Burns, 1, 23-42
Urine output following
John A. D. Settle
Consultant in Clinical Phvsioloav, Reaional
Wakefield, Yorkshire , -I -
A difference of opinion exists concerning the useful-
ness of hourly urine volume as an index of effective
resuscitation following burns. An investigation is
described in which the volume and osmolality of the
hourly urine output of severely burned patients was
measured. The determinants of urine output in normal
and injured patients are described and it is empha-
sized that volume is only one parameter of urine
output. A clear distinction is made between oliguria
and antidiuresis, and the significance of free osmolal
output as an index of renal performance is explained.
It is pointed out that the nature of the infusion
fluid, the methods of assessing effective resuscitation,
and the nature of the urine output are closely inter-
related in any one scheme of resuscitation. From this
it follows that a urine volume judged to indicate
adequate resuscitation in one scheme may have a
different significance in another. The view is expressed
that if effective resuscitation means adequate blood
Row to all tissues, the kidney should not be made an
exception. Adequate renal perfusion is proved only
when the urine contains a free osmolal output
sufficient to permit maintenance of normal body
osmolal balance in the absence of gross changes in
solute-free water intake. It is suggested that urine
output (volume, osmolality and free osmolal output)
is a useful index of the effectiveness of resuscitation
since it provides a reliable indication of renal perfu-
sionexcept when renal function itself is impaired.
For patients resuscitated with plasma, the range in
which an ‘adequate ’urine output can be expected to
lie, is given, and the possible affects of other fluids on
the urine output are discussed. It is stressed that when
renal function is impaired, consideration of the urine
output is a more useful prognostic aid than is a study
of the blood urea levels.
INTRODUCTION
THE satisfactory early management of a patient
with an extensive burn involves the infusion of
fluid at a rate rarely seen in any other situation
except when large amounts of whole blood are
being lost from the circulation. The central role
23
severe burns
Burns Centre,
of hypovolaemia in ‘burns shock ’ was first
emphasized by Blalock (1931), who also showed
that it was correctible by the infusion of plasma.
By comparison with the rapid loss of whole blood,
the insidious leak of plasma from the circulation
to form the bum oedema is much less dramatic.
However, because the rate of loss of fluid from
the circulation is more predictable in burns than
in multiple fractures, ruptured viscera etc. it
should be possible to maintain an adequate
circulation in the burned patient more easily than
is sometimes the case in other forms of trauma
which produce hypovolaemia.
As an index of the effectiveness of resuscitation,
the urine output has been widely recommended.
Moore (1959) stated that ‘It was in dealing with
burns that the use of the short-term urine volume
record was first described (Cope and Moore,
1947) and it is in the care of burns that the hourly
urine output provides such an extremely useful
criterion of homeostatic normalcy ‘. Barclay and
Wallace (1954) were even more definite, ‘The
best check on the adequacy or otherwise of fluid
therapy is an hour-to-hour watch over the renal
output ‘. They went on to say that ‘In adults a
satisfactory hourly excretion is between 50 and
100 ml, less than 30 ml and more than 150 ml
indicate inadequacy or excess ‘.
In the collection of monographs entitled
Contemporary Burn Management (1971) several
contributors endorse the importance of urine
output as an index of effective resuscitation.
Their recommendations for ‘adequate ’ urine
output (in adult patients) show some variation:
Baxter, more than 50 ml per hr; Monafo, 30 ml
per hr; Artz, 30-50 ml per hr; Sorensen, 60 ml
per hr and Stone, 40-70 ml per hr. However, not
all authorities agree that urine output is a
valuable or even useful index of effective resusci-
tation. Wilkinson (1965, 1969, 1971) has re-
peatedly expressed the view that oliguria is one of
the normal consequences of injury and that ’The
volume of urine produced per hour should not be
24
used as an index of success or failure in the
maintenance of a circulating blood volume at an
adequate level’. Barton and Laing (1970) have
reported that during the shock phase they found
the urine volume to be extremely variable and
quite unpredictable.
In the knowledge that some difference of
opinion existed concerning the value of urine
output as an index of the resuscitation of burned
patients, an investigation was planned in which
Tab/e /.-Patients investigated in detail
Type of burn
71 20 per cent full skin
thickness flame burn
10 55 per cent full skin
thickness flame burn
34 30 per cent deep
dermal flame burn
30 per cent mixed
1;
thickness scald
27 25 per cent partial
thickness scald
45 40 per cent full skin
thickness flame burn
40 30 per cent mixed
thickness flame burn
2 45 per cent full skin
months thickness flame burn
the aim was to examine the nature of the urine
output during the shock phase. Preliminary
observations clearly indicated the need to measure
not only the volume of urine excreted per hour
but also its concentration (Settle, 1968).
PATIENTS
During the 1Zmonth period November 1969 to
October 1970, it was possible to perform detailed
studies of urine output on 8 patients admitted to
the Regional Burns Centre. Their ages ranged
from 18 months to 71 years and the extent of their
burns from 20 per cent to 55 per cent with an
average of 35 per cent. Table Z lists the patients
in the order in which they were investigated. In
addition to these 8 patients, less detailed studies
were performed during the same period on a
further 11 patients with severe burns. Three of
these patients were admitted to the Burns Centre
towards the end of the shock phase (resuscitation
having been mainly carried out elsewhere). Two
others were elderly patients with unsurvivable
bums (80 per cent) for whom formal resuscitation
was inappropriate. In these 5 patients, and in a
Burns Vol. 1 /No. 1
further 6 patients, the determinations of hourly
urine concentration were carried out for periods
of less than 24 hours. The findings in these
patients are excluded from this paper only
because of their incompleteness; in no way did
they conflict with the patterns of urine output
observed in the patients reported.
METHODS
In general, the clinical management of the shock
phase followed the scheme described by Muir
and Barclay (1962). Reconstituted dried human
plasma was used as the replacement fluid and the
forecast of the likely amount required calculated
by use of the Muir and Barclay formula. The
first 36 hours following burning are divided into 6
periods of 4 hours, 4 hours, 4 hours, 6 hours, 6
hours and 12 hours. The expected plasma
requirement for each of these periods is:
Weight of patient x percentage area of bum ml
2
Whole blood was substituted for plasma as
recommended by Muir (1961), i.e. an amount
equal to 1 per cent of the patient’s normal blood
volume for each 1 per cent of full-thickness burn.
All intravenous fluids were given via drip sets
incorporating a calibrated burette so that the
exact amount infused per hour was known.
Water for metabolic requirements was given
orally or as 5 per cent dextrose solution intra-
venously. The values accepted as normal for
blood volume, haematocrit (Htc), water require-
ment and minimum urine flow per hour were
those given by Muir and Barclay (1962).
All patients had a self-retaining bladder
catheter inserted shortly after admission. Each
catheter was attached by a few cm of tubing to
a closed drainage bag which could be emptied by
a tap at its most dependent part. The bag was
emptied on the hour, every hour, the volume
measured, and a sample kept for determination
of osmolality.
Venous blood, taken into a dry plastic bottle
containing lithium heparin was used for Htc,
osmolality, urea and electrolyte determinations.
Urine osmolality was usually determined within
a few minutes of the specimen being collected.
Occasionally, specimens obtained during the
night were stored at 4°C and the osmolality
determined a few hours later.
Plasma and urine osmolality determinations
were made on duplicate samples by a depression
of freezing point method using an ‘Advanced ’
osmometer. The accuracy of the determination
was better than h 1 per cent and full details of the
technique used have been published elsewhere
 Settle : Urine Output following Severe Burns 25

(Settle, 1971). Calibration checks using standard CASE REPORTS

solutions were made after every tenth sample but
a change of calibration was never required during
the investigation of any one patient. The normal
value for plasma osmolality was taken to be the
generally accepted figure of 290 mosmol per kg
+I0 (Holmes, 1962; Co&on, 1963; Eklund,
1970).
Case 1
An elderly lady of 71 years, weight 60 kg, sustained a
20 per cent full-thickness flame burn, parts of which
were very deep, as the result of a domestic accident.
Fluid balance and Htc are shown in Fig. 1 and urine
and plasma osmolality in Fig. 2. Intravenous therapy
with plasma was commenced during the third hour

15
-y. .: .~~~... ,........ .., 1
Htc.1 35

Osm/hg.
25 1

ml.
500

400

??
Plasma 3oo

a Blood

m Mannitol
200
??
Dextrose

/g Oral
100 Urine

INTAKE

- 0

OUTPUT
Plasma
-
100

:] Urine

200
HOlIE

0
\
10 20 30 40 50 10 20 30 40 5‘0

Fig. I .--Case I. Fluid balance and Htc. Fig. 2.--Case I. Urine and plasma osmolality.

Clinical management and osmolality deter-
minations were undertaken concurrently by the
same person. It was inevitable, therefore, that
knowledge of changes in urine concentration
would affect the general management of the
patient. Indeed, there were occasions when
alterations in fluid therapy were made mainly
because changes in urine concentration had been
observed, whilst at other times, treatment was
withheld which would probably have been
instituted if the urine concentration had not been
known. As a result of this continual feedback of
information, certain aspects of cause and effect
can only be discerned by a close study of the hour-
by-hour events in the resuscitation of individual
patients. For this reasons, the case histories of
each patient are presented in detail.
after injury and when the bladder was catheterized
at the end of this hour, only 10 ml of clear urine,
cont. 327 mosmol per kg were obtained. By the end of
the fourth hour, the urine output had increased to
20 ml, cont. 380 mosmol per kg and thereafter both
volume and concentration continued to increase for
several hours.
The patient was taking very little water by mouth
and by the tenth hour, although colloid replacement
was considered adequate (55 ml of clear urine, cont.
518 mosmol per kg during the tenth hour), there were
signs of dehydration (plasma osmolality had risen by
9 mosmol per kg over the previous 8 hours). During
the eleventh hour, 400 ml of 5 per cent dextrose were
given intravenously in addition to the plasma infusion.
At the end of that hour, the urine volume had fallen
to 25 ml, concentration was unchanged but, for the
first time, the urine contained blood pigment. Three
hundred and fifty ml of 5 percent dextrose were given
 26
during the twelfth hour, the urine output dropped to
10 ml, was very heavily pigmented, and was less
concentrated (494 mosmol per kg). Following a
further 250 ml of 5 per cent dextrose in the thirteenth
hour, the urine output rose to 28 ml, but was still
heavily pigmented and its concentration had dropped
to 390 mosmol per kg.
Oliguria combined with haemoglobinuria is
generally considered to be an ominous sign of
55
Hlc.% 45
35
Dialysis
1
600 ml.
FJ Plasma
? B?lood
pjzj Oral
INTAKE
OUTPUT
1ooJml.
??
Urine
I
HOUrS
0 10 20 30 40
Fig. 3.-Case 2. Fluid balance and Htc.
impending renal failure (Dudley et al., 1957). The
observation that the oliguria was also associated with
a fall in urine osmolality was interpreted as confirma-
tory evidence of impaired renal function and it was
decided to attempt to produce a solute diuresis.
Over the next 3 hours, 500 ml of 20 per cent mannitol
were given i.v. in addition to the plasma infusion.
Figs. 1 and 2 clearly show the diuretic response to
mannitol, the expected initial fall in urine osmolality
associated with osmotic diuresis (Dudley et al., 1957)
and the concomitant rise in plasma osmolality. The
changes in the Htc indicated that during the period of
oliguria (eleventh to thirteenth hours) the patient was
not oligaemic. Thereafter, the management of this
patient was uneventful, there was no further evidence
of impaired renal function and skin grafting of the
burned areas was undertaken at two operations, 29
and 41 days respectively from the time of burning.
Seven days after the second operation, an episode of
Burns Vol. 1 /No. 1
auricular fibrillation occurred which resolved spon-
taneously but 2 days later she suddenly died. At post-
mortem, a picture of general senile change was
revealed; cerebral atrophy, and cerebral and coronary
artery narrowing and sclerosis.
Case 2
A IO-yea-rold boy, weight 33 kg, sustained a 55 per
cent full-thickness burn as the result of an accident
I
‘6
.!
Wins
‘4
Plasma *3
-
50 1’0 2’0 3’0 4’0 5’0
Fig. 4.-Case 2. Urine and plasma osmolality.
with a bonfire. Parts of the burn were very deep.
Fluid balance and Htc are shown in Fig. 3 and urine
and plasma osmolality in Fig. 4. Resuscitation with
plasma was commenced during the second hour after
injury. On admission to the Burns Unit towards the
end of the third hour, there was no clinical evidence of
oligaemic shock.
Catheterization of the bladder at 3 hours produced
35 ml of clear urine, cont. 715 mosmol per kg.
Plasma osmolality was 315 mosmol per kg and Htc 50
per cent. These findings indicated a possible deficit
of about 400 ml of plasma (17 per cent of the total
blood volume) together with mild dehydration. Over
the next 2 hours no urine could be obtained. By the
end of the sixth hour the deficit of 400 ml of plasma
had been corrected, the Htc was 40 per cent and 10 ml
of urine (cont. 3 10 mosmol per kg) had been obtained.
This urine was loaded with blood pigment. Thereafter,
up to the fortieth hour, the urine output varied
 Settle : Urine Output following Severe Burns
between 8 and 32 ml per hr and averaged 18 ml per hr.
Superficially an adequate output (cf. expected mini-
mum of 15 ml per hr) but since its concentration never
exceeded 375 mosmol per kg it was in fact no more
than a glomerular filtrate.
Peritoneal dialysis was commenced at 54 hours
from the time of burning, the blood urea having risen
to 200mg per cent and potassium to 6,2mEq/l.
Dialysis continued for IO days, by which time a total
100 ‘2
L] Urine
zo I’ ii,,
Hours
0 10 20 30 40 50
Fix. S.-Case 3. Fluid balance and Htc.
of 150 one-litre exchanges had been carried out and the
blood urea had returned to 100 mg per cent. Major
skin grafting operations were undertaken at 42, 57
and 68 days from the time of burning and he was
discharged home 18 weeks after admission.
Case 3
A 33-year-old woman, weight 62 kg, sustained 30 per
cent deep dermal heat burns as the result of an indus-
trial accident. Intravenous therapy with plasma was
commenced during the first hour following burning
and the fluid balance and Htc are shown in Fig. 5.
Osmolality determinations (Fig. 6) were carried out
at much less frequent intervals than in the other cases
reported. (The curtailment of the investigation of this
patient was made necessary by the need to concentrate
maximum attention on the management of the
previous patient, Case 2, whose admission had
preceded this patient by 30 hours.)
27
Urine output, at first around 100 ml per hr with a
concentration of 640 mosmol per kg, gradually fell to
10 ml during the eleventh hour, but its concentration
rose to almost 1000 mosmol per kg. There was no
evidence of blood pigment in this urine on visual
inspection. The Htc had also risen during this time
but serum osmolality had remained unchanged. Here
was certain evidence of oliguria due to oligaemia.
Normally, the rate of colloid infusion would have been
Osm/kg.
Urine
Plasma
-
1'0 2’0 3’0 4’0 Sb
Fig. 6.- Cuss, 3. Urine and plasma osmolality.
reduced at 12 hours, but it was felt that continuation
of the existing rate (250 ml per hr) would make good
the indicated deficit. This proved to be the case; the
Htc fell and the urine volume increased. By 32 hours
after injury, a marked diuresis had commenced and
the urine osmolality had fallen to 330 mosmol per kg.
The circulation was, therefore, judged to be a little
overfilled and intravenous therapy was discontinued.
The urine output then gradually decreased in volume
but its concentration rose to almost 1000 mosmol per
kg. About one-third of the burn required skin
grafting and the patient was discharged 8 weeks after
the injury.
Case 4
An ll-month-old child, weight 10 kg, sustained 30
per cent scalds (10 per cent full thickness) when he
slipped into a washing machine. Intravenous therapy
with plasma was commenced within the hour following
28 Burns Vol. l/No. 1

the injury, the details of fluid balance and Htc are hour, in addition to the existing plasma infusion rate,
shown in Fig. 7, and osmolalities of urine and plasma and the urine output increased to 7 ml per hr, cont.
are shown in Fig. 8. The bladder was emptied at the 680 mosmol per kg. An ’extra ’30 ml of plasma were
end of the second hour, producing 105 ml of clear given during the seventh hour and the urine output
urine, cont. 306 mosmol per kg. The Htc at this time increased to 12 ml per hr, cont. 750 mosmol per kg.
was 42 per cent. At the end of the third hour, only Thereafter, the urine output remained adequate in
1 ml of clear urine was obtained, cont. 315 mosmol both volume and concentration and the rest of the
per kg. In order to check the adequacy of bladder shock phase was ‘uneventful ‘. A small amount of

55
1*0-
Htc.% 45
.b*___-__
35 .. ... .. .... ... ... ... ... .. ..... .. .. ... ... . .... ..
I Osm/kg.

-9

Urine .a-

-7.

.6.

??
Plasma
.5.

:.:.::::::::::::::::::::::::::::::::::::::::::::::::~:::
............................
‘.‘.‘.‘.‘.‘.‘.‘.‘_‘.~.~.~,~.~,~.~.~.’.’.’.’.~.~.~,~.~.~,
‘
‘.‘.‘ .‘.‘.‘.‘.‘,~.~.~,~.~.~.~.~.~.~.’ :....,.... .~,~.~.~.~.~.~.~.~,~.~
-4.
‘_‘
.‘.‘ _~.~,~.~.~.~.~_~.~.~.~.~...~,~...~.~,~.~.~.~
:;::. .,.:
.‘.‘.‘_‘_‘.‘.~.~,~.~.~,~.~.~.~.~.~,~,~.~.~.~.~.~.~..
‘_‘_~.~.~.~.~.~.~,~.~.~.~.~.~...~...~.~.~,~.~.~.~.~
;::,
_._.,.,.,
;:..... ._,,
:.._.,.,.,
INTAKE ~.‘
. . . ..‘
..‘
. .‘
. ..‘
. .‘
. ..‘
._~_~.~.~,~.~.~.~.~,~.’
. . . . . . . . . . . . . . . . . .;..,......
. . .._ .~.~,~.~.~.~.~,~.~.~.~

OUTPUT

-2.
25 I ml. II-j
I-J Urine
105- - tJ
-S Hours
0 4 8 12 16 20 24 2E 32 0 4 b 12 16 20 24 20 32”Ours

Fig. 7.-Case 4. Fluid balance and Htc Fig. 8.-Case 4. Urine and plasma osmolality
drainage, 10 ml of sterile water were introduced into skin grafting was performed 4 weeks after the injury
the bladder; 10 ml of clear fluid were recovered. and the child was discharged home 2 weeks later.
If the urine had been concentrated, there would
have been a clear indication to increase the rate of Case 5
colloid infusion. However, the child was rather A 27-year-old chemical worker, weight 70 kg, sus-
‘chesty ’and it was feared that a colloid challenge to tained a 25 per cent partial-thickness scald when he
the circulation, if it did not produce a diuresis, might was drenched with hot ortho-chloro-paratoluidine
have undesirable pulmonary effects. The problem as the result of an accident at work. Intravenous
centred, therefore, around the possibility of a renal therapy with plasma was commenced during the first
lesion. The urine output during the fourth hour was hour after injury and by the time he reached the Burns
2 ml (still free from pigment) cont. 270 mosmol per kg. Centre, at the end of the second hour, he had received
The apparent reduction in concentration was judged 700 ml of plasma (cf. an expected requirement of
to have been caused by traces of the water used to test 220 ml per hr during the first 12 hours). The fluid
the patency of the catheter. Whatever urine had been balance and Htc are shown in Fig. 9, and urine and
produced could hardly have been very concentrated. plasma osmolalities in Fig. 10. In view of the large
The findings were still equivocal. amount of plasma already given, the infusion rate was
The fifth hour’s urine output was 4 ml, cont. 460 reduced to 180 ml per hr for the remainder of the first
mosmol per kg. With this indication of improving 4 hour period but even so the Htc fell to 37 per cent
renal function, it was decided to perform an infusion and the urine volume remained high. The plasma
test. Sixty ml of plasma were given in the next half an infusion rate was further reduced at 4 hours to 120 ml
Settle: Urine Output following Severe Burns 29

per hr, the Htc remained stationary and the urine
volume averaged about 75 ml per hr. At 12 hours the
plasma infusion rate was reduced to 90 ml per hr and
urine volume gradually fell to an average of about
50 ml per hr.
Much of the scald was very superficial and it is
certain that the actual fluid requirement was con-
siderably less than the estimate calculated on the basis
work. The plasma infusion was commenced within
the hour following burning and by the time he arrived
at the Burns Centre the fourth bottle of plasma was
running in. Fluid balance and Htc are shown in fig.
11 and urine and plasma osmolality in Fig. 12. At 4
hours then, he had received 1300 ml of plasma and
857 ml of clear urine had been obtained on cathe-
terization. The patient was rather overweight for his

Osm/kg.
35’
200

ml.

150 Urine
- -a

100

m Plasma

f- Oral
50

INTAKE

- a

OUTPUT

50

r ] Urine

100 Plasma / - .
-

150

ml.
ti._4*5m,.
f .
01 . . I I I Hours
200 Hours
4 a 12 16 20 24 0 4 6 12 16 20 24

Fig. 9.-Cue 5. Fluid balance and Htc. Fig. IO.---Case 5. Urine and plasma osmolality.

of a 25 per cent injury. Even so the Htc indicated
overfilling of the circulation to the extent of about
900 ml throughout the period from the fourth to the
twenty-fourth hours. Although the urine volume
remained high, it is of interest to note that its
osmolality never fell below 620 mosmol per kg and
that those hourly volumes between 50 and 30 ml
per hr had osmolalities between 800 and 900 mosmol
per kg.
The further management was uneventful, skin
grafting was not required and the patient was dis-
charged home 15 days after the accident although
dressings were required on some areas for a further
3 weeks.
Case 6
A 45-year-old chemical worker, weight 85 kg, sus-
tained a 40 per cent full-thickness flame burn when his
clothing caught fire as the result of an explosion at
height and previous experience had indicated that in
such patients the actual body weight should be
reduced by a factor of about 20 per cent in order to
calculate the expected colloid requirement. His weight
thus became 70 kg and the colloid requirement
1400 ml per period. In addition, a further reduction of
colloid infusion was made during the second period in
that he received only 1000 ml of plasma and blood,
otherwise the management of the shock phase
followed the usual pattern.
From 8 to 24 hours the urine volume varied between
30 and 100 ml per hr (average 60 ml per hr) and its
osmolality varied between 976 and 796 mosmol per kg.
From 24 to 29 hours blood was infused at 200 ml per
hr and resulted in a moderate diuresis as can be seen
inFig. 11.
The patient’s hands were quite badly damaged and
several skin grafting operations were required. He
was discharged home 8 weeks after the accident.
30 Burns Vol. 1 /No. 1

Case 7 per kg. Thereafter the urine output gradually de-

A 40-year-old chemical worker, weight 60 kg, creased in volume from 55 ml per hr during the
sustained a 30 per cent mixed-thickness flame burn eleventh hour to 22 ml during the twenty-fourth hour
when his clothes caught fire as a result of the same whilst its concentration rose from around 500
explosion which caused the bums of the previous mosmol per kg to around 900 mosmol per kg.
patient (Case 6). About half of the burned areas required skin
The fluid balance and Htc are shown in Fig. 13 and grafting and the patient was discharged home 8 weeks
the plasma and urine osmolalities in Fig. 14. The after the accident.

55
1I*O-
litc.% 4s .L . . . . . ,...?
1
35’
o=m/lcp.
*9

10IOO’rn Urine *6

‘7
7

-6.

??
Plasma
‘5.
??
Blood

??
Oral
2
-4.

INTAKE

Plasma -3.
-
OUTPUT

??
Urine
50-m
-2.

851--O
0I 4. 0, 12
, l’s 2’0 24 20 I
32 Hours *1* I . . . . , , . , Hours
0 4 0 12 16 20 24 20 32

Fig. 11.-Case 6. Fluid balance and Htc Fig. 12.~Cure 6. Urine and plasma osmolality.

fluid intake was unusual in that 1000 ml of 5 per cent Case 8

dextrose were given during the sixth and seventh hours.
(The urine output had been 30 ml per hr, cont. 800
mosmol per kg for 2 hours, plasma osmolality was
310 mosmol per kg and the patient was thought to be
short of water rather than colloid.) During the sixth
hour, 30 ml of urine were passed, cont. 870 mosmol
per kg but during the seventh hour, without any
apparent change in the volume of urine output, the
concentration fell to 244 mosmol per kg. The eighth
hourly output was 240 ml, cont. 298 mosmol per kg
and during the ninth hour, 120 ml, cont. 219 mosmol
per kg were obtained. Here was evidence of definite
though transient water diuresis occurring 8 hours after
quite severe trauma and apparently in response to a
substantial water load. During the ninth hour, 500 ml
of blood were given in addition to the existing plasma
infusion rate of 150 ml per hr and during the tenth
hour the urine output was 180 ml, cont. 437 mosmol
A 2-year-old child, weight 13 kg, sustained a 45 per
cent deep full-thickness flame burn when his pyjamas
caught fire whilst he was playing with matches. He
was taken to a large city hospital where an infusion of
plasma was commenced during the fifth hour following
the injury. Catheterization of the bladder before
setting up the drip had produced only 2 ml of urine,
the colour of which was not reported. The fluid
balance and Htc are shown in Fig. 15, and the plasma
and urine osmolalities in Fig. 16.
The child was admitted to the Burns Unit during
the twentieth hour after burning and was said to be
anuric. No urine had been recovered during the first
19 hours (except the 2 ml already mentioned) even
though 65 ml of 10 per cent mannitol had been given
during the ninth hour and the volume of fluid infusion
had been sufficient to lower the Htc to 25 per cent by
the fourteenth hour. The catheter was found to be
Settle : Urine Output following Severe Burns 31

lying in the urethra and on being placed into the
bladder released 125 ml of dark red urine which had
an osmolality of 360 mosmol per kg. The average
urine output since the time of burning was therefore
6.3 ml per hr, cont. 360 mosmol per kg. Even if the
child had not been anuric he had certainly had
prolonged oliguria and haemoglobinuria and the
average concentration was close to that of glomerular
filtrate. The infusion of mannitol appeared to have
had little effect. The findings with regard to urine
output were reminiscent of those described in the case
history of Case 2; renal function had certainly been

1.0

35 1 ‘““/kg.

.9.
I
1000 Urine -6.
c-

*7.
150

.6.

3 Plasma
500

g Blood
.5

B Dextrose

??
D,a, 250
.4.

INTAKE

0 PlZWlM -3.
-
OUTPUT

.2.
] Urine
250

r . . . . . . . 6 .l- , . . 1 . . b Hours
0 4 2 12 16 20 24 28 32”‘“= 0 4 a 12 16 20 24 28 32

Fig. 13.-C’use 7. Fluid balance and Htc. Fig. 14.---Case 7. Urine and plasma osmolality.

Fig. 15.~
--Case 8. Fluid balance and Htc. Fig. 16.---Case 8. Urine and plasma osmolality.
32
impaired and if no improvement occurred during the
subsequent thirty hours, then dialysis seemed to be
inevitable.
During the period from the twentieth to the fiftieth
hour, however, not only did the urine output increase
in volume from about 15 ml per hr to about 30 ml per
hr, but also its concentration rose from around 350
mosmol per kg to around 500 mosmol per kg. This
gradual change was taken to indicate a recovery of
renal function. At 50 hours, on the basis of these
observations of a changing pattern of urine output it
Blood
was confidently predicted that dialysis would not be
required even though it was known that the blood urea
had risen to 186 mg per cent. Over the next 20 hours
the urine osmolality fell, until at 62 hours a transient
water diuresis occurred after which the osmolality rose
again. During this period, reduced urine osmolality
was associated with increased volume output.
The further management of the child was uneventful
from the point of view of renal function and a spon-
taneous fall in blood urea occurred after 50 hours
post burn. Three major skin grafting sessions were
required in order to achieve full skin cover and the
child was discharged home thirteen weeks after the
accident.
COMMENTS
Urine volume and concentration
An easily observed feature of the hourly urine
output (particularly well demonstrated in Cases 5
and 6) is the reciprocal relationship between
volume and concentration. As will be shown
later, this simply implies that, irrespective of the
volume of glomerular filtrate, the concentration
of the final urine is adjusted to maintain a con-
stant osmolal balance in the internal environment
of the body.
When tubular function is impaired, the ability
to produce a concentrated urine (or a very dilute
urine) is lost and when glomerular function is
impaired the ability to increase urine volume is
lost. On the other hand, reduced glomerular
filtration as a consequence of reduced renal
perfusion results in a small urine volume of high
concentration.
Case 4 seems to show that a temporary reduc-
tion in renal function, evidenced by oliguria of low
concentration, can persist for a few hours and
then be succeeded by a more ‘physiological ’
response. In the absence of careful monitoring of
the urine volume and concentration such an event
could probably pass unnoticed.
Case 1 demonstrates the massive diuretic
response which can result from the presence of
mannitol in the glomerular tiltrate but does not
prove that osmotic diuresis prevents, minimizes
or aborts renal failure. It does, however, under-
line the basic fact that the tinal urine volume is
Burns Vol. l/No. 1
determined primarily by the solute load entering
the renal tubules and only secondarily by the
activity of the anti-diuretic hormone (ADH).
Case 8 demonstrates that severe impairment of
renal function, with oliguria apparently resistant
to both colloid overtransfusion and mannitol,
does not necessarily proceed to renal failure.
Consideration of urine output solely in terms of
250
Dialysis commenced
0 20 40 60 80 100 120
Fig. 17.-Blood urea levels of 5 patients during the
first 5 days post burn.
volume does not enable a clear distinction to be
made between the prognosis of Case 8 and that of
Case 2.
Blood urea levels
On the evidence of hour-by-hour changes in the
volume and osmolality of urine output, 4 out of
the 8 patients investigated in detail were
thought to have some impairment of renal func-
tion. Serial blood urea levels for these 4 patients
(Cases 1, 2, 4 and 8) are shown in Fig. 17
together with serial levels for one patient whose
renal function was thought to be unimpaired
(Case 3). No blood urea levels were determined
in Case 5 and those for Cases 6 and 7 were not
obtained with sufficient frequency to warrant
expression as a graph. They did, however, seem
to be of the same order as those in Case 3;
within the range 3MO mg per cent at 6-10 hours
and within the range 45-50 mg per cent at 80 to
90 hours.
In 3 out of the 4 patients in the ‘impaired ’
group, a steep rise in blood urea level was
observed. The rise was of the order of 4 mg per
Settle : Urine Output following Severe Burns
cent per hour and appeared to have an origin soon
after the time of burning. In Case 4, the rise in
blood urea stopped at 14 hours after burning and
Body \
,Hypartonic
,Urine
i 1--,
Fig. IS.--The renal regulation of body water and
osmolal balance.
declined thereafter. A normal level was observed
at 95 hours but may have been achieved much
earlier. Cases 2 and 8 showed continued rises in
blood urea levels so that by 40 hours from the
time of burning, both were uraemic with blood
urea levels of 170 mg per cent. On the basis of
the rate of development of azotaemia and the
levels achieved, the degree of renal impairment
appeared to be similar in both patients. The
decision to proceed with dialysis in Case 2 and
not in Case 8 was made almost entirely on the
evidence concerning urine concentration capacity.
It is possible that not everyone would agree
that inspection of the change (or lack of change)
of urine osmolality during the twentieth to
fortieth hour after burning in these 2 patients
reveals an obvious and clinically significant
difference between them. Fortunately the cumu-
lative free osmolal output which can be calculated
from the measured urine output of the two
patients illustrates the difference more clearly.
Before proceeding to this consideration, a brief
review will be made of the determinants and
33
parameters of urine output in relation to the work
done by the kidney.
URINE OUTPUT AND
RENAL PERFORMANCE
Renal regulation of body water
balance
Identical concentration of intracellular and
extracellular fluid throughout the body is the
result of free movement of water across cell
membranes, governed only by the physical
forces of osmosis and diffusion. The sole
exception is the movement of water across the
renal tubular cell membrane, the permeability of
which can be altered by the action of ADH. The
ultimate mechanism responsible for this unique
phenomenon is not yet known, but on it depends
the ability of the kidney to excrete urine differing
in tonicity from the plasma from which it has been
derived.
Examination of the interstitial fluid in slices of
renal tissue taken from the medulla reveals an
increase in osmolality compared with that found
in the cortex (Wirz et al., 1951). Tubular fluid is
found to be isotonic with plasma in the proximal
tubules, hypertonic at the tip of the papilla and
hypotonic in the proximal part of the distal
tubule. These gradients of osmolality are pro-
duced by the countercurrent multiplier and
exchange systems of Henle’s loop and the vasa
recta. The significant feature of the hypothesis
used to explain this phenomenon is the pumping
of sodium out of the ascending limb of Henle’s
loop into the surrounding tissue fluid, which thus
becomes increasingly hypertonic towards the
papilla. Approximately two-thirds of the glo-
merular filtrate is reabsorbed isotonically in the
proximal segments of the nephron. The re-
mainder becomes increasingly concentrated as it
picks up sodium from the interstitial fluid
surrounding the descending limb and loses water
to this hypertonic fluid. The urine then becomes
less concentrated, by the active loss of sodium, as
it traverses the ascending limb and may be
hypotonic by the time it reaches the collecting
duct. The final concentration of the urine depends
upon the water permeability of the cells of the
collecting duct. ADH increases their permeability
so that water can pass into the surrounding
hypertonic medullary interstitial fluid. The
concentration of the urine can thus be increased
until a maximum of about 1300 mosmol per kg is
reached (corresponding to a specific gravity of
1040). In the absence of ADH the hypotonicfluid
in the proximal distal tubule passes through the
collecting ducts unchanged. It is convenient to
34
think of the final urine as being made up of two
portions. Firstly, the isotonic portion which
contains solute-bound water and secondly either
solute-free water or water-free solute. This
concept is used in Fig. 18 which illustrates the
role of antidiuresis and water diuresis in the renal
regulation of water balance.
Obligatory antidiuresis following
trauma
In the early 195Os, communications were pub-
lished (Le Quesne and Lewis, 1953; Le Quesne,
1954; Eisen and Lewis, 1954) which contained
considerable evidence that a surgical operation is
accompanied by the release of a large amount of
ADH. Eisen and Lewis (1954) concluded that,
‘Until this abnormal quantity of circulating
ADH has been removed, water diuresis cannot
occur. It cannot be forced by administering
large volumes of water intravenously or by
mouth. The administration of large volumes of
water may then lead to water intoxication. ’
Because antidiuresis of an apparently obligatory
nature was noted, not only following surgery,
but also following accidental injury, it
became generally accepted that trauma of any
sort would be followed by a period of obligatory
oliguria.
It is unfortunate that the terms oliguria and
antidiuresis are often used synonymously. Oli-
guria is delined as the excretion of less than
400 ml of urine per day in an adult (Taylor, 1970)
although in practice many clinicans would refer
to an output of less than 600 ml per day (25 ml
per hr) as oliguria. Antidiuresis, however, means
that under the action of ADH, water is being
reabsorbed from the tubular fluid so that the final
urine is hypertonic compared with the glomerular
filtrate. Thus, oliguria describes the quantity of
urine whilst antidiuresis indicates the quality.
It is obvious that oliguria and antidiuresis will
often occur together but the exceptions are
important; the oliguria of acute renal failure is
not associated with antidiuresis whilst, on the
other hand, it is in precisely the circumstances of
maximal activity of ADH that a direct linear
relationship exists between total solute excretion
and urine flow (Moore, 1960).
In considering the nature of the urine output
following trauma, it can be stated as a general rule
that the urine will be concentrated and often of
small volume. This volume will increase in
response to an increase in the filtered solute load
but not to a reduction below normal of the body
fluid osmolality (except in some rare and ill-
understood circumstances). If the urine is small
Burns Vol. 1 /No. 1
in volume but is not concentrated, renal function
has been impaired.
Measurement of urine concentration
It is evident that a meaningful measure of urine
concentration must indicate the extent of re-
absorption of water or of solute which has
occurred during the elaboration of urine from
glomerular filtrate. This parameter of the urine
output is quantitatively expressed by the number
of particles of solute in solution. For aqueous
solutions, osmolality refers to the number of
particles dissolved in one kilogram of water and is
measured in osmoles or milliosmoles per kg.
Osmolarity refers to the number of particles
dissolved in one litre of solution (mosmol per 1).
For practical purposes, the difference between the
two values can be ignored.
The time honoured method of determining
urine concentration is to measure its specific
gravity, but it is in just those circumstances
where knowledge of urine concentrations becomes
vital (impaired renal function) that specific
gravity measurement becomes least reliable as an
index of tubular function.
Specific gravity (SG) is the ratio of the density
of the substance in question to the density of pure
water at 4°C. Since density is mass per unit
volume it follows that the SG of an aqueous
solution is an index of the weight of the solute
dissolved in the water. Because of this, it is
possible for urines of identical osmotic activity to
have widely different SGs as a consequence of
solutes such as glucose and protein being present
in differing amounts. The truth of this may be
seen from the fact that isotonic glucose solution
(5 per cent) has an SG of 1.019 whilst isotonic
saline (0.9 per cent) has an SG of 1.006.
The classical work on the relationship of urine
SG to urine osmolality is that of Miles et al.
(1954). The authors point out not only the effect
upon the relationship between SG and osmolality
produced by substantial quantities of protein or
sugar but also the fact that urines of like osmola-
lity containing neither of these substances may
still show considerable differences in SG. After
considering these unavoidable errors which are
inherent in the use of SG as a measure of osmola-
lity, they note the additional instrumental errors
of SG measurement and conclude that if these
errors summate ‘. . . . it will be obvious that the
specific gravity may give a grossly misleading
idea of the urine osmolality. ’
The only really satisfactory way to determine
both the total and the effective osmolal work
being performed by the kidney is to make direct
Settle : Urine Output following Severe Burns
measurements of plasma and urine osmolalities.
The procedure is simple, quick, and accurate
when the appropriate apparatus is readily
available.
Renal osmolal clearance
Osmolal clearance (C,,,,,) is defined as the
volume of plasma (ml) passing through the kidney
m one minute which is completely cleared of
osmotically active material. It is calculated by
using the formula :
u”m,I :/ v
C”,,“, _____
P Obrn”,
where U,,,,, and P,,,,, are the osmolalities
(mosmol per kg) of urine and plasma respectively
and V is the volume of urine (ml) produced per
minute. In the normal fasting adult, C,,,,, varies
between 2 and 3 ml per min and is more or less
independent of urine flow (Pitts, 1968). It is
independent of urine flow because, assuming
normal renal function, U,,,,, and V are inversely
related. The osmolal content (mosmol) of
C,,,,, is, therefore, also fairly constant since it
varies only as P,,,,, varies and even extreme
values for P,,,,, such as 250 mosmol per kg or 330
mosmol per kg represent only a 14 per cent
change in osmolal content from the normal value
of 290 mosmol per kg.
[The relationship between urea clearance (ml)
and the urea cleared (mg) is quite a different
matter. A rise in plasma urea from 20 mg per
cent to 40 mg per cent is accompanied by a
proportional increase in urea excreted and the
clearance volume remains constant whilst the
urea content of that volume has increased by
100 per cent.]
Renal osmolal output
Although osmolal clearance is the true measure of
total osmolal work done by the kidneys, since the
relationship between clearance and content is
fairly constant, it is convenient (if not quite
accurate) to refer to content rather than clearance
in the context of total osmolal work. The first
advantage which then follows is the obviation of
possible confusion between ml per min of clear-
ance and ml per min of urine output. The
second advantage is that because the osmolal
content of the cleared volume (Cosmol)is the same
as the osmolal content of the urine volume (V)
the actual total osmolal output is also an accept-
able index of total osmolal work done. The third
advantage which then follows is that total
osmolal work and effective osmolal work (i.e.
35
effective upon body fluid osmolality) are both
measured in mosmol per unit time.
With an osmolal clearance between 2 and 3 ml
per min and P,,,,, varying between 280 and 300
mosmol per kg, the range of osmolal output is
from 0.6 to 0.9 mosmol per min. Thus the
calculated daily output (in round figures) for a
fasting adult in normal health is between 850 and
1300 mosmol. The observed average normal
output for an adult on a mixed diet is 1200
mosmol per day (Gamble, 1958). Up to the time
of burning, a normal diet has been taken by most
patients. Thereafter, the renal osmol output will
be decreased by fasting and by extrarenal solute
loss but will be increased by intravenous therapy
and by the marked hypercatabolism which is
characteristic of the burn injury (Eklund, 1970).
It can be safely assumed, therefore, that during
the first 48 hours post-burn, uraemia or hyperos-
molality or both will be avoided only if the renal
osmolal output is at least as great as that of a
normal subject.
Now with maximum ADH activity, the con-
centration of a 24-hr urine collection would not
exceed 1000 mosmol per kg and would usually be
much less. The volume of this urine, therefore, in
order to contain 1200 mosmol would be at least
I200 ml or an average of 50 ml per hr.
Free osmolal output
If the total daily osmolal burden of 1200 mosmol
was eliminated in an isotonic urine it would be
contained in a volume of 4000 ml, or 160 ml per
hour and in order to maintain a normal body
osmolal balance an intake of over 5000 ml of
solute-free water would be required. In practice,
the osmolal balance is maintained as a conse-
quence of the concentration/dilution mechanism
of the renal tubule whereby the ratio of osmoles
to water in the urine can be adjusted.
The effective osmolal work done by the kidney
is usually expressed quantitatively by reference to
free water clearance (Cu20) calculated by using
the formula:
CH,O zy v-c,,,,,.
It is obvious that Cn,o will be a positive value
during water diuresis and a negative value during
antidiuresis. The converse, and equally accept-
able expression of effective osmolal work, is free
osmolal clearance (Cr, osmu,)rcalculated by using
the formula :
Cf. “Srn”l == wJorm”l -Pm”,).
It can be seen that Cf, ormo,refers to the actual
content of free osmoles in the urine and thus
free osmolal clearance is the same as free osmolal
output.
36
URINE OUTPUT OF PATIENTS
INVESTIGATED
The hourly urine outputs of the individual
patients have been shown and some comment has
been made on their individual features. In using
only the volume of the urine to assess the ade-
quacy of resuscitation it is difficult to exclude the
possibility of the volume being increased by even
Fig. 19.-Cumulative renal free osmolal output of dextrose, which is a metabolizable solute, 720
7 patients during the first 2-4 days post burn.
moderate overtransfusion with colloid and
electrolyte solutions. Consideration of the urine
osmolality enables impairment of renal function to
be recognised but still does not permit increased
solute excretion due to overtransfusion to be of
distinguished from the increased solute excretion
secondary to increased catabolism. This distinc-
tion can be made, however, by consideration of
the free osmolal output so long as the intravenous
therapy does not include hypertonic fluids.
Referring back to the concept of urine output
illustrated in Fig. 18 it can be seen that over-
transfusion with isotonic fluid will increase the
volume of the glomerular filtrate, the volume of
the final urine and the total osmolal output by
increasing the ‘isotonic portion ’ of the tubular
fluid but will not affect the free osmolal output.
Thus, free osmolal output represents the actual
amount of solute excreted by the kidneys in order
to preserve normal body osmolal balance and can
be used to calculate the urine output necessary for
the maintenance of homeostasis.
Results
Hourly renal free osmolal output was calculated
from the measured values of V, Uosmoland PoSmot
for the 8 patients investigated. It was then limit the maximum concentration which can be
expressed as an output per kg of body weight.
Burns Vol. 1 /No. 1
The cumulative totals for 7 of the patients were
then plotted against time and are shown in Fig. 19.
(Cumulative totals for Case 3 could not be
calculated since only occasional hourly values
were known.) The osmolal content of the urine
obtained at initial catheterization of the bladder
in each patient was ignored.
The average free osmolal output in mosmol per
hr and also the output per kg body weight, were
calculated for each of the seven patients and are
shown in Table ZZ. For urine of any given
osmolality above that of the plasma, it is possible
to calculate the volume of urine which would
contain the measured free osmolal output by use
of the formula:
C f, OIrnDl
v =
U DSrnOl
-L.,
These volumes, for urines with osmolalities of
1000,750,500 and 350 mosmol per kg respectively
are shown in Table ZZZ.
Case 1
In addition to plasma, this patient received
1000 ml of 5 per cent dextrose solution and
500 ml of 20 per cent mannitol. Excluding the
mosmol of mannitol were accompanied by
approximately 1500 ml of water. This intake can
be considered as 1500 ml of isotonic mannitol
solution plus 270 mosmol of mannitol unaccom-
panied by water. The distribution of 270 mosmol
solute throughout the total body water of 36
litres would produce an increase in osmolality of
7.5 mosmol per kg.
The period of osmotic diuresis (mannitol
detectable in the urine) was from the fourteenth
to the twenty-eighth hours, but from the
twentieth to the thirtieth hours the plasma
osmolality remained constant at 30751
mosmol per kg; a sustained increase of the same
order as that calculated above. The inference,
therefore, is that although mannitol was being
excreted satisfactorily, free osmolal output was
proceeding at its maximal rate for this patient
and other solutes were being retained. The free
osmolal output between the twentieth and
thirtieth hours was 0.23 mosmol per kg per body
weight, whilst the maximum urine osmolality
during the whole of the first 50 hr was 560 mosmol
per kg. An hourly urine volume of 53 ml at a
concentration of 560 mosmol per kg would
enable this free osmolal output to be achieved.
In old age, restrictions on renal tubular function
achieved (Moore, 1959). For this patient, when
Settle : Urine Output following Severe Burns 37

the effects of infusion therapy upon urine output
have been accounted for separately, the main-
tenance of normal osmolal balance still required
a urine output of 50-60 ml per hr at the greatest
concentration of which she was capable. Presu-
mably, it would be correct to describe an output
of 25-30 ml per hr of such urine as inadequate.
output averaging 5.17 mosmol per hr. Calculat-
ing this as an output per kg of body weight
produces an artificially high value if actual body
weight is used. Body surface area would perhaps
be a better denominator for the comparison of
intakes and outputs and since a IO-kg child has
one-half the body surface area of a 25-kg child,

Tab/e //.-Some parameters of the urine outputs of 7 patients during the shock phase

Cumulative Average free

total of free No. of hr to osmolal output
Weight of Average free
Case no. osmolal output produce this (mosmol per hr)
patient (kg) mosmol per hr
per kg body total per kg body
weight weight

9.60 47 0.204 60 12.3

0.98 52 0.019 33 0.62
12.9 25 0.517 IO 5.17
9.48 22 0.431 70 30.2
8.60 21 0.410 85 34.8
4.78 21 0.228 60 13.7
10.7 67 0.160 13 2.08

Table Ill.--The hourly urine volumes which, at various osmolalities, would contain the average free
osmolal output of 7 patients during the shock phase

MI of urine per hour, at the given osmolalities, (mosmol per kg) which would
Case no. contain the average free osmolal output
1000 750 500 350

1 18 27 61 245
2 0.9 1.4 3.1 12
4 7.5 11 26 103
5 43 67 151 603
6 50 77 174 696
7 20 30 68 273
8 3.0 6.8 IO 42

Case 2 12.5 kg might be a more realistic weight factor to

It is self-evident that once the ability to produce a
concentrated urine has been lost, the urine output
is of no value as an index of resuscitation. The
main point of interest in this patient’s urine out-
put is the way in which impaired renal function is
emphasized by the calculation and display of free
osmolal output. The difference between the rate
of free osmolal output of this patient at 40 hr and
that of Case 8 at 40 hr is particularly striking
when it is recalled that the blood urea levels were
identical in both patients at this stage.
Case 4
After the first few hours of dubious renal function,
this patient achieved a fairly constant free osmolal
use in this case. On this basis the average free
osmolal output then becomes 0.414 mosmol per
hr per kg body weight.
Cases 5 and 6
In Case 5 the patient had a constant free osmolal
output of 0.413 mosmol per hr per kg body
weight which represents an output of 43 ml per hr
of highly concentrated urine (1000 mosmol per kg)
or 0.6 ml per hr per kg body weight. A similar
calculation for the patient in Case 6 shows a
figure of 0.59 ml per hr per kg body weight.
However, it is unrealistic to expect an average
urine concentration as high as 1000 mosmol per
kg. If the average concentration was 750 mosmol
38
per kg then the urine volume would be 1.0 ml
per hr per kg body weight in order to maintain
normal body osmolal balance.
Case 7
The free osmolal output of this patient was
probably reduced as a result of the 1OOOml of
5 per cent dextrose solution given during the
sixth and seventh hours. In spite of the transient
water diuresis described in the case history, plasma
osmolality at 10 hours was only 275 mosmol per
kg, although urine osmolality had risen to 437
mosmol per kg. Thereafter, antidiuresis contin-
ued with the free osmolal output fairly constant
and averaging 0.25 mosmol per hr per kg body
weight but it is likely that without ‘mopping-up ’
effect of the electrolyte-free water, the free
osmolal output would have been greater. Urine
volume between the fifteenth and twenty-fourth
hours averaged 28.7 ml per hr (range 35-22 ml)
and its concentration was in the range 730-910
mosmol per kg.
The administration of large amounts of electro-
lyte-free water, when a compensatory water
diuresis cannot properly occur, not only produces
hypotonicity and possibly water intoxication, but
also reduces the need for renal excretion of solute
in order to maintain normal osmolal balance.
Thus hypotonicity is in effect the converse of
solute diuresis and can permit urine output to fall
to levels which otherwise would be inadequate.
Case 8
The impairment of renal function which occurred
in this patient is the nearest state to renal failure
in which the author has seen apparently spontan-
eous recovery. From the for’y-fourth to the fifty-
second hours, free osmolal output was proceeding
at the rate of 0.4 mosmol per hr per kg. In the
light of the similar outputs of patients 4, 5 and 6,
this can be taken as evidence of good tubular
function at that time.
It has been said to the author that severe
oliguria or even virtual anuria is seen commonly
during the first 24 hours after burning and is no
cause for alarm. It may be thought that this case
demonstrates the truth of this comforting advice.
An alternative view of the events in this patient’s
‘shock phase ’would be that apparently normal
renal function at 48 hours does not disclose how
near to renal failure the patient may have been
24 hours earlier or what biochemical insults may
have been sustained. The distinction between
impairment and failure of renal function in
patients 2 and 8 is quite obvious by reference to
the urine output at even 30 hours after burning
Burns Vol. 1 /No. 1
but it is a distinction which is only possible if the
appropriate parameters of the urine output are
known.
DISCUSSION
The differences of opinion concerning the value
of urine output as an index of resuscitation may
have occurred as the result of a failure to recog-
nize the extent of inter-relation of three aspects
of the resuscitation programme; the nature of
the replacement fluid, the assessment of effect-
ive resuscitation, and the nature of the urine
output.
The nature of the replacement fluid
Many different schemes have been proposed for
the management of the shock phase and almost
every contributor to the subject has made new
suggestions concerning the amount of fluid
required, the type of fluid, the rate at which it
should be given, or the way in which the effective-
ness of the resuscitation can be judged. It is not
always fully appreciated that the scheme of fluid
replacement and the way in which its effectiveness
can be judged are closely inter-related. No one
physiological variable is a suitable index of
effective resuscitation for all schemes at all times
and any claims for the value (or uselessness) of a
particular variable should make clear the
circumstances for which the claim is made.
The types of fluid used for resuscitation are
often described simply as colloid or crystalloid
but the different properties of the fluids within
these groups may sometimes be more important
than the basic differences between the groups. It
has already been shown that the tonicity of an
infused crystalloid fluid can be expected to have
a marked effect upon the three parameters of
urine output which have been considered in this
paper: volume, total osmolal output, and free
osmolal output. Similarly, there are some
grounds for expecting that different colloid
solutions will have different effects upon the
nature of the urine output.
Apart from blood and plasma, four dextran
solutions in 0.9 per cent saline are readily
available, each containing a different molecular
weight fraction. Since small molecules of
dextran can be filtered through the glomerulus
and can then produce a type of solute diuresis
(Moore, 1960) it is no surprise to learn that
resuscitation with dextran 70 is accompanied by
urine volumes around 65 ml per hr in the adult
patient (Sorensen, 1971) whilst resuscitation with
dextran 150 is associated with relatively small
urine volumes (Wilkinson, 1971).
Settle : Urine Output following Severe Burns
The relative effects of colloid and crystalloid
fluids upon urine output have been shown by
Masterton and Dudley (1970). They found that
using Ringer-lactate solution they had difficulty
in effecting resuscitation as judged by central
venous pressure (CVP) measurement but no
difficulty in producing an enormous urine flow
rate. An alternative rdgime which included
colloid as one-third of the replacement fluid
enabled effective resuscitation to be undertaken
with more normal urine flow rates. Clearly, the
65 ml per hour of urine which Serrensen (1971)
finds a reliable index of effective resuscitation by
dextran 70, may have a different relevance for a
patient being resuscitated solely by crystalloid
solutions monitored by CVP measurement.
Accepting then, that the clinical significance of
urine output may vary with the nature of the
replacement fluid, it is pertinent to consider how
the measurement of urine output fits into the
general assessment of resuscitation.
Assessment of effective resuscitation
The basic consequence of significant hypovolae-
mia is inadequate perfusion of the tissues with
blood. The assessment of hypovolaemia, and the
recognition of its effective treatment, involves
either the measurement of changes within the
circulation or the measurement of the effective-
ness of tissue perfusion, or both. The changes
within the circulation which are commonly
measured are the blood volume, the haematocrit,
the arterial and venous pressures and the heart
rate.
Measurement of the blood volume would seem
to be the most logical and useful index of hypovo-
laemia. Unfortunately, there are considerable
limitations to its practical usefulness. If it were
possible to have a continuous or even very fre-
quent measurement of the actual blood volume
then perhaps no other index of effective resuscita-
tion would be required. A measurement of blood
volume at the commencement of, or during the
early stages of therapy, is of obvious value in
demonstrating an actual deficit and provides
useful information on the rate of loss of fluid from
the circulation. Late measurements (e.g. 48
hours post burn) are of limited value since they
cannot indicate what has happened in the mean-
time. In any patient who survives the shock
phase, however ill-conceived the management, the
time will come when blood volume returns
towards normal. Thus, at 48 hours, prolonged
hypovolaemia may have been finally corrected by
the right total volume given at the wrong rate. The
second basic failing of blood volume measurement
39
alone is that it gives no indication of the
effectiveness of the circulation.
Measurement of CVP is of varying value de-
pending on the nature of the infusion fluid. As
pointed out by Masterton and Dudley (1970) an
attempt to monitor crystalloid infusion by CVP
measurement leads not only to an enormous
urine flow but also produces a real risk of
inundation of the patient with fluid. CVP
measurement becomes most useful when hypovo-
laemia is profound and large volumes of colloid
are to be infused rapidly, e.g. a patient virtually
exsanguinated by the rapid loss of whole blood.
In view of the acknowledged incidence of
malpositioning of the catheter, and the possibility
of introducing infection to the very centre of the
circulation, it would seem reasonable in all but
the most difficult cases to limit assessment of the
capacitance circuit to inspection of the peripheral
and neck veins. Arterial hypotension is a late
feature of hypovolaemic shock and is thus very
significant when present but less so when absent.
The presence or absence of tachycardia may be
difficult to interpret but a pulse rate falling
towards normal is usually an indication that the
syndrome of shock is responding to treatment.
Measurement of the haematocrit is a widely
accepted and useful index of plasma deficit in
burns. Its value is limited by the fact that un-
known quantities of red cells may also have been
destroyed and that after the infusion of whole
blood its significance may be difficult to determine.
The enthusiastic investigators of blood volume
and pressure changes may perhaps overlook the
fact that the circulatory system is already
equipped with volume and pressure transducers.
The clinical picture of shock illustrates, for all to
see, the effector ‘defence mechanism’ which
serves to maintain blood flow to the vital centres
in the face of hypovolaemia. In general, the
resolution of the syndrome of shock in response
to therapy is a good indication that an adequate
volume of blood in active circulation has been
restored.
The fundamental feature of shock as a ‘defence
mechanism ’ is the reduction of blood flow
through the peripheral and splanchnic circula-
tions. Hence, the irrational basis of vasocon-
strictor drugs in the ‘treatment ’ of shock and
the dangers of the injudicious or thoughtless use
of vasodilator drugs without the appropriate
fluid infusion. The general appearance of the
patient with respect to skin colour, capillary filling,
sweating, restlessness, nausea and vomiting
provides information which all clinicians take
into account when assessing the effectiveness of
40
resuscitation. In addition, actual measurements
can easily be made which indicate the status of the
peripheral and splanchnic circulations respec-
tively; the measurement of skin temperature, and
the measurement of urine output.
The value of actual measurement of skin
temperature, rather than feeling the skin with the
back of the hand, has been reported by Ibsen
(1967). He has shown that the serial comparison
of skin and deep temperatures, together with the
careful use of vasodilator drugs, permits a reliable
assessment to be made of the effectiveness of
resuscitation in hypovolaemia. Ibsen’s views have
been endorsed by Ross et al. (1969) who state
(in the context of patients undergoing thoracic
surgery): ‘Our experience has been such that we
now feel unable to manage the care of a patient
potentially or acutely ill without having the
information that temperature studies give ‘.
A particular advantage of temperature measure-
ment by electrical thermometers is that the status
of the peripheral circulation can be observed and
recorded continuously.
Wilkinson (1971) has used the visual assess-
ment of capillary filling as an index of the effect-
iveness of both peripheral and splanchnic
circulation. He states: ‘The object of resuscita-
tive treatment is to maintain the free circulation
of blood in the peripheral parts of the body; if
this can be achieved, then circulation through the
kidneys will also be satisfactory. This is not to say
that urine will necessarily be produced, since
oliguria, which is a characteristic feature of the
severely injured individual may be due to factors
other than just a reduction in the blood volume ‘.
Moore (1959) takes a different view. He points
out that very early in shock the decrease in renal
blood flow is more marked than that occurring
elsewhere and goes on to say: ‘The action of salt
resorption and antidiuresis acting on a large
solute output (as in shock) will not grossly reduce
urine volume, whereas decreased renal blood flow
will reduce volume drastically and immediately ‘.
If the object of treatment is to restore adequate
tissue perfusion then surely this also includes the
tissues of the kidney. The author takes the view
that adequate perfusion of the kidney does not
simply mean keeping it alive but implies that it is
capable of fulfilling its normal excretory function.
The crux of the matter, therefore, is not whether
the kidney can survive the events which cause it to
stop producing urine, but whether the urine out-
put (or lack of it) is consistent with the excretory
function of an adequately perfused kidney. If the
urine output is not consistent with this function,
then either some mechanism is acting to prevent
Burns Vol. 1/No. 1
adequate renal blood flow or else renal function
itself is in some way impaired.
The nature of the urine output
All too often the terms ‘urine output ’and ‘urine
volume ’ are used synonymously. Thus, urine
volume, which is only one parameter of urine
output, is used as an index of renal performance
and of renal perfusion. It seems likely that this,
more than any other factor, has contributed to
the spread of values of ‘adequate ’urine volumes
recommended as indicative of adequate resuscita-
tion. It is certainly the reason why the diagnosis
of non-oliguric renal failure is often not made as
early as it could be.
It has been indicated earlier in this paper, that
the average hourly urine volume of a normal
70-kg adult on a mixed diet contains approxi-
mately 50 mosmol of solute. It has further been
suggested that the average osmolality of the
urine output is unlikely to exceed 1000 mosmol
per kg. Consequently, the minimum average
urine volume consistent with the maintenance of
normal body osmolal balance in these circum-
stances is of the order of 50 ml per hr. In normal
individuals who have undergone prolonged and
drastic restriction of dietary protein and sodium,
a 24-hour renal osmolal output as low as 400
mosmol has been recorded (Joekes et al., 1957)
which could be eliminated in an hourly urine
volume of 16.7ml at a concentration of 1000
mosmol per kg. It is from these highly specialized
experimental situations that the mistaken impres-
sion has been gained that the daily osmolal out-
put of any 70-kg patient need not exceed 600
mosmol and can thus be excreted in 25 ml per hr
of highly concentrated urine. As mentioned
earlier, Eklund (1970) in the most detailed and
careful study yet published on changes in osmolal
balance following burns, has shown beyond
doubt that an obligatory requirement for renal
excretion of solute in excess of normal rates exists
in these patients. Without the urine in which to
excrete this solute, the development of uraemia
and hyperosmolality is inevitable. The findings
in the small number of patients reported in this
paper are consistent with Eklund’s conclusions
and are thought to constitute at least an indica-
tion of what an adequate urine output should be
during the shock phase.
CONCLUSIONS
In normal health, an adequate urine output in the
gross sense (i.e. excluding consideration of the
individual chemical constituents) is that which
permits maintenance of normal body osmolal
Settle: Urine Output following Severe Burns
balance in the absence of prolonged restriction of
solute-free water intake. Following burns, a
physiological ‘impairment ’ of the kidney’s
ability to excrete solute-free water (i.e. persistent
antidiuresis) precludes renal correction of body
hypo-osmolality. An adequate urine output for
the burned patient, therefore, is that which
permits maintenance of normal body osmolal
balance in the absence of gross changes in solute-
free water intake. The output during the first 24
hours following burning can be expected to
contain at least as much solute as would a normal
24-hour output for that patient but it is unlikely
that its average osmolality will exceed 1000
mosmol per kg.
Lt is suggested that an adequate urine output for
a 70-kg adult during the shock phase can be
expected to contain a free osmolal output of the
order of 30 mosmol per hr. When plasma is the
principal replacement fluid, and in the absence of
overtransfusion with any electrolyte containing
fluid, the hourly urine output can be expected to
have an osmolality in the 75&1000 mosmol per
kg range and a volume in the 40-70 ml range. In
order to take into account the differing sizes of
patients, this output can be generalized as: 0.5-
I .O ml per hr of concentrated urine per kg body
weight (minimum weight 12.5 kg). An hourly
volume in excess of I .5 ml per hr per kg body
weight in the absence of a deliberately induced
osmotic diuresis, can be taken to indicate over-
filling of the circulation.
When dextran is the principal replacement
fluid, the volume of the urine output will be in-
creased by the water-binding activity of small
dextran molecules present in the glomerular
filtrate. Thus, the volume of urine can be expected
to lie in the 0.75-I .25 ml per hr per kg body
weight range and its average osmolality will be
less than when plasma is used. If much dextran 40
is used, an osmotic type diuresis could be expected
and a compensatory increase in the solute-free
water intake would be necessary to prevent
dehydration.
Because saline solutions leave the circulation
quickly, they can produce a rapid expansion of
the extracellular fluid compartment (EFC)
without producing evidence of overfilling of the
circulation as judged by CVP monitoring.
Presumably, it is an inevitable feature of resusci-
tation with saline that fluid will pass from the
circulation to the EFC more rapidly than when
plasma is used. If this is so, an increased urine
volume due to an increase in the iso-osmolal
portion of the urine could be expected. (The free
osmolal output would, of course, be unaffected.)
41
Hence the minimum hourly volume of concen-
trated urine consistent with effective resuscitation
with saline will not be less than when plasma is
used but could be considerably greater.
The urine output should be considered inade-
quate if it demonstrably does not contain the free
osmolal output which can be reasonably expected.
If the inadequate urine output has a high osmo-
lality it can be inferred that renal perfusion is
inadequate and that an increase in the rate of fluid
infusion is indicated. (Evidence of inadequate
peripheral perfusion would usually be present
also.) If the urine is persistently of an osmolality
little above that of the plasma, renal function is
impaired. Careful observation of the hourly
urine volume and osmolality, and calculation of
the free osmolal output, will enable the prognosis
of impaired renal function to be established at an
earlier stage than by observing the rise in the level
of the blood urea.
Acknowledgements
I am deeply indebted to Mr T. L. Barclay,
Consultant Plastic Surgeon, for his constant
encouragement over many years, and to Dr F. M.
Parsons, Consultant in Clinical Renal Physiology
for his advice and practical help in the manage-
ment of impaired renal function. I also wish to
thank Mrs A. Dyson for typing the manuscript.
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