8 Burn Shock: What Defines a Failing Fluid Resuscitation?

TL;DR

This study explores how defining failing fluid resuscitation in burn shock can improve patient survival by guiding timely interventions.

Contribution

The study introduces a framework for identifying failing resuscitation indicators and evaluates their impact on patient outcomes.

Findings

Patients with ≥1000 mL/hr resuscitation who received interventions showed a 46% higher survival likelihood.

Patients with ≥1500 mL/hr resuscitation who received interventions had a 50% lower survival likelihood.

Urine output <30 mL over two hours with intervention was associated with a 6% lower survival likelihood.

Abstract

Major burn injuries often elicit burn shock requiring acute fluid resuscitation for patient survival. Successful resuscitation is a significant challenge for patient management as under-resuscitation and over-resuscitation can lead to greater adverse events. At the ABA-State of the Science in 2021, proposed definitions included >1,500ml IVF per hour, although no clear clinical data supported this expert consensus. A clear definition of a failing resuscitation may better guide physician decision-making for additional interventions. The primary objective of this study was to examine the association between intervention provided within three hours following a defined indication of failing resuscitation and patient survival.

The study utilized the Acute Burn ResUscitation Multicenter Prospective Trial (ABRUPT), consisting of patients ≥18 years with burns ≥20% of total body surface area (TBSA), to examine three indications of failing resuscitation. Three mutually exclusive analyses were conducted on patients that had fluid resuscitation of ≥1000 mL in one hour, fluid resuscitation of ≥1500 mL in one hour, or two consecutive hours of urine output < 30 mL. Intervention was defined as the patient having new vasopressors or a new ventilator within three hours of the first indication of failing resuscitation. Multivariable logistic regression models were used to assess the associations of interest and to adjust for confounders.

Patients with a failing resuscitation indicator of ≥1000 mL/hr who received an intervention were 46% more likely to be alive at the end of the study (OR=0.54: 95% CI=0.22-1.33). Patients with a failing resuscitation indicator of ≥1500 mL/hr who received an intervention were 50% less likely to be alive at the end of the study (OR=1.5: 95% CI=0.47-5.01). Patients with a failing resuscitation indicator of urine output < 30 mL who received an intervention were 6% less likely to be alive at the end of the study (OR=1.06: 95% CI=0.51-2.22). These results were adjusted for age, TBSA %, and inhalation injury.

A lower indication for failing resuscitation (≥1000 mL/hr) followed by an intervention shows potential for increased patient survival, although adjusted analyses were insignificant likely due to the small patient sample size. Further work is needed to conclude a sufficient definition of failing resuscitation for burn shock.

Identifying a clear definition of failing resuscitation will serve as a consistent guide for physician response to burn shock.

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