Published Feb 20, 2014
Currently I am formulating an Albumin protocol in the event that our Parkland formula is not working to the desired effects. I am interested in any possible information that might be available to help me in this process. I understand not every burn center as a clear Albumin protocol and I was wondering if you had something in place. If you already have something in place, would you be willing to share it in order to provide the building blocks for our protocol? I am looking to progressively educate our nursing staff on the overall fluid resuscitation process by having a couple protocols or guidelines in place as a starting point, with deviation as directed by our physicians. I would appreciate any time that you can offer.
So our protocol attempts the parkland fluid resus for two hours. If urine output is not being met during this process after two hours of increasing fluids, then albumin drip is added of 200 ml hr up to 400 per hr. If this fails ffp is added to the mix each unit of ffp is ran over 2 hours. If the burn started off 30% or more a vit c drip would have been started on a pt from the onset. if all these measures had failed fluid, albumin, ffp for something complicated like an electrical burn then a vit c drip would be added even if under 30% burn.
We don't start albumin until about 12 hours from time of injury. Sometimes we'll start it earlier- 9 or 10 hours post injury- it just depends on the patient.
After 12 hours of fluid resuscitation with LR, we take their total fluid need and go half and half with albumin. For example, if at 12 hours the patient is getting 800 ml/hr, they get switched to "half and half"- LR @ 400 ml/hr and Albumin @ 400 ml/hr.
The reason is that 12 hours is about the time that capillary permeability is decreasing and you want to pull all the fluid you've lost into the interstitial space back into the vasculature.
You do NOT give a patient albumin after 2 hours of resuscitation. Capillary permeability is the culprit here and adding albumin will only pull fluid into the interstitial spaces, causing more edema and having no effect on urine output.
What indices do you monitor in terms of hemodynamics (RAP, SVV), dilutional coagulopathy (PT, INR) and osmolality (total protein, serum albumin, osm) to guide fluid resuscitation?
I've never done burns in my career but massive volume resuscitation is a big part of my job now...what are your targets/end points?
In other words, is there something other than UO and MAP that you follow?
We use the Parkland Formula to determine how much fluid the patient should get and their UO target is 0.3-0.5 ml/kg of their dry weight and we try to stick to that range. We don't want to give too much fluid and create a whole new set of problems.
We do use SVV to get an idea of the the patient's fluid status but it's just another tool. And if after 12 hours their INR is greater than 1.5 we'll hang FFP with the albumin and LR ("Half quarter/quarter).
Some factors we consider when a resuscitation isn't going well are CVP, bladder pressures if they're circumferential to rule out abdominal compartment syndrome, medical history, medication history (are they lasix dependent?), did we calculate their TBSA% correctly, base deficit to see how dry they are, and some others I can't think of right now.
If they're UO is incredibly high we'll also want to know their blood alcohol level, blood sugar, medical history, etc. If they're really drunk or an out of control diabetic, we'll know to not back off on the fluids so we don't get behind.
But urine output really is the main factor determining the course of a resuscitation.
Also! Our doctors never bolus during a resuscitation. The idea being its simply a band-aid and you haven't addressed the underlying problem of capillary permeability. Their UO will drop off again in a couple hours guaranteed. If you bolus, you should increase their rate after. Some residents hate this and don't appreciate nurses telling them to call the staff to make sure they're aware of an impending bolus crime, but in the end it works out.
Hope that helps.
Gotta watch out for pulmonary edema also. If the patient has a good, health strong heart prior to the burn injury, they'll be able to handle the fluids. Patients with weak hearts can get backed up into the lungs pretty quickly.
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