Elsevier

Burns

Volume 36, Issue 7, November 2010, Pages 984-991
Burns

Hydroxyethylstarch supplementation in burn resuscitation—A prospective randomised controlled trial

https://doi.org/10.1016/j.burns.2010.04.001Get rights and content

Abstract

Introduction

Hydroxyethylstarches (HES) are thought to be beneficial in trauma and major surgery management, due to their volume expansion and anti-inflammatory properties. This study examined the use of 6% (HES) in burn resuscitation.

Methods

26 adult patients with burns exceeding 15% total body surface area (TBSA) were randomised to either crystalloid (Hartmann's solution) or a colloid-supplemented resuscitation regime, where 1/3 of the crystalloid-predicted requirement was replaced by 6% HES.

Results

There was no difference in age, gender or TBSA between the two groups. The median (95% CI) fluid volume/%TBSA received in the first 24 h was 307 ml and 263 ml for the crystalloid only and HES-supplemented group respectively (p = 0.0234, Mann–Whitney). Body weight gain within the first 24 h after injury was significantly lower in the HES-supplemented group 2.5 kg versus 1.4 kg respectively (p = 0.0039). The median (95% CI) serum C-reactive protein at 48 h after injury was 210(167–257) and 128(74–145) mg/L for the crystalloid only and HES-supplemented group respectively (p = 0.0001). Albumin–creatinine ratio per % burn (ACR, a marker of capillary leak) was lower in the HES-supplemented group at 12 h after burn (p = 0.0310).

Conclusions

Patients treated with HES-supplemented resuscitation required less fluid, showed less interstitial oedema and a dampened inflammatory response compared to patients receiving isotonic crystalloid alone.

Introduction

In the 40 years since Baxter's animal experiments for the development of the Parkland formula, research has been devoted to its refinement as well as the advent of other resuscitation formulae, with relatively less interest into what constitutes the most effective choice of fluid. A survey of 140 US burns centres showed that 78% used Ringer's lactate during the first 24 h according to the Parkland formula [1]. Boldt and Papsdorf more recently carried out a survey of current trends in burns resuscitation across Europe. Of the 120 burns units surveyed, 58% use crystalloid with only 12% adhering strictly to the Parkland formula. Albumin is the preferred fluid choice in 17% of units and a mere 4% include hydroxyethylstarch in their resuscitation regime. When it comes to rescuing situations of hypovolaemia during burn resuscitation, 64% of European units resort to human albumin solution, 53% to hydroxyethylstarch and 45% persevere with crystalloid [2].

Following the 1998 Cochrane Review meta-analysis practice is slowly changing as confidence in albumin has decreased. Protein solutions in the early shock phase period were deemed to be as effective as crystalloid and may have even been responsible for a detrimental accumulation of lung water [3]. One of the criticisms of the reviews, however, was that all the colloids were grouped under the same umbrella [4]. Cochran et al. in a case–control study of 101 burns-resuscitated patients, actually showed albumin to be protective in a multivariate model of mortality. Part of the reason why albumin-treated patients may have displayed worse prognosis in retrospective trials, is that they tend to have suffered more severe injuries and are as a result, more systemically unwell [5]. Is it time to re-consider certain colloids? Goodwin et al. recommend the delay of protein solutions beyond the first 24 h after burn, whereas others administer colloids from the beginning along with crystalloid.

The most widely accepted burn fluid resuscitation regime in use today is undoubtedly the Parkland formula, but a number of recent studies have shown that the formula under-estimates fluid requirement in approximately 50% of cases [6], [7], [8]. Augmentation of crystalloid intake has led to the phenomenon of “fluid creep”, initially described by Pruitt, with associated morbidity. An excellent review of the phenomenon by Saffle has highlighted the fact that the original Parkland formula relied on colloid boluses after 24 h [9]. This raises the question; why not formally include colloids in our current resuscitation regimes or for “rescue” resuscitation? “Permissive hypovolaemia” is another new concept, an attempt to counterbalance the “fluid creep” and minimise the formation of excessive oedema. This has only been possible with meticulous haemodynamic monitoring and the early addition of new generation colloids like hydroxyethylstarch [10].

Hydroxyethylstarches have been recognised as effective plasma expanders in acute burn resuscitation since 1989, with haemodynamic and oxygen transport effects equal or superior to those of 5% albumin [11]. Hydroxyethylstarches, however, have more to offer than their volume-expanding properties, they are known to modulate the inflammatory response through interference with cytokine release and interaction of leukocytes with the vascular endothelium [12], [13], [14]. These are arguments for the introduction of hydroxyethylstarch as a supplementation strategy, early on in the resuscitation phase, in an attempt to tame the inflammatory response and prevent hypoperfusion. This represents a change from their current role, which is to rescue situations of hypovolaemia refractory to increasing the crystalloid infusion rate. There is increasing evidence that maximising the rate of fluid infusion in the immediate phase after burn may be beneficial to the overall outcome [15].

The aim of the study was to determine the effect of hydroxyethylstarch supplementation on total volume of fluid resuscitation, weight gain, renal function and inflammatory response or vascular endothelial permeability following major thermal injury.

Section snippets

Methods

All adult acute burns admissions to the University Hospital Birmingham Burns Centre between May 2004 and May 2006, with injury exceeding 15% total body surface area (TBSA) were considered for inclusion into the study. The exclusion criteria were patient age below 16 or above 80, burn greater than 80% TBSA, pregnancy, transfer delay of more than 6 h from the time of injury, history or biochemical evidence of renal impairment on admission (serum creatinine >130 μmol/L), history or haematological

Results

Of the 43 eligible patients 26 were successfully included in the trial. There was a delay in reaching the burns unit of more than 6 h post-injury in 8 patients. It was not possible to obtain informed consent for participation in a further 5 cases due to intubation prior to transfer (3 patients), intoxication (1 patient) and learning difficulties (1 patient), with no next of kin present to consider or provide assent. One patient had received colloid at the referring hospital and was therefore

Discussion

The Parkland formula under-estimates fluid requirement in up to 50% of cases [8], [9], [10], [11]. Crystalloid “fluid creep” to achieve optimal haemodynamic parameters can lead to interstitial oedema with associated morbidity. Centres that rely on crystalloid resuscitation alone have been reporting an increase in limb and abdominal compartment syndromes [19]. The revelation in the early 1950s that burn fluid loss was plasma, suggested that replacing like with like may be beneficial. Human

Conflict of interest

The UHB Clinical Biochemistry Department has received two research grants from Byer Diagnostics, Germany, for the partial funding of projects not related to the above study. The Eleganza ITU Weighing System was provided on trial by Pegasus LTD., Waterlooville, Hants, UK.

Acknowledgements

We would like to thank Dr Peter Nightingale, UHB NHS Foundation Trust Statistician, for his input with the statistical analysis.

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