Burn Resuscitation with Fresh Frozen Plasma: 5 Years of Experience with the West Penn Formula

Research Article

Austin J Emergency & Crit Care Med. 2015;2(2): 1018.

Burn Resuscitation with Fresh Frozen Plasma: 5 Years of Experience with the West Penn Formula

Jones LM*, Brown N, Phillips G, Blay BA, Bhatti P, Miller SF and Coffey R

Wexner Medical Center, The Ohio State University, USA

*Corresponding author: Larry M Jones, The Ohio State University, Wexner Medical Center, N748 Doan Hall, 410 West 160th Avenue, Columbus

Received: January 23, 2015; Accepted: March 11, 2015; Published: March 13, 2015

Abstract

Introduction: Administering fresh frozen plasma (FFP) for burn resuscitation following the West Penn Formula was first described by Du, et al. in 1991 and subsequently by O’Mara et al. in 2005. Since 2006, the O’Mara modification has been followed for the resuscitation of large burns (>40% TBSA or30% TBSA with concomitant inhalation injury) at our institution. This is a report of our initial 5 years’ experience with a comparison of our outcomes to those reported by Du and O’Mara.

Methods: A retrospective charter view of burn admissions between February 1, 2005 and August 31, 2011, revealed 62 patients suffered large burns and received fluid resuscitation following the West Penn Formula.

Results: Average TBSA was 52±18.9% (average full thickness 28.1±27.6%). Thirty-six (58%) suffered inhalation injury. Average FFP infusion was of 3.2±2.4 liters/24hrs. Urine output averaged 1.1±0.7cc/kg/hr. Average base deficit at 24 hours was1.6±6.1. Ten deaths occurred during the first 48 hours post burn all due to requests of family members to withdraw support.

Conclusions: The West Penn Formula appears to be an effective method to resuscitate patients suffering burn shock secondary to major burns.

Keywords: Burn shock; Fresh frozen plasma; Resuscitation

Introduction

For years the burn community has sought the perfect fluid resuscitation formula to treat patients experiencing burn shock. The goal is to maintain tissue perfusion while avoiding over or under resuscitation and the complications associated with each. Since its introduction in 1968, the Parkland Formula has been the most widely used resuscitation formula by burn surgeons to resuscitate burn patients [1]. The initial Parkland Formula included colloid administration during the second 24 hour period of burn resuscitation [2]. In 1979 a Consensus Formula was introduced by the American Burn Association which excluded the use of colloid [3]. As stated in that report:

“It is the consensus that treatment should be begun with a balanced salt solution, such as Ringer’s lactate or one of its several equivalents… The volume of fluid to be administered in the first 24 hours ranges between 2 to 4 ml/kg/% burn.”

“Colloid is generally incorporated in the regimen; however, the exact timing of its administration cannot beset rigidly. It is generally prescribed after the first 24 hours of resuscitation, and whether or not earlier administration is beneficial has not been truly established.”

The use of colloid is also excluded from the American Burn Association sponsored Advanced Burn Life Support Course [4]. It is believed this exclusion of colloid has led to “fluid creep” and the subsequent questioning by several investigators of the efficacy of the Parkland Formula [5-10]. “Fluid creep”, which is merely the over resuscitation of burn patients, increases the risk of developing pneumonia, bloodstream infections, acute respiratory distress syndrome, multiple system organ failure and death [11].

In 1991, Du, et al. described the use of fresh frozen plasma (FFP) as the primary fluid for burn resuscitation [12]. This formula has subsequently become known as the West Penn Formula, named after The Western Pennsylvania Hospital in Pittsburgh where the work was performed. This report of 10 patients showed that smaller amounts of fluid, in the form of FFP, could be used successfully for burn shock resuscitation while avoiding excessive fluid administration and weight gain. A follow-up report by O’Mara in 2005 demonstrated the West Penn Formula to be effective in resuscitating patients from burn shock while at the same time avoiding the complications of intraabdominal hypertension and abdominal compartment syndrome [13].

Since 2006, the West Penn Formula has been used for resuscitation of large burns (>40% total body surface area or 30% total body surface area with inhalation injury) at The Ohio State University Wexner Medical Center. The resuscitation is carried out following the formula as described by O’Mara, et al. of 75cc FFP/kg bodyweight/24 hours administered over the initial 48 hours plus Lactated Ringer’s Solution at 83cc/hr (2 liters over 24 hours X 48 hours) [13]. The FFP is titrated to maintain a urine output of at least 0.5cc/kg bodyweight/hour. To date, no one has described the use of the West Penn Formula in a large sample size nor compared its use to resuscitation following the Parkland Formula. The primary objective of this study was to describe our experience with the West Penn Formula and compare our outcomes with those reported by both Du and O’Mara [12,13]. Secondary objectives were to compare the total amount of fluid given using the West Penn Formula with Parkland Formula calculations, identify complications associated with FFP resuscitation, describe endpoints of resuscitation such as urine output, serum creatinine and BUN and examine mortality experienced with FFP resuscitation.

Methods

Following IRB approval, a retrospective chart review was conducted of patients with large burns resuscitated using the West Penn Formula admitted to the verified burn center at The Ohio State University Wexner Medical Center between February 01, 2006 and August 31, 2011. Inclusion criteria included only acute burns of > 40% total body surface area or 30% total body surface area with an associated inhalation injury. Exclusion criteria included prisoners and pregnant females. Data was collected by retrospective chart review. Data points collected included total body surface area burn (TBSA), presence of inhalation injury, hourly fluid intake and urine output for the first 48 hours post admission, base deficit, BUN, creatinine, mortality, and cause of death. Predicted Parkland Formula fluid administration was also calculated and compared to the amount of FFP actually given. Deaths were divided into those who died within the first 48 hours post burn and those who died after 48 hours. Descriptive statistics were used since the primary objective was to describe our experience using the West Penn Formula for resuscitation. Age, gender, inhalation injury, TBSA, partial thickness size, and full thickness size were compared to assess if statistically significant differences were present. Age and TBSA were compared between the two groups using two sample t-tests. Comparisons of partial and full thickness were made using Mann-Whitney U tests due to non-normality of the data. Comparisons for gender and inhalation injury were made using Fisher’s Exact Test. Statistical analysis was done using SAS 9.3.

Results

There were 62 patients (42 males, 20 females) who met inclusion criteria of a large burn receiving fluid resuscitation following the West Penn Formula. Average age was 51.1±17.2 years. Average TBSA was 52±18.9 % with an average of 28.1±27.6% being full thickness. Thirty-six (58%) suffered inhalation injury which was diagnosed with bronchoscopy. The baseline characteristics of these patients, with a comparison to patients reported by Du, et al. and O’Mara, et al. are listed in Table 1 [12,13].