Burn Resuscitation: Fluid Management in Paediatric Burns in Scotland, Exams of Industrial Technology

Download Burn Resuscitation: Fluid Management in Paediatric Burns in Scotland and more Exams Industrial Technology in PDF only on Docsity! Page 1 of 12 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 NSD608- 016.01 V1 Page 2 of 12 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]. Page 5 of 12 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. Page 6 of 12 The subgroup concluded that, in the absence of a clear gold standard, the recommended regime should be the one currently used by Birmingham Children’s Hospital. The main advantage was the use of colloid in the latter part of the resuscitation period which was considered, on current evidence, to represent best practice. The fact that the formula had been in use for a number of years was considered to afford a degree of validation. Recommendations  Intravenous fluid resuscitation should be commenced if a child has a burn injury greater than or equal to10% TBSA.  Initial accurate assessment of the burn is vital for calculation of %TBSA. A unified Lund and Browder chart should be used (note that different versions of this chart are available, the one with chest allocated 13% should be used).  An accurate weight should be obtained at first point of arrival in hospital (not estimated).  Once accurate estimation of the % TBSA burned, fluid resuscitation using a formula should be commenced.  Secure intravenous access should be obtained during the initial assessment.  The recommended formula is detailed overleaf. The total volume of crystalloid should be given by 8 hours after injury (taking into account the lag time to presentation). Human Albumin Solution (HAS, 4.5% Albumin) is recommended for the second period of 16 hours.  If, at this time, the patient remains in an institution where HAS is not available, the Parkland formula should be continued.  Hypertonic solutions are not recommended.  Patients with large areas of full thickness burns, high voltage electrical injury, associated trauma, delay in resuscitation and inhalational injury may require additional fluid.  This formula is only a guide. Each child needs to be treated as an individual and clinical observations need to be assessed regularly to evaluate the effectiveness of the fluid replacement.  The amount of fluid administered should be clearly recorded along with physiological parameters. Page 7 of 12 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-Lyte148 = %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-Lyte148 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. Page 10 of 12 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% ×2 Second 16 hours Post Injury Hourly rate of HAS = Wt × TBSA% × 0.1 mls/hr REMEMBER MAINTENANCE FLUIDS Page 11 of 12 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. 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