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Fluid resuscitation following burn injury must support organ perfusion with the least amount of fluid necessary and the least physiological cost. Under resuscitation may lead to organ failure and death. With adoption of weight and injury size-based formulas for resuscitation, multiple organ dysfunction and inadequate resuscitation have become uncommon. Instead, administration of fluid volumes well in excess of historic guidelines has been reported. A number of strategies including greater use of colloids and vasoactive drugs are now under investigation to optimize preservation of end organ function while avoiding complications which can include respiratory failure and compartment syndromes. Adjuncts to resuscitation, such as antioxidants, are also being investigated along with parameters beyond urine output and vital signs to identify endpoints of therapy. Here we briefly review the state-of-the-art and provide a sample of protocols now under investigation in North American burn centers.

Introduction: There is renewed interest in blood product use for resuscitation stimulated by recent military experience and growing recognition of the limitations of large-volume crystalloid resuscitation., Methods: An editorial review of recent reports published by investigators from the United States and Europe is presented. There is little prospective data in this area., Results: Despite increasing sophistication of trauma care systems, hemorrhage remains the major cause of early death after injury. In patients receiving massive transfusion, defined as 10 or more units of packed red blood cells in the first 24 hours after injury, administration of plasma and platelets in a ratio equivalent to packed red blood cells is becoming more common. There is a clear possibility of time dependent enrollment bias. The early use of multiple types of blood products is stimulated by the recognition of coagulopathy after reinjury which may occur as many as 25% of patients. These patients typically have large-volume tissue injury and are acidotic. Despite early enthusiasm, the value of administration of recombinant factor VIIa is now in question. Another dilemma is monitoring of appropriate component administration to control coagulopathy., Conclusion: In patients requiring large volumes of blood products or displaying coagulopathy after injury, it appears that early and aggressive administration of blood component therapy may actually reduce the aggregate amount of blood required. If recombinant factor VIIa is given, it should be utilized in the fully resuscitated patient. Thrombelastography is seeing increased application for real-time assessment of coagulation changes after injury and directed replacement of components of the clotting mechanism.

Objective: To compare vital sign and urine output monitoring of seriously burned patients with invasive monitoring during early resuscitation., Design: Retrospective review., Setting: A university hospital burn unit., Patients: Fourteen seriously burned patients who had pulmonary arterial monitoring. Monitoring data were compared at baseline and after fluid challenges., Results: There was no correlation between invasively derived physiologic variables and vital signs and urine output. Vital signs and urine output changed little after fluid challenge, while variables from invasive monitoring demonstrated significant change. In half of the patients, oxygen consumption increased after fluid challenge; vital signs and urine output did not distinguish these patients., Conclusions: The use of urinary output and vital signs to guide initial burn resuscitation may lead to suboptimal resuscitation. Invasive cardiorespiratory monitoring may be necessary to optimize resuscitation of seriously burned patients.