Challenging Legacy Burn Resuscitation Paradigms with Fluid Restriction and Early Plasma

Fresh frozen plasma (FFP) as an adjunct in burn resuscitation to decrease endothelial cell permeability by restoring the glycocalyx is not yet standard of care despite increasing evidence showing benefits. We hypothesize that using an adjusted body weight index (ABWI) and starting resuscitation at a low rate of 2 mL/kg/% total body surface area (TBSA) with early plasma results in less fluid administration and superior clinical outcomes compared with traditional resuscitation methods, such as the Parkland formula.

This was a retrospective comparative study of burn patients (>20% TBSA) resuscitated with 2 mL/kg/%TBSA lactated Ringer's using their ABWI, early FFP, plus rescue FFP as needed for oliguria. ABWI = ideal weight + 0.3 (actual weight - ideal weight). Patients with >30% TBSA were given 1 to 2 units of FFP at admission. Fluids were titrated 10% to 20% per hour based on urine output (UOP). If oliguric for 2 hours, patients received 1 to 2 U "rescue" FFP. Legacy groups were resuscitated with Parkland formula ("4 mL/kg" group) or a less restrictive 3 mL/kg ABWI group w/rescue FFP only. Demographics, injury characteristics, fluids administered during resuscitation, UOP, outcomes, and death were recorded. Legacy groups were compared with the "2 mL/kg + FFP" ABWI group.

Patients given 2 mL/kg + FFP received significantly less fluid than the 3 and 4 mL groups (1.7 vs 3.3 [p < 0.05] vs 4.15 mL/kg/%TBSA [p < 0.0001]). UOP was significantly reduced from 1.4 to 1 to 0.7 mL/kg/h (p < 0.0001), approaching the goal of 0.5 mL/kg/h. Mortality, mechanical ventilation, tracheostomy, and hemodialysis were significantly less in the 2 mL/kg + FFP group (p < 0.05).

Patients treated with the restrictive 2 mL/kg + FFP formula received less fluid than the 3 mL/kg and Parkland formula controls. With reduced fluids, patients had less mechanical ventilation, less dialysis, fewer tracheostomies, and better survival. Acute kidney injury was minimal despite fluid restriction. Early experience suggests the new protocol is safe and feasible for further study.