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Paediatric Guideline
Fluid Resuscitation
Author: Mr GM Walker, Consultant Paediatric and Neonatal Surgeon, NHS Greater Glasgow and Clyde, October 2010 Reviewed by Mr D McGill, Consultant Plastic Surgeon, NHS Greater Glasgow and Clyde, November 2016. Reviewed By Dr J Freeman, Consultant Anaesthetist, NHS Lothian, June 2020 and approved by COBIS Steering Group. To be reviewed June 2023. NOTE This guideline is not intended to be construed or to serve as a standard of care. Standards of care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advance and patterns of care evolve. Adherence to guideline recommendations will not ensure a successful outcome in every case, nor should they be construed as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgement must be made by the appropriate healthcare professional(s) responsible for clinical decisions regarding a particular clinical procedure or treatment plan. This judgement should only be arrived at following discussion of the options with the patient, covering the diagnostic and treatment choices available. It is advised, however, that significant departures from the national guideline or any local guidelines derived from it should be fully documented in the patient’s case notes at the time the relevant decision is taken.
Care of Burns in Scotland
NSD 608 - 016.01 V
Aim This is to promote a unified approach to fluid resuscitation of children with thermal injuries in Scotland, including the immediate resuscitation in the Emergency Department and further fluid management in specialist units providing ongoing care. Background Thermal injuries affecting more than 20% of the total body surface area (TBSA) in adults and 10% TBSA in children can result in Burn Shock as a result of a combination of electrolyte shifts [Baxter 1968, Moyer 1965, Moylan 1973, Arturson 1979], inflammatory response [Gibran 2000, Scott 2005] and evaporative losses. This sequence of events leads to intravascular hypovolaemia and haemoconcentration that are maximal 12 hours post-injury [Moore 1970]. The clinical sequelae of reduced cardiac output are the combined result of decreased plasma volume, increased afterload, and decreased myocardial contractility. Recent clinical evidence suggests that fluid administration alone is not effective in restoring preload or cardiac output in the first 24 hours post-injury [Holm 2004] which confirms earlier animal based observations [Baxter 1968]. Under resuscitation may lead to decreased perfusion, acute renal failure, and death although since the adoption of formulas for resuscitation based on weight and injury size, multiple organ dysfunction caused by inadequate resuscitation has become uncommon [Pham 2008]. Instead, administration of excessive fluid volumes have been reported [Cancio 2004, Engrav 2000, Pruitt 2000] which can lead to worsening oedema formation, elevated compartment pressures, acute respiratory distress syndrome (ARDS), and multiple organ dysfunction [Klein 2007, Sheridan 1994, Sullivan 2006]. In October 2006, the American Burn Association conducted a meeting to determine a research agenda for the next decade. Participants highlighted over resuscitation as a common, but potentially avoidable phenomenon in today’s burn units [Greenhalgh 2007].
crystalloid-based formula are often in excess of that predicted by the formula [Blumetti 2008, Cartotto 2002]. Administration of large volumes of crystalloid during burn resuscitation decreases plasma protein concentration and further promotes extravascular egress of fluid and oedema formation. Replenishment of plasma protein using colloids (either with albumin or plasma) would theoretically mitigate this effect although there is a lack of evidence to support this. Experimental evidence would suggest that the rate of oedema formation was maximal at 8 to 12 hours after burn injury [Demling 2005] and that any fluid given before this time is susceptible to tissue egress. After this time, nonburn tissues appear to regain the ability to sieve plasma proteins. Virtually all studies using large macromolecules to augment oncotic pressure have documented reduced oedema formation in non-burn tissue, but not in the burn wound itself [Guha 1996, Demling 1984]. A recently reported double-blind randomised controlled trial of albumin administration demonstrated the safety of albumin use and observed that the saline group received 40% more fluid than the albumin group [The SAFE Study Investigators 2004]. Further meta- analysis of published literature has concluded that albumin administration significantly reduces morbidity in ill hospitalised patients, including patients with burn injury [Vincent J-L 2004]. Follow-up reports from the Cochrane Injuries Group have failed to support the earlier claims that albumin administration increases mortality [Alderson 2004]. Many burns centres have now moved to using formulas where crystalloid is given for the first 8 - 12 hours, when capillary leak may be most pronounced, followed by colloid administration thereafter [Personal communication to Gregor Walker 20 09 ]. Monitoring of Resuscitation Traditional dogma suggests that titration of fluids to maintain renal perfusion to obtain a urinary output of 30-50 ml/hr is considered adequate for adults, whereas a urinary output of 0.5-1 ml/kg/hr is an appropriate target for young paediatric patients. The age (or weight) of child where this parameter changes to “adult” values is arbitrary, although 30kg in weight has been recommended [Warden 2006]. Other physiological signs should be regularly assessed and recorded including heart rate, blood pressure, respiratory rate in addition to other signs of end-organ perfusion such as capillary refill time, core-peripheral temperature gap and conscious level. Blood tests such as acid-base balance, lactate and haematocrit
may give further useful information although regular testing out with an intensive care environment is not routinely recommended. Clearly, in the intensive care setting, there are more sophisticated monitoring devices with variable invasiveness, leading some to suggest that resuscitation volumes can be targeted towards normalising cardiac pre-load. A recent prospective randomized trial did not confirm the benefits of this approach whereby neither restoration of intrathoracic blood volume nor cardiac index were attained by an additional 68% of fluid administered in the preload- driven strategy. Based on these results, a preload- driven strategy for burn resuscitation is not advisable. Invasive monitoring with central venous catheters or pulmonary artery catheters may still be occasionally indicated in patients who display an inadequate response to standard treatment [Reynolds 1995]. Maintenance Fluids Until enteral feeding is established, maintenance intravenous fluids should be administered as governed by local guidelines. This should be administered in addition to resuscitation fluids. Oral / Enteral Fluids Oral fluids should be introduced as early as possible following admission as detailed in the accompanying nutritional guidelines. Volumes of enteral feeds or fluids should replace maintenance fluids rather than resuscitation fluids. Enteral fluids should constitute either milk formulas as governed by local guidelines or balanced salt-solutions rather than water to avoid the risk of hyponatraemia. Process of Review and Resulting Recommendation The paediatric subgroup of COBIS in 2009 was made up of representatives from all the Scottish centres involved in the care of the child with a burn injury. Discussion of a unified fluid resuscitation guideline formed part of the larger process aiming to construct a series of management guidelines. Contact was made, in 2009, with various other burns centres to determine other established guidelines including St Andrews Centre in Chelmsford, Birmingham Children’s Hospital, Booth Hall Children’s Hospital in Manchester and the Shriners Burns Institute (Galveston, Texas). All regimes were compared and presented along with available evidence. All fluid regimes were considered, along with another hybrid regime which comprised of a Muir and Barclay type formula that substituted crystalloid for colloid in the first 12 hours.
RESUSCITATION OF PAEDIATRIC BURNS
COBIS GUIDELINE
Weigh the child on arrival in the emergency department Assess and document the percentage Total Burn Surface Area (%TBSA) on the Lund & Browder chart provided (simple erythema should not be included) Obtain Intravenous access The initial resuscitation period is 24 hours, split into 2 periods In the first period a balanced salt solution is used. Hartmann’s or Plasma-Lyte148 are both suitable fluids and are variably available across Scotland. In the second resuscitation period a human albumin solution is used in the lower concentrations. Concentrations of 4%, 4.5% and 5% Human Albumin Solution (HAS) are all suitable and are variably available across Scotland. FIRST 8 HOURS: Modified Parkland formula Total Volume of Hartmann’s or Plasma-Lyte 148 = %TBSA x Wt (in Kg) x 2 i.e Total volume over (8hr - Lag time) It is a clinical decision whether to include bolus volumes in the total amount SECOND 16 HOURS: Further fluid given as Human Albumin Solution (HAS) Hourly Rate of Albumin 4.5% = %TBSA x Wt (in Kg) x 0.1mls/hr REMEMBER TO ADD MAINTENANCE FLUIDS Maintenance fluids should contain sodium in sufficient quantity so as to avoid hyponatraemia and hyperchloraemia and should contain glucose. Suitable initial fluids would be 0.45% sodium chloride and Glucose 5% or Plasma-Lyte 148 and Glucose 5%. Maintenance fluid content should be adjusted according to urea and electrolytes as per local protocols with the addition of potassium as necessary.
The rate of maintenance fluid is calculated as follows: 100ml/kg/day for the first 10 kg body weight
+ 50 ml/kg/day over 10kg and less than 20 kg body weight
+ 20ml/kg/day for each kg over 20kg body weight.
ORAL FLUIDS ARE SUBTRACTED FROM MAINTENANCE FLUIDS ML FOR ML
For further detail on oral or enteral fluids or feeds please refer to the COBIS Paediatric Guideline on Nutrition in Burns which is also on the COBIS website. Suggested Patient Observations: Heart rate Urine output Blood pressure Capillary refill Skin-core temperature gap Acid base balance Central venous pressure (if available and indicated) Conscious level Electrolytes Haematocrit
Volume mls 8 - Lag Time hrs Rate mls/hr Time from Injury (hrs) Total Crystalloid (include boluses) Total HAS Heart rate (bpm)
BP
Urine Output (ml) 8 24 48 Please chart cumulative totals for all fluids and urine output from time 0 HAS Rate mls First 8 hours Post Injury Total Volume of Hartmann’s or Plasma-Lyte 148 = Weight × TBSA% × Second 16 hours Post Injury Hourly rate of HAS = Wt × TBSA% × 0.1 mls/hr
REMEMBER
MAINTENANCE FLUIDS
References
Alderson P, Bunn F, Li Wan Po A, Li L, Roberts I, Schierhout G. Human albumin
solution for resuscitation and volume expansion in critically ill patients. Cochrane
Database of Systematic Reviews 2004, Issue 4. Art. No.: CD001208. DOI:
10.1002/14651858.CD001208.pub2.
Arturson G, Jonsson CE. Transcapillary transport after thermal injury. Scand J Plast Reconstr Surg 1979;13:29 – 38. Baker RHJ, Akhavani MK, Jaliali N. Resuscitation of thermal injuries in the United Kingdom and Ireland. Journal of Plastic, Reconstructive and Aesthetic Surgery 2007;60;642- 45 Baxter CR, Shires T. Physiological response to crystalloid resuscitation of severe burns. Ann N Y Acad Sci 1968;150: 874 – 94. Blumetti J, Hunt J, Arnoldo B, Parks JK, Purdue GF. The Parkland Formula Under Fire: Is the Criticism Justified? Journal of Burn Care Research 2008;29:180 – 186 Cancio LC, Chavez S, Alvarado-Ortega M, et al. Predicting increased fluid requirements during the resuscitation of thermally injured patients. J Trauma 2004;56:404 – 13. Cartotto RC, Innes M, Musgrave MA, Gomez M, Cooper AB. How Well Does The Parkland Formula Estimate Actual Fluid Resuscitation Volumes? J Burn Care Rehabil 2002;23:258 – 265 Cochrane Injuries Group Albumin Reviewers. Human albumin administration in critically ill patients: systemic review of randomised controlled trials. Br Med J 1998;317:235–40. Demling RH. The burn edema process: current concepts. J Burn Care Rehabil 2005;26:207–
Demling RH, Kramer GC, Gunther R, Nerlich M. Effect of nonprotein colloid on postburn edema formation in soft tissues and lung. Surgery 1984;95:593– 602. Engrav LH, Colescott PL, Kemalyan N, et al. A biopsy of the use of the Baxter formula to resuscitate burns or do we do it like Charlie did it? J Burn Care Rehabil 2000;21:91–5. Gibran NS, Heimbach DM. Current status of burn wound pathophysiology. Clin Plast Surg 2000;27:11–22. Greenhalgh DG. Burn resuscitation. J Burn Care Res 2007; 28:555– 65. Guha SC, Kinsky MP, Button B, et al. Burn resuscitation: crystalloid versus colloid versus hypertonic saline hyperoncotic colloid in sheep. Crit Care Med 1996;24:1849 – 57. Holm C, Mayr M, Tegeler J, et al. A clinical randomized study on the effects of invasive monitoring on burn shock resuscitation. Burns 2004;30:798 – 807 Klein MB, Hayden D, Elson C, et al. The association between fluid administration and outcome following major burn: a multicenter study. Ann Surg 2007;245:622– 8.
