Recommendation 1
Adult patients with burns greater than 20% total burn surface area  (TBSA), and pediatric patients with burns greater than 10%  TBSA, should be formally resuscitated with salt-containing fluids;  requirements should be based on body weight and percentage burn.

Considerations in formulating Recommendation 1
Available evidence identifies fluid resuscitation with saltcontaining  fluids as a foundational aspect of burn care [75–77].

Balance of benefits and harms
Significant agreement from the literature substantiates that resuscitation  volumes should be correlated with burn size and patient-weight  based; however the fluid composition and the injury  threshold at which resuscitation should be instituted does  not represent unanimity of opinion.

Values and preferences
Health care providers and policymakers from resource limited settings  (RLS)—and providers the world over during events involving  mass casualties—face a critical challenge, as the cost  and availability of properly sterilized intravenous catheters  and intravenous salt solutions mean these resources may  be unattainable. (See below: recommendation 3 regarding oral  rehydration.) Otherwise, the unanimous preference would  be to provide this life-saving therapy that so greatly impacts  patient pathophysiology downstream.

Costs of intravenous catheters, their sterile introduction and maintenance,  and sterilized intravenous salt solutions can be challenging  in RLS, depending on the particular scenario. In general,  however, use of effective and timely fluid resuscitation  is greatly favorable for economizing the total cost of care downstream  after burn.

Q: What are the recommendations describing the lower limit of  burn size that is an indication for burn shock resuscitation in  infants?
A:  No supportive literature substantiates recommendations  for infants. However, some experts feel that infant patients  with >10% TBSA injuries should receive resuscitation [78].
Q:  Are there other factors that might compel clinicians to use  resuscitation for smaller TBSA injuries or that indicate an increase  in predicted fluid needs?
A:  Inhalation injury and exceedingly deep burns (e.g., 4th degree  injuries) typically amplify the need for fluid resuscitation.
Q:  Can you be more specific about choice of salt-containing fluids?
A:  Many experts consider it better to use balanced salt solutions  (e.g., lactated Ringer’s), which are less acidic and more  similar to normal plasma electrolytes, compared with normal  saline.
Q:  What if there is a several-hour delay after burn? How is resuscitation  managed then?
A:  Most experts judge that several hours’ delay prior to presentation  requires an initial accelerated administration of fluids,  which would have been earmarked for those hours in transit.  Using urine output and other monitoring values of adequate  volume status becomes even more critical given this type  of additional uncertainty.

Recommendation 2
When IV fluid administration is practical, between 2 and 4 mL/kg body  weight/burn surface area (% total body surface area, TBSA) should  be administered within the first 24 h after injury, with alertness  to over-resuscitation.

Considerations in formulating Recommendation 2
Morbidity and mortality resulting from over-resuscitation must  be avoided. The value of employing colloids remains unresolved  [79–84].

Balance of benefits and harms
The available evidence demonstrates a continuum of effects, both  positive and negative, based on the amount of IV fluid administration  as a function of weight and burn size. The theoretical  objective is to alleviate the post-burn hypovolemia and  hypoperfusion by ensuring adequate end organ perfusion. Erring  on the side of excessive, gratuitous fluid administration has  a converse detrimental effect, sometimes resulting in death.  Although such fluid administration is widely practiced, no  study has yet been conducted to corroborate extensive empirical  conclusions that colloids are in fact an often-critical component  of resuscitation from the worst incidences of burn shock.

Values and preferences
Given the lack of supporting studies, health care providers and  policymakers are likely to allot a low value to the routine use  of colloids in burn shock resuscitation. In the end, the treating  provider is ultimately responsible for the clinical outcome,  and if pragmatism is to prevail, local successful practice  patterns (constricted by fiscal realities) must be honored.

Colloids are prohibitively expensive as compared with salt  solutions. Cost alone may provide sufficient justification for  eliminating colloid use from local standard practice patterns.

Q: What are some of the benefits perceived by those experts who  choose to include colloids in their burn shock resuscitation  practices?
A:  Several respected burn experts believe that resuscitation of  very large injuries (e.g., >70% TBSA) proceeds much more smoothly  with the inclusion of colloids. Others believe that ‘‘fluid  creep’’ (very large volumes of salt solutions that can be dangerous  and sometimes lethal) is less likely to develop with colloid  administration.

Recommendation 3
If only oral fluid administration is practical, drinking liquids (typical  of the local diet) equivalent to 15% of the body weight every  24 h is recommended for two days. Five-gram tablets of table  salt (or the equivalent) must be ingested for each liter of oral  fluids.

Considerations in formulating Recommendation 3
Class 1 evidence is lacking for the use of oral fluids in resuscitating  burn shock patients. Peer-reviewed scholarly articles  are greatly needed.

Balance of benefits and harms
Despite the lack of evidence supporting this recommendation, expert  opinion encourages the use of oral resuscitation. Especially  under circumstances where the alternative is no resuscitation,  the promoted benefits are compelling and outsize  the potential risks [85–88]. Inadequate resuscitation equates  with unnecessary deaths.

Values and preferences
Even in light of a paucity of evidence to inform our determination  of benefits or harms, health care providers are  likely to reach for oral resuscitation when treating patients with  burn shock, and consider it justified in this work, because the  alternative is to do nothing in the face of a known potentially  lethal pathophysiology.

The costs of the oral rehydration schemes presented here are trivial,  even in RLS.

Q: Is this amount of oral fluid tolerable? Will it simply induce vomiting?
A:  The few experts with experience using oral fluid resuscitation  for burn shock believe that administering frequent,  small fluid amounts (50 mL or less each time) is the  most sensible way to effectively employ the oral route of fluid  administration.
Q:  What if salt tablets are not available?
A:  Use one level teaspoon of table salt, which is roughly 5 grams.
Q:  What are some examples of useable fluids?
A:  Multiple fluids indigenous to the setting can be used.
Some  examples include:
  • Rice water (congee) with salt    
  • Fresh lime water with salt and sugar    
  • Vegetable or chicken soup with salt    
  • Lassi (yogurt drink with salt and sugar)    
  • Sugarcane juice with lemon, black pepper, and salt    
  • Sports drink (e.g., Gatorade) with ¼ tsp salt and ¼ tsp baking  soda for each quart    
  • Carrot soup with salt    
  • Gruel (cooked cereal diluted with water) with salt    
  • World Health Organization UNICEF Oral Rehydration
  • Solution  (ORT), used for infectious diarrhea    
  • Oral fluid formula used for cholera (Cera Lyte 90)

Recommendation 4
When practical, monitoring the adequacy of resuscitation can be conducted  by titrating salt-containing fluids. For adults, titrate provided  fluids to average patients’ urine outputs of 0.3–0.5 mL/ kg/hour;  in children titrate to 1 mL/kg/hour. For the first 3 h of resuscitation,  values may still approach anuria, irrespective of the rate  of fluid administration.

Considerations in formulating Recommendation 4
Balance of benefits and harms
Available evidence shows that monitoring the adequacy of burn  resuscitation efforts is of great import to outcomes [89– 93].  The use of bladder catheters is not practical in RLS and bears  potential infectious consequences. The accuracy and applicability  of using simpler methods to quantify urine output  are not well documented.

Values and preferences
Given the variances of affordability and practicality of urine output  monitoring in different settings, policy experts are likely  to promote and health care providers are likely to implement  such monitoring consonant with available resources  and the increased complexity/risk of urinary tract infection.

Unfortunately, until published studies validate the use of simpler  methods to quantify urine output (e.g., weighing diapers),  routine bladder catheterization remains a prohibitively  expensive luxury that may or may not be attainable in RLS.

Q: Isn’t monitoring of urine output compulsory and a standard of  care?
A:  By and large, monitoring of urine output during burn shock  resuscitation is the most sensible and reliable method to  ensure adequate therapy. However, there may be circumstances  geographically and temporally around the globe where  it is just not practical.
Q:  Aren’t these recommended urine outputs rather low?
A:  It is true that these values for urine outputs, gleaned from  studies and comments in the published literature, are on  the low side. A judgment had to be made regarding the chosen  set-point of these recommendations, taking into
consideration the relative risk of spawning either inadequate or  excessive resuscitation, both of which are highly undesirable.
Q:  Can you further clarify the statement in Recommendation  4 that ‘‘for the first three hours of resuscitation, values may  still approach anuria, irrespective of the rate of fluid administration’’?
A:  There is often a lag time in human burn shock pathophysiology  such that ‘‘priming of the pump’’ cannot be  accelerated by more aggressive fluid delivery; a compulsory time  factor must be taken into account.

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