burns 36 (2010) 13161321

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journal homepage: www.elsevier.com/locate/burns

Response to Letter to the Editor

Fluid resuscitation in burns
Burns response to Letter to the Editor concerning Burn resuscitation: the results of the ISBI/ABA survey [1]. I appreciate the letter from Dr. Burd concerning my survey related to practices of burn shock resuscitation around the world. I agree with every idea that he presents. I was prompted to examine the practices of the initial burn resuscitation after participating in the American Burn Associations 2006 State of the Science Meeting where it became obvious that there are many differences in our resuscitation practices. As stated in the conclusion of that meeting [2] the top ve topics for investigation were (1) Dene the endpoints of burn shock resuscitation. (2) Develop a better understanding of the pathophysiology of burn shock edema. (3) Determine the cause of uid creep. (4) Develop an oral resuscitation protocol. (5) Perform a multicenter trial with an agent that reduces the capillary leak of burn shock (i.e. Vitamin C). The goal of the ISBI/ABA survey was to document how much difference really existed, and to my surprise; the differences were more marked than expected. As a rule, when there are multiple ways of performing a task, then there is no best way to perform that task. None of the resuscitation formulas work well and attention to detail to the patients response is also inadequate. More research is needed to improve our resuscitation techniques. We need to work to develop better ways to initiate resuscitation, identify physiologic endpoints and then improve our responses to those changes. Clearly, multi-center trials to address these issues would be the best way to resolve resuscitation problems.
[2] Greenhalgh DG. Burn resuscitation. J Burn Care Res 2007;28:55565.

David G. Greenhalgh* Shriners Hospitals for Children Northern California and UC Davis Medical Center, 2425 Stockton Boulevard, Sacramento, CA 95817, United States *Tel.: +1 916 453 2000; fax: +1 916 453 2352 E-mail address: david.greenhalgh@ucdmc.ucdavis.edu 25 May 2010 0305-4179/$36.00 # 2010 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2010.05.022

Letter to the Editor

Fluid resuscitation in burns
The results of the survey by David G. Greenhalgh were interesting if not predictable [1]. The wide range of clinical practice reects the reality that there is no one way to achieve satisfactory resuscitation. This can be a restatement of Dr. Greenhalghs conclusion that the large variance in formulas and uids tell us that no protocol is perfect; in effect every protocol has the capacity to achieve a perfect result because it would be unethical to use it if it was consistently bad. And this underlines the fundamental challenge in burns resuscitation; we are dealing with individuals not populations. Formulae are for populations and the essential point is how to quickly, smoothly and reliably tailor the resuscitation to the individual patient. This challenge becomes even greater when there has been a delay in beginning resuscitation or where the patient has a medical co-morbidity that can complicate the resuscitation process. I certainly agree that better end points to resuscitation need to be developed but perhaps of greater importance are the parameters that are measured during resuscitation and the response, in terms of uid infusion, to deviations outside a pre-established range of values. An example of this is described in Latensers review article [2] which contains Safes algorithm for resuscitation of adult

Conict of interest statement

There is no conict of interest related to this response to the Letter to the Editor.

references

[1] Greenhalgh DG. Burn resuscitation: the results of the ISBI/ ABA survey. Burns 2010;36:17682.