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 >>
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