Fluid Creep in Major Pediatric Burns

Introduction

Adequate fluid resuscitation is a critical component in the management of major burns. The early restoration of intravascular volume and the maintenance of tissue perfusion has almost eliminated post burn renal failure and significantly reduced mortality [1] [2] [3].

The Parkland formula estimates a 24-hour fluid volume for resuscitation of 4 milliliters per kilogram body mass (ml/kg) per percentage total body surface area (TBSA) burn for the first 24 h. Half of the calculated volume is administered in the first 8 h after the burn has been sustained and the balance during the subsequent 16 h [4]. Baxter published his experience with his formula after a ten-year period of use, concluding that it is an accurate guide for 70% of patients, with 12% requiring more fluid and 18% requiring less fluid [5]. The systemic ‘capillary leak’ that causes the shift of fluid usually ‘seals off’ after 24 h if resuscitation has been adequate. Fluid volume infusions are therefore reduced to 1.5 ml/kg/% burn during the second 24 h. These guidelines are effective, provided that the clinical response is monitored and the fluid therapy modified accordingly [6].

In recent years there has been a tendency to increase the volume of total resuscitation administered and a recent review of 28 burn centers revealed that 58% of patients received more than the 4 ml/kg/% burn recommended by Baxter and Shires [7]. Other publications have demonstrated that up to 73% of patients now receive volumes between 4 and 8 ml/kg/% burn [8].

The Advanced Paediatric Life Support (APLS) Course Manual (4^th edition, 2005) maintains that the Parkland formula “is only a guide; subsequent therapy will be guided by urine output, which should be kept at 2 ml/kg/hour or more” [9]. The pendulum has therefore swung from inadequate resuscitation to excessive volume replacement [1]. The consequences are encapsulated in the term ‘fluid creep’, coined by Pruitt in 2000 [10].

Over-resuscitation can result in Acute Respiratory Distress Syndrome (ARDS), pneumonia, Multiple Organ Dysfunction (MODS), abdominal and limb compartment syndromes and cerebral edema. Clinicians, it appears, are chasing urine outputs well in excess of those required [11] [12] [13].

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