Burn State of the Science: Fluid Resuscitation

Recognition of fluid creep has driven a large amount of the scientific investigation in the area of acute fluid resuscitation for burn patients. The role of colloids in ameliorating fluid creep is controversial, despite the fact that a fluid-sparing effect of colloids has been recognized for some time. All but one of the available prospective studies using colloids are more than a decade old, and a modern randomized controlled trial (RCT) comparing crystalloids to colloids is long overdue. While urinary output continues to be the main endpoint for fluid titration, there has been a moderate amount of interest in the use of transpulmonary thermodilution to guide fluid resuscitation. The available studies have found that transpulmonary thermodilution has had an inconsistent effect on limiting fluid resuscitation volumes and improving clinical outcomes. Computerized Decision Support Systems show great promise in optimizing fluid titration and reducing fluid resuscitation volumes, and an RCT comparing Computerized Decision Support Systems with conventional titration approaches will be the important next step. Use of high-dose vitamin C (ascorbic acid) has become a popular approach to limit fluid resuscitation volumes and edema formation, but it has been investigated in only two clinical studies: one a pseudo-randomized prospective study and the other a retrospective study. Improvements in clinical outcome have not been convincingly demonstrated, and concerns persist surrounding the possibility of induction of an osmotic diuresis, leading to intravascular volume depletion. An RCT is urgently required to evaluate high-dose vitamin C as an adjunct to crystalloid resuscitation compared with the use of crystalloids alone.