Pot beta-blocantele să reducă necesarul intraoperator de agenţi anestezici?

Jurnalul Român de Anestezie Terapie Intensivă 2013 Vol.20 Nr.1, 3-4

The role of albumin in the fluid resuscitation of major burn

Burns and burn resuscitation remain a significant patterns seem to exist: immediate use (within 8 hours
challenge to anesthesiologists and intensivists world- of injury); intermediate use (sometime between 8 and
wide. As is well known, major burn injuries produce 12 hours post injury); and later use (sometime between
profound and prolonged increases in capillary permea- 18 and 24 hours post-injury). There does not appear to
bility within the burn wound microcirculation, starting be any consensus on either timing or approach.
immediately, peaking around 8 hours post-burn and In this issue of the journal, Cucereanu-Badica et
persisting for at least 48 hours [1-3]. Albumin (ALB), al. investigate the correlation between burn size and
being the most abundant of all plasma proteins in the serum albumin in the immediate 48 hours following
body (50% of all plasma protein, with the majority being major burn injury [7]. In their paper, the authors pro-
extra vascular), is particularly affected in burns and posed to develop a method of calculating the expected
other syndromes involving capillary leakage. serum albumin related to the extent of burn areas.
Fluid resuscitation practices vary substantially Specifically, their aim was to find whether there was a
worldwide and the decision to employ crystalloid vs. correlation between the percentage of the burned body
colloid early in the resuscitation process has been surface area and the lowest serum albumin during the
controversial. In the USA, the most recent practice first 48 hours after severe burn injury. Forty-seven pa-
guidelines of the American Burn Association on burn tients admitted to the intensive care unit of a single
shock resuscitation state that one option is to administer hospital were studied, with burns ranging from 25-90%,
colloid-containing fluids (type unspecified) between 12 over a six and a half year period. Patients with burns
and 24 hours post-injury to decrease overall fluid less than 25%, as well as those with significant cardio-
requirements during acute burn resuscitation [4, 5]. vascular, hepatic and renal disease were excluded.
Practices in Europe are more variable. A 2008 survey Fluid resuscitation was similar in all patients, and used
of 80 European burn units found that although 86% of the Parkland protocol (crystalloid in the first 24 hours).
practitioners “always or often” use crystalloids for All patients obtained enteral as well as parenteral
acute resuscitation, 44% initiate colloids before 24 nutrition. Serum albumin levels were determined twice
hours post-burn, and ALB is the colloid of choice in daily, and the nadir of serum albumin during the first
51% of cases (starches, dextran, and plasma com- 48 hours was recorded. The authors found a negative
prising the other half) [6]. What is generally well esta- linear correlation between the burned surface area and
blished with ALB usage is that it has a volume-sparing serum albumin level during the first 48 hours; they later
effect and promotes adequate volume resuscitation with sought to establish a mathematical correlation, where:
less overall fluid requirement and less edema formation albumin = burned surface area × (p1 + p2)
than with crystalloids alone. Worldwide, the actual
where:
timing of ALB administration varies and three general
p1 = -0.01925 (range, -0.02398 to -0.01452)
Adresa pentru corespondenţă: Harish Ramakrishna, MD, FASE
p2 = 2.573 (range, 2.323 to 2.823)
Department of Anesthesiology The authors state that the p1 and p2 coefficients
5777 East Mayo Boulevard
Phoenix, AZ 85054 are purely numerical values, with no clinical or
E-mail: [email protected] physiologic correlation. The p1 variable is always
4 Ramakrishna

negative, with values in parentheses that represent colloid administration dictated by patient status, hemo-
minimal and maximal values that can be used to cal- dynamic stability and laboratory testing. Nevertheless,
culate minimal and maximal albumin levels for a this study addresses a very important issue, and like
particular burn area. The authors concluded that their most studies that challenge the “clinical status quo”,
formula could be used to predict albumin levels in a its value is more in asking the questions, not necessarily
burn range of 25-90% of body surface area. in answering them. We look forward to future studies
Based on their findings, the authors propose that that will address these questions.
since the magnitude of the initial hypoalbuminemia is
related to the severity of burn injury, albumin should Harish Ramakrishna MD FASE
be started early on in the initial phase of the resusci- Chair, Division of Cardiovascular and Thoracic
tation.
Anesthesiology, Mayo Clinic Arizona, USA
This small but potentially important study raises
some interesting questions. Are current fluid protocols
physiologically correct? Should we routinely administer
albumin to all patients with major burn injuries? There References
are definite limitations in this study: a very small patient
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ever, that their mathematical model is just a prototype
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and agree that the rationale for this study is to establish
American Burn Association practice guidelines burn shock
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