Hold the pendulum: Rates of acute kidney injury are increased in patients who receive resuscitation volumes less than predicted by the parkland equation

Objective: To determine whether restrictive fluid resuscitation results in increased rates of acute kidney injury (AKI) or infectious complications. Background: Studies demonstrate that patients often receive volumes in excess of those predicted by the Parkland equation, with potentially detrimental sequelae. However, the consequences of under-resuscitation are not well-studied. Methods: Data were collected from a multicenter prospective cohort study. Adults with greater than 20% total burned surface area injury were divided into 3 groups on the basis of the pattern of resuscitation in the first 24 hours: volumes less than (restrictive), equal to, or greater than (excessive) standard resuscitation (4 to 6 cc/kg/% total burned surface area). Multivariable regression analysis was employed to determine the effect of fluid group on AKI, burn wound infections (BWIs), and pneumonia. Results: Among 330 patients, 33% received restrictive volumes, 39% received standard resuscitation volumes, and 28% received excessive volumes. The standard and excessive groups had higher mean baseline APACHE scores (24.2 vs 16, P<0.05 and 22.3 vs 16, P<0.05) than the restrictive group, but were similar in other characteristics. After adjustment for confounders, restrictive resuscitation was associated with greater probability of AKI [odds ratio (OR) 3.25, 95% confidence interval (95% CI) 1.18-8.94]. No difference in the probability of BWI or pneumonia among groups was found (BWI: restrictive vs standardOR0.74, 95%CI 0.39-1.40, excessive vs standard OR 1.40, 95%CI 0.75-2.60, pneumonia: restrictive vs standard, OR 0.52, 95% CI 0.26-1.05; excessive vs standard, OR 1.12, 95% CI 0.58-2.14). Conclusions: Restrictive resuscitation is associated with increased AKI, without changes in infectious complications.