 |
AUTHORS:
Robert H. Demling, M.D.
Leslie DeSanti R.N., Dennis
P. Orgill, M.D. PhD.
Section
3c
Common
Pitfalls In Initial Fluid Resuscitation
|
Initial
Under resuscitation
The
largest fluid shifts occur in the first several hours
postburn. If there has been a significant delay in
initiation of fluid infusion and a shock state is
present, initial crystalloid infusion based on a
formula will often be inadequate. More volume is
needed. A volume expander such as a non-protein
colloid or protein solution or hypertonic saline can
be very useful along with isotonic crystalloid to
correct the shock state.
|
|
Initial
Over resuscitation
Aggressive
fluid infusion is now frequently initiated in most
emergency rooms with placement of large lines. The
practice of "wide open" fluid infusion
during early assessment and transport regardless of
hemodynamic response is to be avoided. The excess
fluid cannot be compensated for by decreasing infusion
rate in subsequent hours because the extra fluid is
already out of the vascular space.
|
|
Striving for Ideal Numbers
It
is quite possible to achieve ideal numbers (pulse less
than 120, blood pressure more than 100, urine output
0.5 to 1 cc/kg/hr) in a young patient with a
moderate-sized uncomplicated burn. Attempts at pushing
fluids beyond reasonable amounts to achieve
"ideal numbers" in the massive burn (more
than 60% total body surface), especially in the
presence of inhalation injury or in the elderly, will
only accentuate edema-induced complications. Adequate
perfusion is not the same as "ideal
numbers." An intelligent treatment plan
considering developing pulmonary and chest wall
edema-induced complications must be devised.
|
|
Consideration
of Fluid Alone for Treatment of Impaired Perfusion
Hypovolemia
from burn-induced fluid and protein shifts is the
predominant cause of hypoperfusion, and fluid infusion
is the treatment. However, two other processes must be
considered. The first is impaired cardiac output due
to an increasing mean airway pressure , particularly
from a noncompliant chest wall burn. Ventilator
adjustments, chest wall escharotomy, elevation of the
head of the bed to decrease chest edema, and the use
of an agent, such as low-dose dopamine, to assist
fluids can be very helpful in maintaining perfusion.
Secondly, cardiac depression from a deep body burn is
well described, particularly in the elderly.
Supplementation of fluids both crystalloid and colloid
with a beta agonist can help reverse a downward course
reflected by continually increasing fluid requirements
and decreasing perfusion.
|
|
Use
of Urine Output Alone as Monitor for Volume
Restoration
Although
usually a reliable indicator of renal perfusion,
factors such as high plasma alcohol or glucose levels
will often lead to an inappropriately high urine
output relative to the status of tissue perfusion. The
value of the urine output must be considered to be
unreliable under these circumstances.
|
|
Failure
to Secure Intravenous Lines
As
edema develops, tape unravels and the intravenous
catheter slips out of the vein into the surrounding
tissue. Not only does this lead to transient
hypovolemia, but finding a new site when edema is
present can be extremely difficult. A solution is to
secure the intravenous line with sutures.
|
OTHER
NECESSARY PROCEDURES
Nasogastric
Tube Insertion
A
gastric ileus is common after any significant trauma,
especially a major burn. Decompression of the stomach
decreases the work of gastric dilatation and
aspiration.
Pain
Medication
Once
fluid resuscitation has begun the patient with a major
burn will require pain management. Small doses of
narcotics given intravenously can effectively
control pain while avoiding hemodynamic or respiratory
dysfunction.
Role
of Antibiotics
Prophylactic
antibiotics are not indicated in the initial
management of a burn.
  
|
|
