1. As stated, the TRADITION quoted in a gadzillion books is for the adults 10% and kids 15%. Will be very difficult to deviate from this "standard" of care, as arbitrary as it is, because "everybody's doing it" 2. Use Crystalloids, because just about everyone else does and, as you have scanned through the evidence, you know no-one will be able to show you have done less than best, regardless of whether Albumin could ALSO be OK. So I agree with the rest to advise crystalloid and have NEVER ONCE used Albumin. 3. There are many calculations one could make but the 10% & 15% come from the era predating evidence. i.e. There has not been (to my knowledge) a study done documenting outcome vs. percentage point at which IV hydration is necessary. It's somewhere between 0 & 100% and kids were known in those days to be more "vulnerable" - hence the guideline. If you worked out outcomes with good stats I'm sure you'll come up with something like people above 10 or 15% do better IV, but you may well have the same result using a 20% cut-off for adults or 5% for children. It is likely that one could work out a formulat based upon weight, surface area, %burn and time elapesed, which gives a better, universal guideline, but it will be a heck of a study to then conduct to prove this... 4. When you're done with this, there are other guidlelines we can tackle: - A HI patient who requires neurological observation ('cause radiologists have found some excuse not to scan him) should be observed for 6 hours OR 10 hours OR 12 hours or until the sun has set once and risen again (known as "overnight obs" regardless of how long this is). All of these I have found in various local "SHO books" - A patient in a medical ward will need to be reviewed every time the consultant/registrar/SHO happens to arrive at the hospital, i.e. weekdays am, which means the very same patient with the very same problem admitted at 5am on a weekday is seen at, say 9am, while if admitted at 6pm on a Friday, it's Monday am... - A department bearing the sign "Accident & Emergency" should at all times and under any circumstances, regardless of patient load, staffing levels and case mix be able to see and appropriately dispose of all its patients within 4 hours. ... Until we run out of thumbs to suck numbers out of (or, for the last one, don't get me started) ----Original Message Follows---- From: Goat <[log in to unmask]> Reply-To: Accident and Emergency Academic List <[log in to unmask]> To: [log in to unmask] Subject: Re: Burns - volume replacement Date: Wed, 28 Jul 2004 22:06:17 +0100 Thanks for reply, very stimulating! I think you are using Muir and Barclay (colloid?) here... > 10 x 15/2 = 75mls over four hours, equating to 18 mls/hour. and comparing it to crystalloid here.... > But > remember that a 10kg child has maintenance requirements of 40mls > per hour, so the increment is not huge (45%), no bigger than what > might be required on a hot day or after exertion. To compare like with like, using Parkland (crystalloid)... 10 x 15 x 4 = 600mls in 1st 24hrs, of which half (300mls) in 1st 8hrs, which is almost the same as the maintenance fluid requirement of 320mls (=4x10x8) crystalloid. The additional fluid is therefore 94% of total crystalloid required in 1st 8rs. By similar calcs, a 70Kg adult with same burn SA would require a total of 2100mls additional resus volume in 1st 8 hrs, which 263% of usual maintenance fluid requirements. So whichever formula you use, adults warrant a proportionately higher volume of resus fluid than a child. Looked at the other way round, a child suffering a 15% SA burn requires the same proportionate increase in fluid input as an adult suffering only a 5% burn (try a goal seek on the attached EXCEL file). So perhaps the SHO manual is nearer the truth after all!... Of course there are other things to consider (e.g. circulating volume as % of body weight etc.), but this is already far to complicated for me: the nice thing with the formulas is they are relatively simple and stress plenty fluids early! As long as they are peeing at a reasonable rate for their age, the organs are probably being perfused. But the question of different thresholds for triggering iv fluid resus is an intriguing one, isn't it? Most intriguing is that the original Muir & Barclay guidance you quoted (higher threshold for adults) seems at odds with physiology. I notice that the excellent Westmead site also suggests lower threshold for iv volume resus in kids. Have we missed the point? Is it actually a question of smaller volume reserves in kids (which was my initial thought)? So Adrian and others, what's the "bottom line" here? Should there be a different threshold (%SA burns) guiding us in choosing to admit / iv resuscitate different sized patients? If so, which way - higher or lower ??? Goat G Ray Sussex << burnsvolumeresus.xls >> _________________________________________________________________ Want to block unwanted pop-ups? Download the free MSN Toolbar now! http://toolbar.msn.co.uk/