Fluid management in burn patients: Results from a European survey—More questions than answers

Changes in total body surface area and the distribution of skin surfaces in relation to body mass index

BACKGROUND

A correct estimation of total burn surface area is important since it is used for determining fluid resuscitation volumes, nutritional estimates and hospital admission criteria. Wallace's rule of nines is the most commonly used methods for this purpose. However, fat distribution is non-uniform and the total body surface area changes with obesity. The aim of this study was to determine if the rule of nines applies to all body mass index groups.

METHODS

A total of 217 individuals were included in the study. The patients were divided into 4 groups according to their BMI (18.5-25kg/m² (60 persons)), 25-29.9kg/m² (61 individuals)), 30-34.9kg/m² (55 persons)), >35kg/m² (41 persons)). Each patient underwent a complete duel-energy X-ray absorptiometry body scan to determine the surface area (cm²) of the various regions of the body.

RESULTS

We found no statistically significant variations between the Wallace body percentage distributions and our results in the men for all BMI ranges (head p=0.331, arms p=0.861, legs p=0.282, trunk p=0.696). In contrast, among women we found a statistically significant change in body surface area percentage distribution between the BMI groups and specific body regions (head p=0.000, legs p=0.000 and trunk p=0.001).

CONCLUSION

The Wallace rule of nines is a quick and acceptable method for estimating the total burn surface area percentage in men of all BMI ranges. However, for women, a more accurate method of burn area estimation is required as proposed by our BMI adjusted charts.

Goal-Directed Fluid Resuscitation Protocol Based on Arterial Waveform Analysis of Major Burn Patients in a Mass Burn Casualty

BACKGROUND

Adequate fluid titration during the initial resuscitation period of major burn patients is crucial. This study aimed to evaluate the feasibility and efficacy of a goal-directed fluid resuscitation protocol that used hourly urine output plus the arterial waveform analysis FloTrac (Edwards LifeSciences, Irvine, Calif) system for major burns to avoid fluid overload.

METHODS

We conducted a retrospective cohort study of 43 major burn patients at the Tri-Service General Hospital after the Formosa Fun Coast Dust Explosion on June 27, 2015. Because of the limited capacity of intensive care units (ICUs), 23 intubated patients were transferred from the burn wards or emergency department to the ICU within 24 hours. Fluid administration was adjusted to achieve a urine output of 30 to 50 mL/h, cardiac index greater than 2.5 L/min/m, and stroke volume variation (SVV) less than 12%. The hourly crystalloid fluid infusion rate was titrated based on SVV and hourly urine output.

RESULTS

Of the 23 critically burned patients admitted to the ICU, 13 patients who followed the goal-directed fluid resuscitation protocol within 12 hours postburn were included in the analysis. The mean age (years) was 21.8, and the mean total body surface area (TBSA) burned (%) was 68.0. The mean Revised Baux score was 106.8. All patients sustained inhalation injury. The fluid volumes administered to patients in the first 24 hours and the second 24 hours (mL/kg/% total body surface area) were 3.62 ± 1.23 and 2.89 ± 0.79, respectively. The urine outputs in the first 24 hours and the second 24 hours (mL/kg/h) were 1.13 ± 0.66 and 1.53 ± 0.87, respectively. All patients achieved the established goals within 32 hours postburn. In-hospital mortality rate was 0%.

CONCLUSIONS

The SVV-based goal-directed fluid resuscitation protocol leads to less unnecessary fluid administration during the early resuscitation phase. Clinicians can efficaciously manage the dynamic body fluid changes in major burn patients under the guidance of the protocol.

TRALI following fresh frozen plasma resuscitation from burn shock

INTRODUCTION

Resuscitation from burn shock using fresh frozen plasma (FFP) has been described. Critics of FFP resuscitation cite the development of transfusion related acute lung injury (TRALI) as a deterrent to its use. This study examines the occurrence of TRALI with FFP resuscitation of critically ill burned patients.

METHODS

A retrospective chart review was conducted of severely burned patients who received FFP resuscitation. Data points included age, TBSA, TBSA full thickness, presence of alternate etiologies of acute lung injury, total FFP administered, and signs and symptoms of TRALI as defined per the Canadian Blood Services Consensus Conference.

RESULTS

Eighty-three patients met the definition of severe burn and received FFP resuscitation. Of those, 65 met exclusion criteria. Eighteen patients were left for analysis with only one found to have signs and symptoms of TRALI. That patient suffered a 53.5% TBSA burn, received a total of 6228ml FFP, had no competing etiologies of ALI, and was diagnosed with TRALI within 6h of completing the FFP transfusion.

CONCLUSION

The possible occurrence of TRALI in burn patients receiving FFP resuscitation should be weighed against the reported benefits of such a resuscitation strategy.

Low cardiac index and stroke volume on admission are associated with poor outcome in critically ill burn patients: a retrospective cohort study

Background

Impact of early systemic hemodynamic alterations and fluid resuscitation on outcome in the modern burn care remains controversial. We investigate the association between acute-phase systemic hemodynamics, timing of fluid resuscitation and outcome in critically ill burn patients.

Methods

Retrospective, single-center cohort study was conducted in a university hospital. Forty critically ill burn patients with total body surface area (TBSA) burn-injured >20 % with invasive blood pressure and cardiac output monitoring (transpulmonary thermodilution technique) within 8 h from trauma were included. We retrospectively examined hemodynamic variables during the first 24 h following admission, and their association with 90-day mortality.

Results

The median (interquartile range 25th–75th percentile) TBSA, Simplified Acute Physiology Score II (SAPS II) and Abbreviated Burn Severity Index of the study population were 41 (29–56), 31 (23–50) and 9 (7–11) %, respectively. 90-Day mortality was 42 %. There was no statistical difference between the median pre-hospital and 24-h administered fluid volume in survivors and non-survivors. On admission, stroke volume (SV), cardiac index (CI), oxygen delivery index and mean arterial pressure (MAP) were significantly lower in patients who died despite similar fluid resuscitation volume. ROC curves comparing the ability of initial SV, CI, MAP and lactate to discriminate 90-day mortality gave areas under curves of, respectively, 0.89 (CI 0.77–1), 0.77 (CI 0.58–0.95), 0.73 (CI 0.53–0.93) and 0.78 (CI 0.63–0.92); (p value <0.05 for all). In multivariate analysis, SAPS II and initial SV were independently associated with 90-day mortality (best cutoff value for SV was 27 mL, sensitivity 92 %, specificity 69 %). During 24 h, no interaction was found between time and outcome regarding macrocirculatory parameters changes. Hemodynamic parameters improved during the first 24-h resuscitation in all patients but patients who died had lower SV and CI on admission, which remained through the first 24 h.

Conclusion

Low initial SV and CI were associated with poor outcome in critically ill burn patients. Very early hemodynamic monitoring may in help detecting under-resuscitated patients. Future prospective interventional studies should explore the impact of early goal-directed therapy in these specific patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s13613-016-0192-y) contains supplementary material, which is available to authorized users.

Update on Severe Burn Management for the Intensivist

Thermal injury of humans causes arguably the most severe perturbations in physiology that can be experienced. These physiologic derangements start immediately and can persist in some form until months or even years after the burn wounds are healed. Burn shock, marked activation of the systemic inflammatory response, multiple-organ failure, infection, and wound failure are just a few of the insults that may require management by the intensivist. The purpose of this article is to review recent advances in the critical care management of thermally injured patients.

Burn resuscitation--hourly urine output versus alternative endpoints: a systematic review

Controversy remains over appropriate endpoints of resuscitation during fluid resuscitation in early burns management. We reviewed the evidence as to whether utilizing alternative endpoints to hourly urine output produces improved outcomes. MEDLINE, CINAHL, EMBASE, Cochrane Library, Web of Science, and full-text clinicians' health journals at OVID, from 1990 to January 2014, were searched with no language restrictions. The keywords burns AND fluid resuscitation AND monitoring and related synonyms were used. Outcomes of interest included all-cause mortality, organ dysfunction, length of stay (hospital, intensive care), time on mechanical ventilation, and complications such as incidence of pulmonary edema, compartment syndromes, and infection. From 482 screened, eight empirical articles, 11 descriptive studies, and one systematic review met the criteria. Utilization of hemodynamic monitoring compared with hourly urine output as an endpoint to guide resuscitation found an increased survival (risk ratio [RR], 0.58; 95% confidence interval, 0.42-0.85; P < 0.004), with no effect on renal failure (RR, 0.77; 95% confidence interval, 0.39-1.43; P = 0.38). However, inclusion of the randomized controlled trials only found no survival advantage of hemodynamic monitoring over hourly urine output (RR, 0.72; 95% confidence interval, 0.43-1.19; P = 0.19) for mortality. There were conflicting findings between studies for the volume of resuscitation fluid, incidence of sepsis, and length of stay. There is limited evidence of increased benefit with utilization of hemodynamic monitoring, however, all studies lacked assessor blinding. A large multicenter study with a priori-determined subgroup analysis investigating alternative endpoints of resuscitation is warranted.

A review of the use of human albumin in burn patients

This review article examines the use of human albumin (HA) in burn treatment. Generally, there are two scenarios where HA may be administered: acutely as a volume expander during burn shock resuscitation and chronically following resuscitation to correct hypoalbuminemia. Although colloids were the cornerstone of the earliest burn resuscitation formulas, HA was in fact rarely used. More recently however, with the recognition of fluid creep, HA usage during resuscitation has increased. Animal studies demonstrate that during acute fluid resuscitation, administration of colloids, including albumin (ALB), have no ability to arrest the formation of burn wound edema, but they do reduce edema formation in the nonburn soft tissues and help preserve intravascular volume and reduce resuscitation fluid requirements with no apparent increase in extravascular water accumulation in the lung. Human studies suggest that immediate use of ALB during acute resuscitation achieves adequate resuscitation using a lower total overall volume requirement, transiently provides better maintenance of intravascular volume and cardiac output, produces less overall edema gain than crystalloid resuscitation alone but may be associated with increased extravascular lung water accumulation during the first postburn week. However, many questions remain unanswered, and modern, large-scale prospective studies are desperately needed. Maintenance of normal serum ALB levels through continuous supplementation of HA following burn resuscitation is even less well understood. Although this approach makes physiologic sense, the limited amount of available data from human burn studies reveal that chronic ALB supplementation is expensive and may not result in any major clinical benefits. Again, modernized prospective studies are greatly needed in this area.

Evolving changes in the management of burns and environmental injuries

Burns and environmental injuries are common as primary or secondary problems in survivors of natural disasters, terrorist incidents, and combat operations. In recent years, intensive military medical experience has resulted in substantial progress in treatment of these important problems. This article reviews practical applications of this new knowledge.

Evaluation of arterial waveform derived variables for an assessment of volume resuscitation in mechanically ventilated burn patients

OBJECTIVE

The purpose of this study was to assess the usefulness of stroke volume variations to monitor the early fluid resuscitation in mechanically ventilated burn ICU patients.

METHODS AND RESULTS

Data of 29 burn patients (APACHE II - 9.8±3.6, SAPS II - 29±5, TBSA - 39.5±14) were prospectively included in this observational study. Hemodynamic parameters were determined using arterial pressure wave analysis for up to 36h after burn. Statistically significant changes in cardiac index (CI), systemic vascular resistance index (SVRI), stroke volume variation (SVV) were recorded during the observation period. There were significant correlations between CI and SVV (r=-0.454, p=0.03), SVV and SVRI (r=0.482, p=0.02) at 16 h postburn; CI and SVV (r=-0.513, p=0.012), SVV and SVRI (r=0.480, p=0.02) at 24 h postburn, CI and SVV at 36 h postburn (r=-0.478, p=0.021). Significant changes in CI (1.9±1 vs. 3.4±0.9), p=0.02 and in SVV (24.9±3 vs. 14.6±2, p=0.01) were observed in patients with low cardiac output state after administration of 10 ml/kg of Ringer lactate.

CONCLUSION

Our results suggest that measurement of stroke volume variations by arterial pulse contour analysis is valuable in monitoring volume administration and in predicting volume responsiveness during the early postburn period.

Review of a fluid resuscitation protocol: "fluid creep" is not due to nursing error

Recent reviews of burn resuscitation have included the suggestion that "fluid creep" may be influenced by practitioner error. Our center uses a nursing-driven resuscitation protocol that permits titration of fluid based on hourly urine output, including the addition of colloid when patients fail to respond appropriately. The purpose of this study was to examine protocol compliance. We reviewed 140 patients (26 children) with burns of ≥20% TBSA who received protocol-directed resuscitation from 2005 to 2010. We compared each patient's actual hourly fluid infusion with that predicted by the protocol. Sixty-seven patients (48%) completed resuscitation using crystalloid alone, whereas 73 patients required colloid supplementation. Groups did not differ in age, gender, weight, or time from injury to admission. Patients requiring colloid had larger median total burns (33.0 vs 23.5% TBSA) and full-thickness burns (15.5 vs 4.5% TBSA) and more inhalation injuries (60.3 vs 28.4%; P < .001) than those who resuscitated with crystalloid alone. Because we included basic maintenance fluids in their regimen, patients had median predicted requirements of 5.4 ml/kg/%TBSA. Crystalloid-only patients required fluid volumes close to Parkland predictions (4.7 ml/kg/%TBSA), whereas patients who received colloid required more fluid than the predicted volume (7.5 ml/kg/%TBSA). However, the hourly difference between the predicted and received fluids was a median of only 1.0% (interquartile range: -6.1 to 11.1%) and did not differ between groups. Pediatric patients had greater calculated differences than adults. Crystalloid patients exhibited higher urine outputs than colloid patients until colloid was started, suggesting that early over-resuscitation did not contribute to fluid creep. Adherence to our protocol for burn shock resuscitation was excellent overall. Fluid creep exhibited by more seriously injured patients was not due to nurses' failure to follow the protocol. This review has illuminated some opportunities for practice improvement, possibly using a computerized decision support system.

Fluid resuscitation protocols for burn patients at intensive care units of the United Kingdom and Ireland

Introduction: The objective of this study was to determine the thermal injury fluid resuscitation protocols at intensive care units (ICUs) in the United Kingdom and Ireland.

Materials and methods: A telephone questionnaire was designed to survey the fluid resuscitation protocols of ICUs at all hospitals with plastic/burn surgery departments in the British Isles in 2010. The feedback from the questionnaire was from the senior nurse in charge of the ICUs.

Results: 32/64 (50%) of these ICUs had provided care to burns patients. A 100% response from these 32 units was obtained. 71.4% commence fluid resuscitation at 15% total body surface area burn (TBSA), 21.4% at 20% TBSA and 7.1% at 10% TBSA in adults. The estimated resuscitation volume was most often calculated using the Parkland/Modified Parkland formula (87.5%) or the Muir and Barclay formula (12.5%). Interestingly, of the ICUs using formulae, two had recently moved from using the Muir and Barclay formula to Parkland formula and one had recently moved from using the Parkland formula to Muir and Barclay formula. Despite this, 37.5% of ICUs using a formula did not rigidly follow it exactly. The most commonly used resuscitation fluid was Ringer’s lactate solution (46.9%) and Human Albumin Solution was used in 12.5%. No ICU used red cell concentrate as a first line fluid. 18.8% used a central line. 40.6% ICUs considered changing the IV solution during resuscitation. 78.1% ICUs consider urine output to be the most important factor in modifying resuscitation volumes. 59.4% ICUs calculate a maintenance fluid rate after completion of resuscitation. The endpoint for resuscitation was at 24 h in 46.9% ICUs and at 36 h in 9.4%. 5/32 (16%) felt their protocol gave too little and 6/32 (19%) felt their protocol gave too much. 59.3% ICUs gave oral/enteral fluids by naso-gastric or naso-jejenal tubes. 21.9% felt that oral/enteral resuscitation worked. Exactly half of the units believed that the formula that they used provided approximately the right amount of fluid, with 25% believing that it provided too much and 21.9% that it provided too little.

Discussion and conclusion: There is substantial variation in the fluid resuscitation protocols for burns of ICUs in the British Isles. The different practices demonstrated in this survey may have important consequences as inadequate fluid resuscitation can limit perfusion to potentially recoverable burns, grafted tissue and body organs not directly injured.

Effects of fluid resuscitation methods on the pro- and anti-inflammatory cytokines and expression of adhesion molecules after burn injury

Fluid resuscitation management can influence inflammatory response after burn injury. The aim of this study was to analyze the effects of two fluid resuscitation methods on the cytokine production and on the expression of the leukocyte surface markers. Thirty patients were included in this prospective randomized study with burn injury affecting more than 20% of the body surface area. Fluid resuscitation was guided by hourly urine output (HUO, n = 15) or by intrathoracic blood volume index (ITBVI, n = 15). Blood samples were taken on admission and on the next five consecutive mornings. Concentrations of interleukin (IL)-1beta, IL-6, IL-8, IL-10, IL-12p70, and tumor necrosis factor-alpha were measured in phorbol myristate acetate-stimulated and -nonstimulated samples. Leukocyte surface marker expressions (CD11a, CD11b, CD14, CD18, CD49d, and CD97) were also determined. In the ITBVI group, IL-6 levels on days 2 to 3 and IL-6/IL-10 ratios on days 2 to 3, and the IL-8/IL-10 ratios on days 3 to 5 were significantly higher than those in HUO group (P < .05). In the HUO group, IL-10 levels were significantly higher (P < .05) on days 4 and 5. Granulocyte CD11a levels on day 2, CD11b levels on days 4 to 6, lymphocyte CD11a on days 5 to 6, CD11b on days 3 to 6, CD49d on days 2 to 6, CD97 on day 6, monocyte CD11a, CD11b, CD18 levels on days 4 to 6, and CD14 levels on days 3 to 5 were significantly higher in the HUO group (P < .05). Our study suggests that ITBVI-guided fluid resuscitation of burned patients suppresses the shift toward anti-inflammatory imbalance and the expression of leukocyte surface markers more than HUO-guided resuscitation.

Colloid normalizes resuscitation ratio in pediatric burns

Fluid resuscitation of burned children is challenging because of their small size and intolerance to over- or underresuscitation. Our American Burn Association-verified regional burn center has used colloid "rescue" as part of our pediatric resuscitation protocol. With Institutional Review Board approval, the authors reviewed children with ≥15% TBSA burns admitted from January 1, 2004, to May 1, 2009. Resuscitation was based on the Parkland formula, which was adjusted to maintain urine output. Patients requiring progressive increases in crystalloid were placed on a colloid protocol. Results were expressed as an hourly resuscitation ratio (I/O ratio) of fluid infusion (ml/kg/%TBSA/hr) to urine output (ml/kg/hr). We reviewed 53 patients; 29 completed resuscitation using crystalloid alone (lactated Ringer's solution [LR]), and 24 received colloid supplementation albumin (ALB). Groups were comparable in age, gender, weight, and time from injury to admission. ALB patients had more inhalation injuries and larger total and full-thickness burns. LR patients maintained a median I/O of 0.17 (range, 0.08-0.31), whereas ALB patients demonstrated escalating ratios until the institution of albumin produced a precipitous return of I/O comparable with that of the LR group. Hospital stay was lower for LR patients than ALB patients (0.59 vs 1.06 days/%TBSA, P = .033). Twelve patients required extremity or torso escharotomy, but this did not differ between groups. There were no decompressive laparotomies. The median resuscitation volume for ALB group was greater than LR group (9.7 vs 6.2 ml/kg/%TBSA, P = .004). Measuring hourly I/O is a helpful means of evaluating fluid demands during burn shock resuscitation. The addition of colloid restores normal I/O in pediatric patients.

[Guidelines on therapy with blood components and plasma derivatives: human albumin. Recommendations of the scientific advisory board of the Medical Council]

Human albumin (HA) is by far the most expensive option for volume replacement and correction of hypoalbuminemia but is still widely used. The value of HA in the clinical setting continues to be controversial and it remains unclear whether there is still a place for using such a high-priced substance in the present cost-consciousness climate. Thus the Medical Council has presented some recommendations with regard to blood and plasma products including HA. There appear to be no indications for HA to correct hypovolemia either perioperatively or in the intensive care setting including children and patients undergoing cardiac or liver surgery. For maintaining colloid oncotic pressure (COP) cheaper modern synthetic colloids can be alternatively given and the value of HA for correcting hypoalbuminemia is also not clearly justified. Some small uncontrolled studies have shown that only patients with liver cirrhosis, spontaneous bacterial peritonitis and massive ascites drainage may profit from HA. Theoretical benefits such as oxygen radical scavenging or binding of toxic substances are no indications for using HA as beneficial clinical consequences have not yet been demonstrated. Experimental data from cell lines or animals must be viewed with skepticism because they do not mimic the clinical setting. According to the recommendations of the scientific advisory board of the Medical Council the use of HA should be considered very cautiously.

Early fluid resuscitation with hyperoncotic hydroxyethyl starch 200/0.5 (10%) in severe burn injury

Introduction

Despite large experience in the management of severe burn injury, there are still controversies regarding the best type of fluid resuscitation, especially during the first 24 hours after the trauma. Therefore, our study addressed the question whether hyperoncotic hydroxyethyl starch (HES) 200/0.5 (10%) administered in combination with crystalloids within the first 24 hours after injury is as effective as 'crystalloids only' in severe burn injury patients.

Methods

30 consecutive patients were enrolled to this prospective interventional open label study and assigned either to a traditional 'crystalloids only' or to a 'HES 200/0.5 (10%)' volume resuscitation protocol. Total amount of fluid administration, complications such as pulmonary failure, abdominal compartment syndrome, sepsis, renal failure and overall mortality were assessed. Cox proportional hazard regression analysis was performed for binary outcomes and adjustment for potential confounders was done in the multivariate regression models. For continuous outcome parameters multiple linear regression analysis was used.

Results

Group differences between patients receiving crystalloids only or HES 200/0.5 (10%) were not statistically significant. However, a large effect towards increased overall mortality (adjusted hazard ratio 7.12; P = 0.16) in the HES 200/0.5 (10%) group as compared to the crystalloids only group (43.8% versus 14.3%) was present. Similarly, the incidence of renal failure was 25.0% in the HES 200/0.5 (10%) group versus 7.1% in the crystalloid only group (adjusted hazard ratio 6.16; P = 0.42).

Conclusions

This small study indicates that the application of hyperoncotic HES 200/0.5 (10%) within the first 24 hours after severe burn injury may be associated with fatal outcome and should therefore be used with caution.

Trial registration

NCT01120730.

Hydroxyethylstarch supplementation in burn resuscitation--a prospective randomised controlled trial

INTRODUCTION

Hydroxyethylstarches (HES) are thought to be beneficial in trauma and major surgery management, due to their volume expansion and anti-inflammatory properties. This study examined the use of 6% (HES) in burn resuscitation.

METHODS

26 adult patients with burns exceeding 15% total body surface area (TBSA) were randomised to either crystalloid (Hartmann's solution) or a colloid-supplemented resuscitation regime, where 1/3 of the crystalloid-predicted requirement was replaced by 6% HES.

RESULTS

There was no difference in age, gender or TBSA between the two groups. The median (95% CI) fluid volume/%TBSA received in the first 24 h was 307 ml and 263 ml for the crystalloid only and HES-supplemented group respectively (p=0.0234, Mann-Whitney). Body weight gain within the first 24 h after injury was significantly lower in the HES-supplemented group 2.5 kg versus 1.4 kg respectively (p=0.0039). The median (95% CI) serum C-reactive protein at 48 h after injury was 210 (167-257) and 128 (74-145) mg/L for the crystalloid only and HES-supplemented group respectively (p=0.0001). Albumin-creatinine ratio per % burn (ACR, a marker of capillary leak) was lower in the HES-supplemented group at 12h after burn (p=0.0310).

CONCLUSIONS

Patients treated with HES-supplemented resuscitation required less fluid, showed less interstitial oedema and a dampened inflammatory response compared to patients receiving isotonic crystalloid alone.

International albumin use: 1995 to 2006

Over the last ten years more reliable information regarding the risks and benefits of the use of albumin for fluid resuscitation has emerged. To determine what influence this has had on clinical practice, we sought to document albumin use (from mass of albumin supplied to hospitals) in 16 industrialised countries between 1995 and 2006. Data on national albumin and synthetic colloid use was sought from independent intensive care researchers and albumin issuers. The mass of albumin supplied per 10,000 persons on an annual basis by country and aggregated across the study countries was calculated. Volumes of synthetic colloid supplied per 10,000 persons were calculated. Data were obtained for 15 countries. Albumin use varied significantly between countries and throughout the observation period. Overall, aggregate albumin use decreased from a peak of 2.54 kg per 10,000 persons in 1995 to 1.40 kg per 10,000 persons in 1999; use has remained relatively constant since. Data on supply of synthetic colloids was available in only three countries and varied from 11.7 litres per 10,000 persons in Canada in 1995, to 231.8 litres per 10,000 persons in Denmark in 2004. Between 1995 and 1999 albumin use decreased and has been materially constant since; where data were available, use of synthetic colloids increased. Whether these practice changes have resulted in a net health gain or in harm requires further research.

Use of albumin: an update

Human albumin (HA) is widely used for volume replacement or correction of hypoalbuminaemia. The value of HA in the clinical setting continues to be controversial, and it is unclear whether in today's climate of cost consciousness, there is still a place for such a highly priced substance. It is therefore appropriate to update our knowledge of the value of HA. With the exception of women in early pregnancy, there appears to be few indications for the use of HA to correct hypovolaemia. Some studies of traumatic brain injury and intensive care patients suggest negative effects on outcome and organ function of (hyperoncotic) HA. Modern synthetic colloids appear to be a cheaper alternative for maintaining colloid oncotic pressure. The value of using HA to correct hypoalbuminaemia has not been clearly justified. Theoretical and pharmacological benefits of HA, such as oxygen radical scavenging or binding of toxic substances, have not as yet been shown to have beneficial clinical consequences. Experimental data from cell lines or animals do not appear to mimic the clinical setting. Convincing data justifying the use of HA either for treating hypovolaemia or for correcting hypoalbuminaemia are still lacking. A restricted use of HA is recommended.

Quality assessment of clinical practice guidelines for adaptation in burn injury

OBJECTIVES

A number of clinical practice guidelines (CPGs) are available for managing burn injury patients but clinical practice is highly variable. We report the first steps to trans-contextual adaptation of international burn CPGs to local settings.

METHODS

Key clinical topics and questions to be covered in the final guideline were defined and prioritized. Systematic search between 1990 and 2008 retrieved 546 citations, of which 24 were CPGs on the general and intensive care of burn patients. Assessment of the clinical content of CPGs was carried out. Methodological quality of CPGs was evaluated using the AGREE instrument.

RESULTS

Of the 24 CPGs evaluated, 10 (42%) were evidence-based. All major burn topics were covered by at least one CPG, but no single CPG addressed all areas important in terms of outcomes. According to the AGREE criteria, 2 CPGs (8%) were strongly recommended, 14 with provisos or alterations (58%) and the rest were not recommended for adaptation.

CONCLUSIONS

Although existing CPGs for the management of burn may accurately reflect agreed clinical practice, most performed poorly when evaluated for methodological quality. Future CPG efforts addressing these methodological shortcomings would add substantially to the improved management of burned patients.

The year in burns 2008

For 2008, approximately 1200 original burn research articles were published in scientific journals using the English language. This article reviews those with the most impact on burn treatment according to the Editor of one of the major journals (Burns). As in the previous year's review, articles were divided into the following topic areas: epidemiology, wound characterisation, critical care physiology, inhalation injury, infection, metabolism and nutrition, psychological considerations, pain management, rehabilitation, and burn reconstruction. Each selected article is mentioned briefly with editorial comment.

Severe cutaneous adverse reactions: emergency approach to non-burn epidermolytic syndromes

INTRODUCTION

Although severe cutaneous adverse reactions (SCARs), such as Stevens-Johnson syndrome and toxic epidermal necrolysis, are rare, they are associated with considerable morbidity and mortality.

METHODS

The current knowledge regarding background, differential diagnoses, critical care and implications for inter-hospital emergency medical service (EMS) transport of these patients is discussed.

CONCLUSION

SCAR patients will substantially benefit from early interdisciplinary care and thorough consideration of complications during EMS transport and intensive care treatment.