 4 to 6 OE/kg had required an average of 25,154 +/- 4,386 ml, and those who received >6 OE kg had required an average of 32,969 +/- 3,982 ml. In this single center retrospective study, we have shown a statistically significant increase in resuscitation fluids (from 1975 to 2007) and an association of resuscitation volumes with opioids. Opioids have been shown to increase resuscitation volumes in critically ill patients through both central and peripheral effects on the cardiovascular system. Because increased fluid resuscitation has been associated with adverse consequences in other studies, further research on alternative pain control strategies in thermally injured patients is warranted.

Harborview Burns – 1974 to 2009

“…Since tracheal intubation is associated with increased fluids, this is another issue that might be addressed. Sullivan [63] and Wibbenmeyer [64] also suggested that large doses of opioids might be involved. The extreme rise in opioid administration in 1998–2002 likely followed the events described by Peck [65].…”

Plasma for burn shock resuscitation: is it time to go back to the future?

“…Sullivan and coauthors noted an increase in the use of opioid analgesics between the late 1970s and the early 2000s, which they termed opioid creep . The effect of more opioid use during burn shock is to increase the likelihood of hemodynamic instability and thus fluid needs . Possibly, changes in the medical fitness of the population, with an increased incidence of diabetes and substance addiction, may also affect fluid needs …”

“…28 The effect of more opioid use during burn shock is to increase the likelihood of hemodynamic instability and thus fluid needs. 29 Possibly, changes in the medical fitness of the population, with an increased incidence of diabetes and substance addiction, may also affect fluid needs. 30 In a thorough evaluation of the literature, Guilabert et al 77 performed a nonsystematic review to help determine the current evidence and recommendations for the early resuscitation of burn patients.…”

Review of Burn Research for the Year 2010

“…6 In another study of intensive insulin therapy in pediatric burn-injured patients, the investigators found that intensive insulin therapy reduced resting energy expenditure in the first week after burn injury, improved mitochondrial oxidation capacity, and improved hepatic glucose metabolism. 7 Taken together, these two articles build an argument that in burn patients, intensive insulin therapy may reduce inflammation and improve energy utilization.…”