Harm from fluid restriction in burn patients

Short Attention Span Summary

The pendulum has swung from giving large amounts of crystalloid for trauma and burn patients to using more restrictive fluid strategies.  When I was a resident, we used to say, "You have to swell to get well."  Recently, a more restrictive fluid strategy than Parkland formula has been used for burn patients, but perhaps the pendulum has swung too far.  This retrospective analysis found that about one third of burn patients received a restrictive fluid strategy, a third were very near Parkland (4-6mL/kg), and roughly a third got more than Parkland.  After adjustment for severity of illness, they found the restrictive strategy was associated with increased risk for acute kidney injury.  The larger volume strategy was not associated with increased pneumonia or burn wound infection.


Abstract

Ann Surg. 2016 Jun 17. [Epub ahead of print]

Hold the Pendulum: Rates of Acute Kidney Injury are Increased in Patients Who Receive Resuscitation Volumes Less than Predicted by the Parkland Equation.

Mason SA1, Nathens AB, Finnerty CC, Gamelli RL, Gibran NS, Arnoldo BD, Tompkins RG, Herndon DN, Jeschke MG; Inflammation and the Host Response to Injury Collaborative Research Program.

Author information:

1*Department of Surgery, Sunnybrook Health Sciences Centre and Division of General Surgery, University of Toronto, Toronto, Canada †Shriners Hospitals for Children - Galveston and Department of Surgery, University of Texas Medical Branch, Galveston, TX ‡Sealy Center for Molecular Medicine and the Institute for Translational Science, University of Texas Medical Branch, Galveston, TX §Department of Surgery, Loyola University Stritch School of Medicine, Maywood, IL ¶Department of Surgery, University of Washington School of Medicine, Harborview Medical Center, Seattle, WA ||Department of Surgery, University of Texas Southwestern Medical School, Dallas, TX **Department of Surgery, Massachusetts General Hospital, Shriners Hospital for Children, Harvard Medical School, Boston, MA ††Ross Tilley Burn Centre Sunnybrook Health Sciences Centre and Division of Plastic Surgery University of Toronto, Toronto, ON, Canada.

Abstract

OBJECTIVE:

To determine whether restrictive fluid resuscitation results in increased rates of acute kidney injury (AKI) or infectious complications.

BACKGROUND:

Studies demonstrate that patients often receive volumes in excess of those predicted by the Parkland equation, with potentially detrimental sequelae. However, the consequences of under-resuscitation are not well-studied.

METHODS:

Data were collected from a multicenter prospective cohort study. Adults with greater than 20% total burned surface area injury were divided into 3 groups on the basis of the pattern of resuscitation in the first 24 hours: volumes less than (restrictive), equal to, or greater than (excessive) standard resuscitation (4 to 6 cc/kg/% total burned surface area). Multivariable regression analysis was employed to determine the effect of fluid group on AKI, burn wound infections (BWIs), and pneumonia.

RESULTS:

Among 330 patients, 33% received restrictive volumes, 39% received standard resuscitation volumes, and 28% received excessive volumes. The standard and excessive groups had higher mean baseline APACHE scores (24.2 vs 16, P < 0.05 and 22.3 vs 16, P < 0.05) than the restrictive group, but were similar in other characteristics. After adjustment for confounders, restrictive resuscitation was associated with greater probability of AKI [odds ratio (OR) 3.25, 95% confidence interval (95% CI) 1.18-8.94]. No difference in the probability of BWI or pneumonia among groups was found (BWI: restrictive vs standard OR 0.74, 95% CI 0.39-1.40, excessive vs standard OR 1.40, 95% CI 0.75-2.60, pneumonia: restrictive vs standard, OR 0.52, 95% CI 0.26-1.05; excessive vs standard, OR 1.12, 95% CI 0.58-2.14).

CONCLUSIONS:

Restrictive resuscitation is associated with increased AKI, without changes in infectious complications.

PMID: 26764868 [PubMed - as supplied by publisher]