Abstract
The goal of fluid resuscitation in the burn patient is maintenance of vital organ function at the least immediate or delayed physiological cost. To optimize fluid resuscitation in severely burned patients, the amount of fluid should be just enough to maintain vital organ function without producing iatrogenic pathological changes. The composition of the resuscitation fluid in the first 24 hours postburn probably makes very little difference; however, it should be individualized to the particular patient. The utilization of the advantages of hypertonic, crystalloid, and colloid solutions at various times postburn will minimize the amount of edema formation. The rate of administration of resuscitation fluids should be that necessary to maintain satisfactory organ function, with maintenance of hourly urine outputs of 30 cc to 50 cc in adults and 1–2 cc/kg/% burn in children. When a child reaches 30 kg to 50 kg in weight, the urine output should be maintained at the adult level. With our current knowledge of the massive fluid shifts and vascular changes that occur, mortality related to burn-induced hypovolemia has decreased considerably. The failure rate for adequate initial volume restoration is less than 5% even for patients with burns of more than 85% of the total body surface area. These improved statistics, however, are derived from experience in burn centers, where there is substantial knowledge of the pathophysiology of burn injury. Inadequate volume replacement in major burns is, unfortunately, common when clinicians lack sufficient knowledge in this area.
Résumé
Le but du remplissage liquidien chez le brûlé est de maintenir les fonctions des organes vitaux et de minimiser les conséquences nocives immédiates et secondaires. Pour optimiser les effets du remplissage, la quantité de liquide doit être calculée pour maintenir les fonctions vitales sans créer de modifications pathologiques iatrogènes. La composition du liquide de remplissage dans les 24 premières heures qui suivent la brûlure n'a probablement que peu d'importance. Cette quantité devrait être calculée et adaptée pour chaque patient. L'utilisation judicieuse des solutions hypertoniques macromoléculaires, cristalloïde et colloïde, permet, du fait de leurs avantages respectifs, de minimiser l'oedème postbrûlure. La quantité de liquide nécessaire est celle qui maintient un débit urinaire de 30 à 50 cc chez l'adulte et 1 à 2 cc/kg/% surface brûlée chez l'enfant. Lorsque l'enfant atteint un poids de 30–50 kgs, le débit urinaire à maintenir est celui d'un adulte. Grâce à nos connaissances actuelles sur les modifications massives de l'équilibre hydroélectrolytique et les conséquences vasculaires qui en dépendent, la mortalité liée à l'hypovolémie post-brûlure a diminué très nettement. Le taux d'échec de la ressuscitation initiale est inférieure à 5%, même pour les brûlures touchant plus de 85% de la surface corporelle. Cette amélioration est le fruit de la recherche des centres spécialisés qui ont pu approfondir les connaissances physiopathologiques des brûlures. Une compensation hydro-électrolytique insuffisante est malheureusement fréquente lorsque le médecin traitant n'est pas familiarisé avec cette pathologie.
Resumen
El objetivo de la resucitación con líquidos es el mantenimiento de la función orgánica vital al menor costo fisiológico, inmediato y tardío. Para optimizar la resucitación con líquidos en pacientes con quemaduras graves, la cantidad de líquido administrado debe ser apenas la suficiente para mantener la función orgánica vital sin producir alteraciones patológicas yatrogénicas. La composición del líquido de resucitación en las primeras 24 horas después de la quemadura posiblemente hace poca diferencia; sin embargo, debe ser individualizada para cada paciente en particular. La utilización de las características ventajosas de las soluciones hipertónicas, cristaloides y coloides, en las etapas siguientes a la quemadura logra minimizar la magnitud del edema. La rata de administración de los líquidos de resucitación debe ser la necesaria para mantener una función orgánica satisfactoria, y una excreción urinaria de 30–50 cc en los adultos y de 1–22 cc kg/% quemadura en niños. Cuando el niño alcanza 30–50 kg de peso, la excreción urinaria debe ser mantenida al nivel del adulto. Con nuestro conocimiento actual sobre los cambios masivos de líquidos y las alteraciones vasculares que ocurren, se ha reducido considerablemente la mortalidad relacionada con la hipovolemia inducida por la quemadura. La tasa de fracaso de la restauración inicial adecuada es de menos de 5%, aún en pacientes con quemaduras de más de 85% de la superficie corporal total. Estas mejores cifras, sin embargo, se derivan de la experiencia de centros especializados en quemaduras, donde existe considerable conocimiento sobre la patofisiología de la lesión por quemadura. Desafortunadamente el inadecuado reemplazo de volumen en los pacientes con quemaduras mayores es común cuando los médicos carecen de conocimientos suficientes en esta área.
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Warden, G.D. Burn shock resuscitation. World J. Surg. 16, 16–23 (1992). https://doi.org/10.1007/BF02067109
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DOI: https://doi.org/10.1007/BF02067109