Resuscitation in major burns: the problem of fluid creep

To the Editor: We have noticed an alarming tendency for burn patients to be over-resuscitated, and we believe that protocols should be reviewed in light of our own and international experience. We recently managed an 8-year-old boy with 52% fullthickness burns, who developed abdominal and limb compartment syndromes during the period of resuscitation. The fluid volumes infused above those calculated were 1.6 and 4.7 litres on days 1 and 2 respectively to maintain haemodynamic stability and urine output above 2 ml/kg/h. Within 48 hours of the injury, he developed poor peripheral perfusion and a distended abdomen; the intravesical pressure was 32 mmHg and the abdominal perfusion pressure 23 mmHg. Abdominal decompression and three limb fasciotomies were performed, but small-bowel and lower limb muscle necrosis had developed. The patient deteriorated rapidly despite inotropic support and died. Fluid calculations were based on the Parkland formula at 4 ml/kg/% burn, and a major goal of resuscitation was to maintain urine output above 2 ml/kg/h. 1 The Advanced Paediatric Life Support (APLS) course manual 2 states 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’. Such formulae and guidelines do not negate the value of regular re-assessment of the patient’s clinical condition. Over-reliance on the Parkland formula, and attempts at maintaining fluid output above 2 ml/kg/h as prescribed by APLS, 2 may lead to over-hydration; if severe, this may manifest as compartment syndromes in unburnt limbs and in the abdomen, with potentially lethal consequences. 3-5