Optimized fluid management improves outcomes of pediatric burn patients

Abstract

Background: One of the major determinants for survival of severely burned patients is appropriate fluid resuscitation. At present, fluid resuscitation is calculated based on body weight or body surface area, burn size, and urinary output. However, recent evidence suggests that fluid calculation is inadequate and that over- and under-resuscitations are associated with increased morbidity and mortality. We hypothesize that optimizing fluid administration during the critical initial phase using a transcardiopulmonary thermodilution monitoring device (pulse contour cardiac output [PiCCO]; Pulsion Medical Systems, Munich, Germany) would have beneficial effects on the outcome of burned patients.

Methods: A cohort of 76 severely burned pediatric patients with burns over 30% of the total body surface area who received adjusted fluid resuscitation using the PiCCO system were compared with 76 conventionally monitored patients (C). Clinical hemodynamic measurements, organ function (DENVER2 score), and biomarkers were recorded prospectively for the first 20d after burn injury.

Results: Both cohorts were similar in demographic and injury characteristics. Patients in the PiCCO group received significantly less fluids (P<0.05) with similar urinary output, resulting in a significantly lower positive fluid balance (P<0.05). The central venous pressure in the PiCCO group was maintained in a more controlled range (P<0.05), associated with a significantly lower heart rate and significantly lower incidence of cardiac and renal failure (P<0.05).

Conclusions: Fluid resuscitation guided by transcardiopulmonary thermodilution during hospitalization represents an effective adjunct and is associated with beneficial effects on postburn morbidity.

Figure 1

Decision tree for the adjustment of fluid and catecholamine therapy according to PiCCO derived parameters adjusted according the manufacturers recommendations [12].

Figure 2. Survival curve of the first 20 days of the acute stay

PiCCO monitored patients showed lower mortality during the crucial initial phase after injury.

Figure 3. Critical organ functions assessed according the DENVER2 score

PiCCO monitored patients had less severe cardiac and renal failure compared to the conventional group reflected by the maximum DENVER2 scores for each component (A). Administered catecholamines reflected by the DENVER 2 score for cardiac failure did not differ significantly among the groups over time (B).

Figure 4. PiCCO monitored parameters

Increasing extra vascular lung water index starting (ELWI) indicating for fluid reposition in lung tissue. The systemic vascular resistance index (SVRI) decreased for the duration of the observation period. The intrathoracic blood volume index (ITBVI) reached the normal range after day nine.

Figure 5. Resuscitation outcomes

PiCCO monitored patients received significantly less fluid with improved diuresis.

Figure 6. Hemodynamic measurements

PiCCO monitoring resulted in less fluctuation in the CVP (A, B) resulting in more stable hemodynamic parameters such as heart rate (C) and systolic blood pressure (D).

Figure 7. Clinical serum parameters

In PiCCO patients the acute phase protein CRP indicates a lower inflammatory response (A). Albumin (B) and potassium (C) were significantly closer to normal values.