Introduction:
Delayed fluid resuscitation in burn patients is associated with higher cumulative fluid requirements and additional complications including pulmonary vascular congestion, congestive heart failure (CHF), longer duration of mechanical ventilation and longer intensive care unit (ICU) stay. As a continuous effort to improve burn care, our institution evaluated fluid resuscitation and requirements in patients with greater than 20% total burn surface area (TBSA) in the ICU and their outcomes to determine if an algorithm for fluid administration (minimizing delays in obtaining approval) would lead to more prompt fluid boluses and less cumulative fluid intake and less complications. Such algorithm would allow for prompt additional fluid administration based on magnitude of hypotension, further stratified according to urinary output, cardiac performance, hemodynamic variables, and adequacy of tissue perfusion based on serum lactate and base deficit.

Methods:
After IRB approval, we performed a retrospective chart review of patients admitted to burn ICU with greater than 20% TBSA over the last 5 years. The following data was evaluated 24 to 48 hours post burn injury: fluid intake, urine output, serum lactate, base deficit, episodes of desaturation (pO2<60 mmHg or SpO2<90%), pleural effusion, pulmonary edema, and episodes of hypotension (SBP<100 mmHg but >80 mmHg and/or MAP<65 mmHg but >60 mmHg). Other outcomes evaluated included: new diagnosis of CHF (within 96 hours), survival at hospital discharge, ICU length of stay, and ventilator days. Patients were divided into two groups for analysis based on before fluid administration algorithm implementation (Group 1) and after fluid administration algorithm implementation (Group 2) in 2019. Data was analyzed using chi square/Fisher exact test for categorical variables and ttest/Wilcoxon rank sum test for continuous variables.

Results:
Our preliminary data included 85 patients who met inclusion criteria (with 49 patients in Group 1 and 36 patients in Group 2). Our patient sample consisted of average age of 46 years, 76% male, average TBSA of 36% (3 with electrical burns), and 20% with inhalation injury. 63% of patients required more fluids than calculated based on modified Parkland formula (with most of the patients in Group 1). 59% of patients experienced hypotension within the first 24 hours. Group 2 had lower fluid intake in the first 24 hours; however, it was not statistically significant. Group 2 had statistically significantly lower amount of fluid intake within 48 hours (p=0.03). There was no significant difference in total ICU length of stay and total vent days between the two groups. There was also no significant difference between the two groups in CHF, pleural effusion and pulmonary edema incidences within the first 96 hours and survival at hospital discharge, although Group 1 (before algorithm implementation) had higher incidences of pleural effusion and pulmonary edema.

Conclusions:
This evaluation showed that an algorithm for fluid administration allowing nursing staff to provide prompt fluid resuscitation may lead to less cumulative fluid intake and complications. We hope to further evaluate, refine and validate our algorithm for fluid administration for burn patients with > 20% TBSA burn injuries.