Burn Resuscitation

One of the great advances in burn care, developing a strategy for treating burn shock resuscitation, occurred in the 1960s and 1970s. Before this period, most people with extensive burns (!30% TBSA) would simply die within hours or, if they survived, would suffer from renal failure. Currently, burn shock resuscitation has become an afterthought that is relegated to residents and nursing staff. Calculations are performed based on protocols, and it is known that fluid rate titration should be based on urine output. Recently, however, concerns have arisen that suggest that over-resuscitation has become common. “Fluid creep” has become the term to describe a trend in giving patients too much fluid. The issue of “fluid creep” seems to be substantiated by increased numbers of publications describing complications such as compartment syndromes, especially abdominal compartment syndrome. These realizations suggest that there still is a long way to go in understanding the mechanisms of burn shock. The purpose of this review will be to summarize the presentation, discussions, and conclusions of burn resuscitation at the recent “State of the Science Meeting,” which took place in Washington, DC, October 26, 2006. The goal of the review will be to ask several questions: ● Have we made progress in our resuscitation formulas? ● Can we do a better job with resuscitation? ● Do we need to do a better job? ● What is the pathophysiology of burn shock? ● Is there agreement on resuscitation formulas? ● What is the best resuscitation fluid? ● How do newer technologies assist with resuscitation? ● What should the endpoints of resuscitation be? ● Can we alter the capillary leak of burn shock? The answers to these questions are, unfortunately, not simple. We have made progress, but not enough. There is not even universal agreement on which formula to use. We know that the ultimate goal is optimal perfusion but we still do not have adequate indicators of perfusion. One guideline for resuscitation has been clearly defined: urine output. Are we following urine output like we should? Often enough, we are not. Is urine output good enough? Maybe urine output leads to over-resuscitation. Does it really matter if we do a good job with resuscitation or not? Most patients tolerate our inaccuracies and do just fine despite our mistakes. According to the recent publication by the Institution of Medicine, this attitude will not be tolerated. There are increased efforts to reduce medical errors. We cannot tolerate doing an “adequate” job when we can put forth a “good” or excellent” effort. The challenge to our colleagues, then, is to improve our knowledge of the science of resuscitation to reduce errors and improve the outcomes of our patients.