Burn resuscitation: the results of the ISBI/ABA survey

Diagnosis and Management of Orbital Compartment Syndrome in Burn Patients - a Systematic Review

Orbital compartment syndrome is a poorly understood complication of acute burns. The purpose of this systematic review is to summarize the literature describing orbital compartment syndrome in burn patients to provide greater detail on risk factors and guide management of this morbid condition. A systematic review of the PubMed, Embase, and Cochrane Library databases was performed in June 2023 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study quality was assessed using two validated scoring systems. After removing duplicates, 303 unique articles were reviewed and 8 met inclusion criteria. All publications were retrospective. Most studies considered intraocular pressure >30-40mmHg as diagnostic for orbital compartment syndrome. Sixty unique cases of orbital compartment syndrome were reported. Orbital compartment syndrome occurred most frequently within 24 hours post-burn. The mean total body surface area of burn was 58.7%; the mean 24-hour resuscitation volume was 6.01 cc/kg/%total burn surface area; and 86.5% of cases had periorbital burns. Surgical decompression always started with lateral canthotomy. When pressures were not immediately reduced, cantholysis was performed. Study quality per Median Newcastle Ottawa Scores ranged from 38.9% to 94.4% (median 66.7%). A precise threshold for surgical decompression of OCS remains conflicted; however, IOP>30-40mmHg warrants intervention. Burn surgeons/intensivists should be aware of the risk factors for this vision-threatening complication and act appropriately.

[Treatment of Burn Shock - The First 24 hours and Beyond]

Acute phase and resuscitation after burn trauma are challenging even for specialised burn centres due to the individual onset and differences compared with other forms of shock. The guidelines of the German Society of Burn Medicine (DGV) cover the scientific basis of modern burn treatment. Nevertheless, uncertainty remains regarding the detailed practical handling. This expert consensus focuses on best practices for the treatment of patients with major burns in specialised burn centres and by clinical first responders. The short version of this expert consensus can be downloaded at: https://verbrennungsmedizin.de/files/dgv_files/pdf/positionspapier/Pos%20Therapie%20des%20Verbrennungsschock%20AK%20Intensivmedizin%202023.pdf.

The Short- and Long-Term Outcome Priorities of a Western Australian Adult Burn Population

To optimize patient recovery, understanding which outcomes are most important to burn patients is key. However, research to determine what outcomes are patient priorities is limited. Therefore, we assessed what outcomes are most important to Western Australian burn patients, separately in the short-term (<6 months) and long-term (6-24 months) after injury. Adult patients who had a burn injury 3-36 months ago completed a survey, rating the importance of 36 short- and long-term outcomes. The survey items were ranked according to the number of patients reporting the outcome as "very important." Results were compared between subgroups based on age, gender, burn size, and number of surgeries. Ninety-three patients were included. In the short-term, "not having a wound infection" (87.1%), "good wound healing" (83.9%), and "walking or moving around" (74.7%) were the most important outcomes. "Lifting or moving something" (67.6%), "walking or moving around" (66.2%), and "being independent" (66.2%) were reported as most important in the long-term. Scar-related outcomes were more important to females and to patients with multiple surgeries; mental health outcomes were priorities for females and patients with major burns; walking and moving around to males and older patients; and social and financial outcomes were rated highly by patients with major burns and multiple surgeries. In conclusion, the most important outcomes were consistent across time periods, indicating the importance of core outcomes in longitudinal follow-up. The wide range of priority outcomes and differences between subgroups underlines the need for multidisciplinary care and a patient-centered approach to support patients.

Regional Burn Review: Neither Parkland Nor Brooke Formulas Reach 85% Accuracy Mark for Burn Resuscitation

Prolonged resuscitation can result in burn wound conversion and other complications. Our team switched from using Parkland formula (PF) to the modified Brooke formula (BF) in January 2020. Secondary to difficult resuscitations using BF, we sought to review our data to identify factors associated with resuscitation requiring greater than predicted resuscitation with either formula, defined as 25% or more of predicted, hereafter referred to as over-resuscitation. Patients admitted to the burn unit between January 1, 2019 and August 29, 2021 for a burn injury with a percentage of total body surface area (%TBSA) ≥15% were included. Subjects <18 years, or weighing <30 kg, and those who died or had care withdrawn within 24 hours of admission were excluded. Demographics, injury information, and resuscitation information were collected. Univariate and multivariate analyses were performed to identify factors associated with over-resuscitation by either formula. P < .05 was considered significant. Sixty-four patients were included; 27 were resuscitated using BF and 37 using PF. No significant differences were observed in demographics and burn injury between the groups. Patients required a median of 3.59 ml/kg/%TBSA for BF and 3.99 ml/kg/%TBSA for PF to reach maintenance (P = .32). Over-resuscitation was more likely to occur when using BF compared to PF (59.3% vs 32.4%, P = .043). Over-resuscitation was associated with longer time to reach maintenance (OR = 1.179 [1.042-1.333], P = .009) and arrival via ground transportation (OR = 10.523 [1.171-94.597], P = .036). Future studies are warranted to identify populations in which BF under-performs and sequelae associated with prolonged resuscitation.

Assessment and Management of Acute Burn Injuries

Burn injuries can affect patients from all walks of life and represent a significant healthcare problem globally. The skin is the largest organ of the body and consequences of injury range of minor pain to severe end-organ dysfunction and even death. The acute assessment and management of burn-injured patients is a critical part of their short-term and long-term outcomes and often benefit from specialty, multidisciplinary care. Local wound care and appropriate excision and grafting are important parts of managing the functional, cosmetic, and physiologic derangements caused by burn injuries. Large burns also require judicious fluid resuscitation. Electrical, chemical, and inhalational injuries are less common than thermal burns but require additional care and are often associated with increased morbidity.

Surviving Sepsis After Burn Campaign

INTRODUCTION

The Surviving Sepsis Campaign was developed to improve outcomes for all patients with sepsis. Despite sepsis being the primary cause of death after thermal injury, burns have always been excluded from the Surviving Sepsis efforts. To improve sepsis outcomes in burn patients, an international group of burn experts developed the Surviving Sepsis After Burn Campaign (SSABC) as a testable guideline to improve burn sepsis outcomes.

METHODS

The International Society for Burn Injuries (ISBI) reached out to regional or national burn organizations to recommend members to participate in the program. Two members of the ISBI developed specific "patient/population, intervention, comparison and outcome" (PICO) questions that paralleled the 2021 Surviving Sepsis Campaign [1]. SSABC participants were asked to search the current literature and rate its quality for each topic. At the Congress of the ISBI, in Guadalajara, Mexico, August 28, 2022, a majority of the participants met to create "statements" based on the literature. The "summary statements" were then sent to all members for comment with the hope of developing an 80% consensus. After four reviews, a consensus statement for each topic was created or "no consensus" was reported.

RESULTS

The committee developed sixty statements within fourteen topics that provide guidance for the early treatment of sepsis in burn patients. These statements should be used to improve the care of sepsis in burn patients. The statements should not be considered as "static" comments but should rather be used as guidelines for future testing of the best treatments for sepsis in burn patients. They should be updated on a regular basis.

CONCLUSION

Members of the burn community from the around the world have developed the Surviving Sepsis After Burn Campaign guidelines with the goal of improving the outcome of sepsis in burn patients.

Burn Resuscitation Practices in North America: Results of the Acute Burn ResUscitation Multicenter Prospective Trial (ABRUPT)

OBJECTIVES

ABRUPT was a prospective, noninterventional, observational study of resuscitation practices at 21 burn centers. The primary goal was to examine burn resuscitation with albumin or crystalloids alone, to design a future prospective randomized trial.

SUMMARY BACKGROUND DATA

No modern prospective study has determined whether to use colloids or crystalloids for acute burn resuscitation.

METHODS

Patients ≥18 years with burns ≥ 20% total body surface area (TBSA) had hourly documentation of resuscitation parameters for 48 hours. Patients received either crystalloids alone or had albumin supplemented to crystalloid based on center protocols.

RESULTS

Of 379 enrollees, two-thirds (253) were resuscitated with albumin and one-third (126) were resuscitated with crystalloid alone. Albumin patients received more total fluid than Crystalloid patients (5.2 ± 2.3 vs 3.7 ± 1.7 mL/kg/% TBSA burn/24 hours), but patients in the Albumin Group were older, had larger burns, higher admission Sequential Organ Failure Assessment (SOFA) scores, and more inhalation injury. Albumin lowered the in-to-out (I/O) ratio and was started ≤12 hours in patients with the highest initial fluid requirements, given >12 hours with intermediate requirements, and avoided in patients who responded to crystalloid alone.

CONCLUSIONS

Albumin use is associated with older age, larger and deeper burns, and more severe organ dysfunction at presentation. Albumin supplementation is started when initial crystalloid rates are above expected targets and improves the I/O ratio. The fluid received in the first 24 hours was at or above the Parkland Formula estimate.

Comparison of Albumin and Fresh Frozen Plasma as Colloid Therapy in Patients With Major Burns

BACKGROUND

Burn injuries are one of the main causes of morbidity and mortality throughout the world, and burn patients have higher chances of recovery if they are treated with effective fluid and colloid management. Fresh frozen plasma (FFP) and albumin suspension used as a colloid treatment agent are very useful for the treatment of severe burns.

METHODS

This retrospective clinical trial was conducted at the Numune Education and Research Hospital Burn Center, Ankara, Turkey. Two hundred and nine patients who had severe burns that involved more than 30% of their total body surface area (TBSA) were studied. After the first 24 hours, 13 patients were deceased, leaving 196 patients remaining in the study, including 139 patients in the fresh frozen plasma group and 57 patients in the albumin group. Both the fresh frozen plasma and albumin groups received the standard therapy of the burn center, which was based on a standard protocol. Then, these patients were compared according to their clinical findings and mortality.

RESULTS

There were no significant differences between the groups with respect to age, gender, and comorbidities. The laboratory findings, blood, urine, and wound culture results were also similar between groups. The mortality rate was higher in the group receiving albumin than in the group receiving fresh frozen plasma (78.9% and 33.8%, respectively; p=0.0007).

CONCLUSIONS

According to this study, there was a significant relationship between the improvement in mortality and the mode of colloid treatment in patients with major burns.

Vasoactive and/or inotropic drugs in initial resuscitation of burn injuries: A systematic review

BACKGROUND

According to current guidelines, initial burn resuscitation should be performed with fluids alone. The aims of the study were to review the frequency of use of vasoactive and/or inotropic drugs in initial burn resuscitation, and assess the benefits and harms of adding such drugs to fluids.

METHODS

A systematic literature search was conducted in PubMed, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, UpToDate, and SveMed+ through 3 December 2021. The search included studies on critically ill burn patients receiving vasoactive and/or inotropic drugs in addition to fluids within 48 h after burn injury.

RESULTS

The literature search identified 1058 unique publications that were screened for inclusion. After assessing 115 publications in full text, only two retrospective cohort studies were included. One study found that 16 out of 52 (31%) patients received vasopressor(s). Factors associated with vasopressor use were increasing age, burn depth, and % total body surface area (TBSA) burnt. Another study observed that 20 out of 111 (18%) patients received vasopressor(s). Vasopressor use was associated with increasing age, Baux score, and %TBSA burnt in addition to more frequent dialysis treatment and increased mortality. Study quality assessed by the Newcastle-Ottawa quality assessment scale was considered good in one study, but uncertain due to limited description of methods in the other.

CONCLUSION

This systematic review revealed that there is a lack of evidence regarding the benefits and harms of using vasoactive and/or inotropic drugs in addition to fluids during early resuscitation of patients with major burns.

Review of History of Basic Principles of Burn Wound Management

Thermal energy is an essential and useful resource to humans in modern society. However, a consequence of using heat carelessly is burns. Burn injuries have various causes, such as exposure to flame, radiation, electrical, and chemical sources. In this study, we reviewed the history of burn wound care while focusing on the basic principles of burn management. Through this review, we highlight the need for careful monitoring and customization when treating burn victims at each step of wound care, as their individual needs may differ. We also propose that future research should focus on nanotechnology-based skin grafts, as this is a promising area for further improvement in wound care.

Burn Shock and Resuscitation: Review and State of the Science

Burn shock and acute fluid resuscitation continue to spark intense interest and debate among burn clinicians. Following a major burn injury, fluid resuscitation of burn shock is life-saving, but paradoxically can also be a source of increased morbidity and mortality because of the unintended consequence of systemic edema formation. Considerable research over the past two decades has been devoted to understanding the mechanisms of edema formation, and to develop strategies to curb resuscitation fluids and limit edema development. Recognition of burn endotheliopathy - injury to the endothelium's glycocalyx layer- is one of the most important recent developments in our understanding of burn shock pathophysiology. Newer monitoring approaches and resuscitation endpoints, along with alternative resuscitation strategies to crystalloids alone, such as administration of albumin, or plasma, or high dose ascorbic acid, have had mixed results in limiting fluid creep. Clear demonstration of improvements in outcomes with all of these approaches remains elusive. This comprehensive review article on burn shock and acute resuscitation accompanies the American Burn Association's State of the Science meeting held in New Orleans, LA on November 2-3, 2021 and the Proceedings of that conference published in this journal.

Utilization and Efficacy of Resuscitation Endpoints in Trauma and Burn Patients: A Review Article

Shock is a sequelae in trauma and burn patients that substantially increases the risk for morbidity and mortality. The use of resuscitation endpoints allows for improved management of these patients, with the potential to prevent further morbidity/mortality. We conducted a review of the current literature on the efficacy of hemodynamic, metabolic, and regional resuscitation endpoints for use in trauma and burn patients. Hemodynamic endpoints included mean arterial pressure (MAP), heart rate (HR), urinary output (UO), compensatory reserve index (CRI), intrathoracic blood volume, and stroke volume variation (SVV). Metabolic endpoints measure cellular responses to decreased oxygen delivery and include serum lactic acid (LA), base deficit (BD), bicarbonate, anion gap, apparent strong ion difference, and serum pH. Mean arterial pressure, HR, UO, and LA are the most established markers of trauma and burn resuscitation. The evidence suggests LA is a superior metabolic endpoint marker. Newer resuscitation endpoint technologies such as point-of-care ultrasound (PoCUS), thromboelastography (TEG), and rotational thromboelastometry (ROTEM) may improve patient outcomes; however, additional research is needed to establish the efficacy in trauma and burn patients. The endpoints discussed have situational strengths and weaknesses and no single universal resuscitation endpoint has yet emerged. This review may increase knowledge and aid in guideline development. We recommend clinicians continue to integrate multiple endpoints with emphasis on MAP, HR, UO, LA, and BD. Future investigation should aim to standardize endpoints for each clinical presentation. The search for universal and novel resuscitation parameters in trauma and burns should also continue.

A Review on the Use of Plasma During Acute Burn Resuscitation

The problem of fluid creep has generated renewed interest in the use of colloids during acute burn resuscitation. Currently, human albumin solution is usually chosen as the resuscitation colloid. However, human plasma was a fundamental component of numerous burn resuscitation formulas historically, but it largely fell out of favor due to concerns surrounding transmission of infectious viruses. Nevertheless, plasma is an effective volume expander which has been demonstrated to reduce overall volume requirements during burn resuscitation. Furthermore, plasma may have beneficial effects on the endothelium by diminishing the microvascular leak that follows a major burn injury. Fresh frozen plasma (FFP) is now much safer from a disease transmission standpoint, and newer forms of solvent-detergent-treated plasma and lyophilized plasma offer potentially even greater safety and efficacy. The use of FFP and newer forms of plasma, which have not been extensively studied, should be investigated as potential adjuncts to acute burn resuscitation.

Role of resuscitation ratio in monitoring burn patients

INTRODUCTION

Efforts with the utilization of an Input/Output ratio (I/O ratio) are done with success for analyzing and moving forward the treatment in the resuscitation phase of the burn patient. The need for conducting this research is to apply the I/O ratio in our cohort as a helpful index for classifying the resuscitation response of the burn patients. Our prespecified hypothesis is if it matters the analysis of the I/O ratio at 8 h of fluid resuscitation period.

MATERIAL AND METHOD

This prospective observational study was performed in 50 patients (22 adults and 28 children) admitted in the Intensive Care of the Service of Burns in Tirana, Albania in the period January to December 2016. We calculated the I/O ratio at 8 h and the end of the 1st 24 h based on the stratification of patients according to the ratio in respective groups. In the adult population we did an analysis whereby the ratio I/O at 8 h has a relationship with the 24 h results as well as with ICU-free days.

RESULTS

The 24 h fluid resuscitation was done with the majority clustered in the range 2-4 ml/kg/% TBSA with fluid-weight score (ml/kg) correlated with % TBSA. After calculation of the I/O ratio at 8 h, 29 patients were assigned in over-responders (<0.166), 16 patients in the expected group(0.166-0.334), and 5 patients were assigned in under-responders (>0.334). There is a strong correlation between the I/O ratio at 8 h and the I/O ratio at 24 h and I/O ratio predict better the longer ICU-free days.

CONCLUSIONS

The I/O ratio is a very useful parameter not only at 12 h and 24 h but also at 8 h after burns. By classifying the patients into outcome groups that reflect not only the volume given but moreover the physiologic reactions to the resuscitation volume gotten, we were more attentive to patients in under-responders at 8 h. This parameter fulfills the criteria for better classifying patients and a better understanding of the physiology of burns.

Mathematical Modeling, In-Human Evaluation, and Analysis of Volume Kinetics and Kidney Function after Burn Injury and Resuscitation

OBJECTIVE

Existing burn resuscitation protocols exhibit a large variability in treatment efficacy. Hence, they must be further optimized based on comprehensive knowledge of burn pathophysiology. A physics-based mathematical model that can replicate physiological responses in diverse burn patients can serve as an attractive basis to perform non-clinical testing of burn resuscitation protocols and to expand knowledge on burn pathophysiology. We intend to develop, optimize, validate, and analyze a mathematical model to replicate physiological responses in burn patients.

METHODS

Using clinical datasets collected from 233 burn patients receiving burn resuscitation, we developed and validated a mathematical model applicable to computer-aided in-human burn resuscitation trial and knowledge expansion. Using the validated mathematical model, we examined possible physiological mechanisms responsible for the cohort-dependent differences in burn pathophysiology between younger versus older patients, female versus male patients, and patients with versus without inhalational injury.

RESULTS

We demonstrated that the mathematical model can replicate physiological responses in burn patients associated with wide demographic characteristics and injury severity, and that an increased inflammatory response to injury may be a key contributing factor in increasing the mortality risk of older patients and patients with inhalation injury via an increase in the fluid retention.

CONCLUSION

We developed and validated a physiologically plausible mathematical model of volume kinetic and kidney function after burn injury and resuscitation suited to in-human application.

SIGNIFICANCE

The mathematical model may provide an attractive platform to conduct non-clinical testing of burn resuscitation protocols and test new hypotheses on burn pathophysiology.

A simplified fluid resuscitation formula for burns in mass casualty scenarios: Analysis of the consensus recommendation from the WHO Emergency Medical Teams Technical Working Group on Burns

BACKGROUND

Burn fluid resuscitation guidelines have not specifically addressed mass casualty with resource limited situations, except for oral rehydration for burns below 40% total body surface area (TBSA). The World Health Organization Technical Working Group on Burns (TWGB) recommends an initial fluid rate of 100 mL/kg/24 h, either orally or intravenously, beyond 20% TBSA burned. We aimed to compare this formula with current guidelines.

METHODS

The TWGB formula was numerically compared with 2-4 mL/kg/%TBSA for adults and the Galveston formula for children.

RESULTS

In adults, the TWGB formula estimated fluid volumes within the range of current guidelines for burns between 25 and 50% TBSA, and a maximal 20 mL/kg/24 h difference in the 20-25% and the 50-60% TBSA ranges. In children, estimated resuscitation volumes between 20 and 60% TBSA approximated estimations by the Galveston formula, but only partially compensated for maintenance fluids. Beyond 60% TBSA, the TWGB formula underestimated fluid to be given in all age groups.

CONCLUSION

The TWGB formula for mass burn casualties may enable appropriate fluid resuscitation for most salvageable burned patients in disasters. This simple formula is easy to implement. It should simplify patient management including transfers, reduce the risk of early complications, and thereby optimize disaster response, provided that tailored resuscitation is given whenever specialized care becomes available.

A History of Fluid Management-From "One Size Fits All" to an Individualized Fluid Therapy in Burn Resuscitation

Fluid management is a cornerstone in the treatment of burns and, thus, many different formulas were tested for their ability to match the fluid requirements for an adequate resuscitation. Thereof, the Parkland-Baxter formula, first introduced in 1968, is still widely used since then. Though using nearly the same formula to start off, the definition of normovolemia and how to determine the volume status of burn patients has changed dramatically over years. In first instance, the invention of the transpulmonary thermodilution (TTD) enabled an early goal directed fluid therapy with acceptable invasiveness. Furthermore, the introduction of point of care ultrasound (POCUS) has triggered more individualized schemes of fluid therapy. This article explores the historical developments in the field of burn resuscitation, presenting different options to determine the fluid requirements without missing the red flags for hyper- or hypovolemia. Furthermore, the increasing rate of co-morbidities in burn patients calls for a more sophisticated fluid management adjusting the fluid therapy to the actual necessities very closely. Therefore, formulas might be used as a starting point, but further fluid therapy should be adjusted to the actual need of every single patient. Taking the developments in the field of individualized therapies in intensive care in general into account, fluid management in burn resuscitation will also be individualized in the near future.

A new resuscitation formula based on burn index provides more reliable prediction for fluid requirement in adult major burn patients

BACKGROUND

The Third Military Medical University (TMMU) formula is widely utilized in the fluid resuscitation in China. However, the actual volume needs usually exceed the prediction provided by the TMMU formula in major burn patients with a high proportion of full-thickness burn wounds.

METHOD

This retrospective study included 149 adult major burn patients (≥40% TBSA) who were admitted to the Burn Department, Southwest Hospital from 2014 to 2020 and received appropriate fluid resuscitation by the TMMU protocol. The actual volume infused in the first 48 hours post-burn was compared to the estimation by the TMMU formula. A new fluid volume prediction formula was developed by multivariate linear regression analysis.

RESULT

The mean fluid requirements were 2.35 ml/kg/%TBSA and 1.75 ml/kg/%TBSA in the 1 st and 2 nd 24 hours post-burn, respectively. The TMMU formula underestimated the fluid requirement, and its prediction accuracy was 54.1% and 25.8% for the 1 st and 2 nd 24 hours, respectively. The proportion of full-thickness burn wound was found to be associated with the fluid requirements after burn. A revised multifactorial formula consisting of the burn index, body weight and inhalation injury was developed. Using the revised formula, the prediction reliability of resuscitation fluid volume improved to 65.3% and 61.1% in the 1st and 2nd 24 hours, respectively.

CONCLUSION

The TMMU formula showed low accuracy in predicting fluid requirements among major burn patients. A revised formula based on burn index was developed to provide better guidance for initiative fluid resuscitation for major burns by the TMMU protocol.

An Assessment of Research Priorities to Dampen the Pendulum Swing of Burn Resuscitation

On June 17 to 18, 2019, the American Burn Association, in conjunction with Underwriters Laboratories, convened a group of experts on burn resuscitation in Washington, DC. The goal of the meeting was to identify and discuss novel research and strategies to optimize the process of burn resuscitation. Patients who sustain a large thermal injury (involving >20% of the total body surface area [TBSA]) face a sequence of challenges, beginning with burn shock. Over the last century, research has helped elucidate much of the underlying pathophysiology of burn shock, which places multiple organ systems at risk of damage or dysfunction. These studies advanced the understanding of the need for fluids for resuscitation. The resultant practice of judicious and timely infusion of crystalloids has improved mortality after major thermal injury. However, much remains unclear about how to further improve and customize resuscitation practice to limit the morbidities associated with edema and volume overload. Herein, we review the history and pathophysiology of shock following thermal injury, and propose some of the priorities for resuscitation research. Recommendations include: studying the utility of alternative endpoints to resuscitation, reexamining plasma as a primary or adjunctive resuscitation fluid, and applying information about inflammation and endotheliopathy to target the underlying causes of burn shock. Undoubtedly, these future research efforts will require a concerted effort from the burn and research communities.

Is the Parkland formula still the best method for determining the fluid resuscitation volume in adults for the first 24 hours after injury? - A retrospective analysis of burn patients in Germany

BACKGROUND

R Rapid fluid resuscitation is a crucial therapy during the treatment of patients with extensive burns. In 1968, the Parkland Formula was introduced for the calculation of the estimated volume of the resuscitation fluid. Since then, different methods for the calculation of fluid resuscitation volume have been developed. We aimed to evaluate if the Parkland formula is still the most effective method for fluid resuscitation volume calculation in burn patients.

METHODS

In the period between January 2015 and January 2019, data from 569 patients over 16 years old with burns of more than 20% total body surface area (TBSA) and at least 15% TBSA full thickness burns were entered in the German burn registry. The patients were divided into 5 groups (0, +1, -1, +2, -2) according to the volume of the resuscitation fluid they received. Group 0 patients received the amount of fluid calculated according to the Parkland formula (n = 83). The 4 other groups received reduced (-1, -2) or increased (+1, +2) fluid volumes in comparison to the value obtained by the Parkland formula.

RESULTS

Patients in Group 0 presented a significantly lower mortality in the first week (4.5%) compared to groups -2 (16.7%) and group +2 (19.5%) (p = 0.021). Furthermore, the mean number of operations in group +2 (5.81) was higher than in group -2 (3.81). Surviving patients from group +2 presented a longer hospital stay (68.1 days) compared to the other groups. Additionally, the logistic regression analysis showed a higher survival of patients in groups -2 and -1 (regression coefficients -0.11 and -0.086; Odds Ratio 0.896 and 0.918; 95% Confidence Interval (CI) 0,411-1.951 and 0.42-2.004).

CONCLUSION

In this retrospective study, register based analysis a restrictive fluid regime was associated with a higher survival compared to the liberal Parkland guided fluid regime.

Mortality following combined burn and traumatic brain injuries: An analysis of the national trauma data bank of the American College of Surgeons

BACKGROUND

Severe burn and traumatic brain injuries (TBI) lead to significant mortality, and combined burn-TBI injuries may predispose towards even worse outcomes. The purpose of this study was to investigate the mortality of patients with burn, burn with non-TBI trauma, and combined burn/TBI to determine if combined injury portends a worse outcome.

METHODS

We obtained the National Trauma Data Bank from 2007 to 2012, identifying 32,334 patients with burn related injuries, dividing this cohort into three injury types: BURN ONLY, BURN with TRAUMA/NO TBI, and BURN with TBI. For each patient, demographic data was obtained, including age, gender, presence of trauma, TBI, or inhalation injury, burn total body surface area (TBSA), Glasgow Coma Scale, Injury Severity Score, and mortality. Multivariable logistic regression was performed.

RESULTS

Age, gender, and TBSA were similar across the three injury groups, but the incidence of inhalation injury was doubled in the BURN with TRAUMA/NO TBI (15.4 %) and BURN with TBI (15.3 %) groups when compared to the BURN ONLY (7.2 %) group. Mortality differed across injury categories after adjusting for age, TBSA, and inhalation injury. Increased mortality was seen in BURN with TRAUMA/NO TBI versus BURN ONLY (OR = 1.27 [1.06, 1.53]) and was higher when comparing BURN with TBI versus BURN ONLY (OR = 4.22 [2.85, 6.18]). BURN with TBI also had higher mortality when compared to BURN with TRAUMA/NO TBI (OR = 3.33 [2.30, 4.82]). The logs odds of mortality also increased with increasing age, TBSA and presence of inhalation injury.

DISCUSSION

This analysis of the NTDB suggests that mortality following burn-related injuries may be higher when burn injury is combined with TBI when compared to burns with other trauma, even after correcting for age, TBSA, and inhalation injury. Further clinical and laboratory research is needed to validate these findings and better understand how to optimize combined TBI and burn injury treatment.

Variation in acute fluid resuscitation among pediatric burn centers

BACKGROUND

Accurate resuscitation of pediatric patients with large thermal injury is critical to achieving optimal outcomes. The goal of this project was to describe the degree of variability in resuscitation guidelines among pediatric burn centers and the impact on fluid estimates.

METHODS

Five pediatric burn centers in the Pediatric Injury Quality Improvement Collaborative (PIQIC) contributed data from patients with ≥15% total body surface area (TBSA) burns treated from 2014 to 2018. Each center's resuscitation guidelines and guidelines from the American Burn Association were used to calculate estimated 24-h fluid requirements and compare these values to the actual fluid received.

RESULTS

Differences in the TBSA burn at which fluid resuscitation was initiated, coefficients related to the Parkland formula, criteria to initiate dextrose containing fluids, and urine output goals were observed. Three of the five centers' resuscitation guidelines produced statistically significant lower mean fluid estimates when compared with the actual mean fluid received for all patients across centers (4.53 versus 6.35ml/kg/% TBSA, p<0.001), (4.90 versus 6.35ml/kg/TBSA, p=0.002) and (3.38 versus 6.35ml/kg/TBSA, p<0.0001).

CONCLUSIONS

This variation in practice patterns led to statistically significant differences in fluid estimates. One center chose to modify its resuscitation guidelines at the conclusion of this study.

Burn injury

Burn injuries are under-appreciated injuries that are associated with substantial morbidity and mortality. Burn injuries, particularly severe burns, are accompanied by an immune and inflammatory response, metabolic changes and distributive shock that can be challenging to manage and can lead to multiple organ failure. Of great importance is that the injury affects not only the physical health, but also the mental health and quality of life of the patient. Accordingly, patients with burn injury cannot be considered recovered when the wounds have healed; instead, burn injury leads to long-term profound alterations that must be addressed to optimize quality of life. Burn care providers are, therefore, faced with a plethora of challenges including acute and critical care management, long-term care and rehabilitation. The aim of this Primer is not only to give an overview and update about burn care, but also to raise awareness of the ongoing challenges and stigmata associated with burn injuries.

Fluid volumes infused during burn resuscitation 1980-2015: A quantitative review

INTRODUCTION

'Fluid creep' or excessive fluid delivered to burn patients during early resuscitation has been suggested by several studies from individual burn centers.

METHODS

We performed a Medline search from 1980 to 2015 in order to identify studies of burn patients predominantly resuscitated with lactated Ringers with infusion adjusted per urinary output. Data was abstracted for 48 publications (3196 patients) that met entry criteria.

RESULTS

Higher resuscitation volumes compared to Parkland estimates were reported, but the trend of increasing resuscitation volumes over the last 30 years is not supported by regression of total fluid infused versus year of study. Mean 24h fluid infused for all studies was 5.2±1.1mL/kg per %TBSA. The mean 24h urinary output reported in 30 studies was 1.2±0.5mL/kg per hr. Burns with inhalation injuries (5 studies) received significantly more fluid than non-inhalation injured burn patients (5.0±1.3 versus 3.9±0.9mL/kg per %TBSA). Fluid infused and urinary outputs were similar for adults and pediatric patients. The most striking finding of our analyses was the great ranges of the means and high standard deviations of volumes infused compared to the original Baxter publication that introduced the Parkland formula CONCLUSIONS: These analyses suggest that burn units currently administer volumes larger than Parkland formula with great patient variability. Individual patient hourly data is needed to better understand the record of burn resuscitation and Fluid Creep.

Fluid resuscitation in trauma: what are the best strategies and fluids?

BACKGROUND

Traumatic injuries pose a global health problem and account for about 10% global burden of disease. Among injured patients, the major cause of potentially preventable death is uncontrolled post-traumatic hemorrhage.

MAIN BODY

This review discusses the role of prehospital trauma care in low-resource/remote settings, goals, principles and evolving strategies of fluid resuscitation, ideal resuscitation fluid, and post-resuscitation fluid management. Management of fluid resuscitation in few special groups is also discussed.

CONCLUSIONS

Prehospital trauma care systems reduce mortality in low-resource/remote settings. Delayed resuscitation seems a better option when transport time to definitive care is shorter whereas goal-directed resuscitation with low-volume crystalloid seems a better option if transport time is longer. Few general recommendations regarding the choice of fluid are provided. Adhering to evidence-based clinical practice guidelines and local modifications based on patient population, available resources, and expertise will improve patient outcomes.

Plasma for burn shock resuscitation: is it time to go back to the future?

Patients with burn shock can be challenging to resuscitate. Burn shock produces a variety of physiologic derangements: Patients are hypovolemic from volume loss, have a increased systemic vascular resistance, and may have a depressed cardiac output depending on the extent of the thermal injury. Additionally, the burn wound produces a significant inflammatory cascade of events that contributes to the shock state. Fluid resuscitation is foundational for the initial treatment of burn shock. Typical resuscitation is with intravenous lactated Ringer's in accordance with well-established formulas based on burn wound size. In the past century, as therapies to treat thermal injuries were being developed, plasma was the fluid used for burn resuscitation; in fact, plasma was used in World War II and throughout the 1950s and 1960s. Plasma was abandoned because of infectious risks and complications. Despite huge strides in transfusion medicine and the increased safety of blood products, plasma has never been readopted for burn resuscitation. Over the past 15 years, there has been a paradigm shift in trauma resuscitation: Less crystalloid and more blood products are used; this strategy has demonstrated improved outcomes. Plasma is a physiologic fluid that stabilizes the endothelium. The endotheliopathy of trauma has been described and is mitigated by transfusion strategies with a 1:1 ratio of RBCs to plasma. Thermal injury also results in endothelial dysfunction: the endotheliopathy of burns. Plasma is likely a better resuscitation fluid for patients with significant burn wounds because of its capability to restore intravascular volume status and treat the endotheliopathy of burns.

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.

Burn intensive care treatment over the last 30 years: Improved survival and shift in case-mix

PURPOSE

Mortality in burn intensive care unit (ICU) has been decreasing and treatment appears to be changing. The aims of this study: (1) examine outcome in burn patients, (2) examine changes in ICU indication and (3) explore the influence of a changing case-mix.

METHODS

Retrospective study in patients admitted to ICU (1987-2016). Four groups were specified: major burns (≥15% TBSA), inhalation injury with small injury (<15% TBSA, inhalation injury), watchful waiting (<15% TBSA, without inhalation injury), tender loving care (patients withheld from treatment). Logistic regression was performed to evaluate the relation between case-mix and outcome.

RESULTS

Overall mortality decreased to 7%. Mortality of major burns decreased by 15%. The major burn group decreased by 36%. The inhalation injury and watchful waiting group increased by 9% and 21%. The percentage of ventilated patients increased by 14% in the major burn group. 40% of patients were ventilated in the watchful waiting group.

CONCLUSIONS

After correction for case-mix, survival improved, mainly in the major burn group. Case-mix shifted towards inhalation injury and watchful waiting. Growth of the watchful waiting group is not necessarily harmful. However, the increase of mechanical ventilation could be. We suggest raising awareness for risks and consequences of mechanical ventilation.

Fluid resuscitation in paediatric burns: how do we get it right? A systematic review of the evidence

BACKGROUND

Optimal fluid resuscitation in children with major burns is crucial to prevent or minimise burn shock and prevent complications of over-resuscitation.

OBJECTIVES

To identify studies using endpoints to guide fluid resuscitation in children with burns, review the range of reported endpoint targets and assess whether there is evidence that targeted endpoints impact on outcome.

DESIGN

Systematic review.

METHODS

Medline, Embase, Cinahl and the Cochrane Central Register of Controlled Trials databases were searched with no restrictions on study design or date. Search terms combined burns, fluid resuscitation, endpoints, goal-directed therapy and related synonyms. Studies reporting primary data regarding children with burns (<16 years) and targeting fluid resuscitation endpoints were included. Data were extracted using a proforma and the results were narratively reviewed.

RESULTS

Following screening of 777 unique references, 7 studies fulfilled the inclusion criteria. Four studies were exclusively paediatric. Six studies used urine output (UO) as the primary endpoint. Of these, one set a minimum UO threshold, while the remainder targeted a range from 0.5-1.0 mL/kg/hour to 2-3 mL/kg/hour. No studies compared different UO targets. Heterogeneous study protocols and outcomes precluded comparison between the UO targets. One study targeted invasive haemodynamic variables, but this did not significantly affect patient outcome.

CONCLUSIONS

Few studies have researched resuscitation endpoints for children with burns. Those that have done so have investigated heterogeneous endpoints and endpoint targets. There is a need for future randomised controlled trials to identify optimal endpoints with which to target fluid resuscitation in children with burns.

Weight changes and patterns of weight measurements in hospitalized burn patients: a contemporary analysis

Background

Severe burn is associated with significant changes in body weight due to resuscitation volumes, fluid shifts, a hypermetabolic state, prolonged bed rest, and caloric intake. Our goal was to quantify and describe trends in weight change in patients with burns of all severities under modern treatment conditions and to identify the time points at which these changes occur.

Methods

An institutional review board-approved chart review was conducted of acute burn patients treated at an American Burn Association-verified regional burn center from February 2016 to November 2016. Patients were then divided into three groups based on percent of total burn surface area (%TBSA) burn: 1–19%, 20–39%, and ≥ 40%. Weight was expressed as percent change of weight from baseline. Regression analysis was conducted on percent weight changes for each TBSA group.

Results

We identified 197 burn patients with a length of stay (LOS) of ≥ 7 days. Of the study cohort, 149 had TBSA burn of 1–19%, 27 had TBSA burn of 20–39%, and 21 had TBSA burn of ≥ 40%. All groups had a majority of White male, non-Hispanic patients with mean ages between 40 and 42 years. Burn patients with > 20% TBSA burn had a median increase in weight above baseline of approximately 5 to 8% likely due to resuscitation fluids within the first week of hospitalization. Weight loss below baseline often did not exceed 10% and was more pronounced as LOS increased, mostly in patients with > 20% TBSA burn. Whereas patients with 1–19% TBSA burn on average returned to baseline weight at last measurement, patients with 20–39% TBSA and ≥ 40% TBSA burn continued a decline in weight at 4 weeks (r² = 0.57 and 0.55, respectively) on the same trajectory.

Conclusions

Burn patients with > 20% TBSA burn had an increase in weight above baseline of up to 8%, likely due to resuscitation fluids within the first week of hospitalization. Weight loss below baseline often did not exceed 10% and was more pronounced as LOS increased, mostly in patients with > 20% TBSA burn. Therefore, our patients on average, lost body weight to a lesser extent than the maximum mean loss of 22% of pre-burn weight reported prior to modern treatment conditions.

Albumin in Burn Shock Resuscitation: A Meta-Analysis of Controlled Clinical Studies

Critical appraisal of outcomes after burn shock resuscitation with albumin has previously been restricted to small relatively old randomized trials, some with high risk of bias. Extensive recent data from nonrandomized studies assessing the use of albumin can potentially reduce bias and add precision. The objective of this meta-analysis was to determine the effect of burn shock resuscitation with albumin on mortality and morbidity in adult patients. Randomized and nonrandomized controlled clinical studies evaluating mortality and morbidity in adult patients receiving albumin for burn shock resuscitation were identified by multiple methods, including computer database searches and examination of journal contents and reference lists. Extracted data were quantitatively combined by random-effects meta-analysis. Four randomized and four nonrandomized studies with 688 total adult patients were included. Treatment effects did not differ significantly between the included randomized and nonrandomized studies. Albumin infusion during the first 24 hours showed no significant overall effect on mortality. However, significant statistical heterogeneity was present, which could be abolished by excluding two studies at high risk of bias. After those exclusions, albumin infusion was associated with reduced mortality. The pooled odds ratio was 0.34 with a 95% confidence interval of 0.19 to 0.58 (P < .001). Albumin administration was also accompanied by decreased occurrence of compartment syndrome (pooled odds ratio, 0.19; 95% confidence interval, 0.07–0.50; P < .001). This meta-analysis suggests that albumin can improve outcomes of burn shock resuscitation. However, the scope and quality of current evidence are limited, and additional trials are needed.

Burns: Pathophysiology of Systemic Complications and Current Management

As a result of many years of research, the intricate cellular mechanisms of burn injury are slowly becoming clear. Yet, knowledge of these cellular mechanisms and a multitude of resulting studies have often failed to translate into improved clinical treatment for burn injuries. Perhaps the most valuable information to date is the years of clinical experience and observations in the management and treatment of patients, which has contributed to a gradual improvement in reported outcomes of mortality. This review provides a discussion of the cellular mechanisms and pathways involved in burn injury, resultant systemic effects on organ systems, current management and treatment, and potential therapies that we may see implemented in the future.

Does Overestimation of Burn Size in Children Requiring Fluid Resuscitation Cause Any Harm?

Overestimation of burn size especially in children is common. It is unclear if this may cause harm. This study was designed to assess the accuracy of burn size estimation by referring non-burn clinicians and investigate whether inaccurate estimates caused any harm. Three and a half years retrospective review of pediatric resuscitation burns (ie, ≥10% TBSA) referred to a tertiary burns center from other hospitals was performed. This included basic demographics, data from referring emergency departments (initial TBSA estimations and fluid volumes prescribed), and data on arrival to the burn center (actual burn TBSA sustained, fluid volumes given prior to arrival, and actual fluid volumes required). Clinical parameters at 8 and 24 hr after injury were also examined. Forty-six patients were identified. Mean age was 3.9 years and weight 18 kg. Mean time to arrival from initial burn injury to our tertiary center was 5 hr. Thirty-two children (70%) had their burns overestimated, seven (15%) underestimated, and another seven (15%) were correctly estimated. After accurate calculations of the burn size and the required resuscitation fluids on arrival to the burns center, only five children of the entire cohort of 46 patients (11%) had received more fluids than required. These five children were in the overestimated burn size group. Only three children received the appropriate amount of fluid prior to arrival to the burns center. There were no mortalities or significant clinical adverse events in any of the children. Overestimation led to overprescription of fluid volumes, but this did not translate into over-resuscitation, and in most cases was in fact associated with inadequate fluid administration. Although 70% of the children in our cohort had the burn size overestimated, only 11% had actually received more fluids than required before arrival. None of these children went on to have any significant complications as a result of overestimation. Training and education is essential for clinicians in emergency departments. However, estimation of size in pediatric burns, in particular scalds, is challenging and the importance of early transfer to a specialist service cannot be overemphasized.

Improved Survival of Patients With Extensive Burns: Trends in Patient Characteristics and Mortality Among Burn Patients in a Tertiary Care Burn Facility, 2004-2013

Classic determinants of burn mortality are age, burn size, and the presence of inhalation injury. Our objective was to describe temporal trends in patient and burn characteristics, inpatient mortality, and the relationship between these characteristics and inpatient mortality over time. All patients aged 18 years or older and admitted with burn injury, including inhalation injury only, between 2004 and 2013 were included. Adjusted Cox proportional hazards regression models were used to estimate the relationship between admit year and inpatient mortality. A total of 5540 patients were admitted between 2004 and 2013. Significant differences in sex, race/ethnicity, burn mechanisms, TBSA, inhalation injury, and inpatient mortality were observed across calendar years. Patients admitted between 2011 and 2013 were more likely to be women, non-Hispanic Caucasian, with smaller burn size, and less likely to have an inhalation injury, in comparison with patients admitted from 2004 to 2010. After controlling for patient demographics, burn mechanisms, and differential lengths of stay, no calendar year trends in inpatient mortality were detected. However, a significant decrease in inpatient mortality was observed among patients with extensive burns (≥75% TBSA) in more recent calendar years. This large, tertiary care referral burn center has maintained low inpatient mortality rates among burn patients over the past 10 years. While observed decreases in mortality during this time are largely due to changes in patient and burn characteristics, survival among patients with extensive burns has improved.

Burn State of the Science: Fluid Resuscitation

Recognition of fluid creep has driven a large amount of the scientific investigation in the area of acute fluid resuscitation for burn patients. The role of colloids in ameliorating fluid creep is controversial, despite the fact that a fluid-sparing effect of colloids has been recognized for some time. All but one of the available prospective studies using colloids are more than a decade old, and a modern randomized controlled trial (RCT) comparing crystalloids to colloids is long overdue. While urinary output continues to be the main endpoint for fluid titration, there has been a moderate amount of interest in the use of transpulmonary thermodilution to guide fluid resuscitation. The available studies have found that transpulmonary thermodilution has had an inconsistent effect on limiting fluid resuscitation volumes and improving clinical outcomes. Computerized Decision Support Systems show great promise in optimizing fluid titration and reducing fluid resuscitation volumes, and an RCT comparing Computerized Decision Support Systems with conventional titration approaches will be the important next step. Use of high-dose vitamin C (ascorbic acid) has become a popular approach to limit fluid resuscitation volumes and edema formation, but it has been investigated in only two clinical studies: one a pseudo-randomized prospective study and the other a retrospective study. Improvements in clinical outcome have not been convincingly demonstrated, and concerns persist surrounding the possibility of induction of an osmotic diuresis, leading to intravascular volume depletion. An RCT is urgently required to evaluate high-dose vitamin C as an adjunct to crystalloid resuscitation compared with the use of crystalloids alone.

The role of preliminary hospitals in the management of a mass burn casualty disaster

PURPOSE

The Formosa Fun Coast explosion is an internationally-known event that occurred in Taiwan on June 27th, 2015. The blast involved 495 casualties in total, with 253 patients receiving 2nd degree or deeper burns on greater than 40% of the total body surface area (TBSA). Questions were raised regarding whether these victims were sent to the appropriate hospitals or not. Therefore, we analyzed the effect of the initial admission destination in this study.

MATERIAL AND METHODS

We retrospectively reviewed all of the victims from the explosion who were sent to the emergency department of Linkou and Keelung Chang Gung Memorial Hospitals. Patients were divided by direct admission and received via transfer. The basic demographics, the efficacy of the initial resuscitation and the clinical outcomes were analyzed.

RESULTS

In total, forty-six patients were included. Thirty-five of them were primarily admitted, and eleven of them were received via transfer. Between the two groups, there was no significant difference in the resuscitation outcome. The ratio of delaying intubation was similar (14.3% vs 27.3%, p=0.322). The rate of delayed-detected ischemic events was significantly increased in the referral group (0% vs 27.3%, p=0.001). However, there was no amputation event in either group. No difference in mortality was observed between groups (5.7% vs 9.1%, p=0.692).

CONCLUSION

Our preliminary findings suggest that local hospitals are capable of providing high-quality acute care to mass casualty burn victims. Our results suggest that patients with suspected limb ischemia should be rapidly transferred to a regional burn center to ensure optimal care. Systemic pre-planning such as employing telemedicine and personnel collaboration, should be considered by the administration to maximize the function of preliminary hospitals in burn care.

Pediatric burn resuscitation: past, present, and future

Burn injury is a leading cause of unintentional death and injury in children, with the majority being minor (less than 10%). However, a significant number of children sustain burns greater than 15% total body surface area (TBSA), leading to the initiation of the systemic inflammatory response syndrome. These patients require IV fluid resuscitation to prevent burn shock and death. Prompt resuscitation is critical in pediatric patients due to their small circulating blood volumes. Delays in resuscitation can result in increased complications and increased mortality. The basic principles of resuscitation are the same in adults and children, with several key differences. The unique physiologic needs of children must be adequately addressed during resuscitation to optimize outcomes. In this review, we will discuss the history of fluid resuscitation, current resuscitation practices, and future directions of resuscitation for the pediatric burn population.

Future Therapies in Burn Resuscitation

Since the 1940s, the resuscitation of burn patients has evolved with dramatic improvements in mortality. The most significant achievement remains the creation and adoption of formulae to calculate estimated fluid requirements to guide resuscitation. Modalities to attenuate the hypermetabolic phase of injury include pharmacologic agents, early enteral nutrition, and the aggressive approach of early excision of large injuries. Recent investigations into the genomic response to severe burns and the application of computer-based decision support tools will likely guide future resuscitation, with the goal of further reducing mortality and morbidity, and improving functional and quality of life outcomes.

Colloids in Acute Burn Resuscitation

Colloids have been used in varying capacities throughout the history of formula-based burn resuscitation. There is sound experimental evidence that demonstrates colloids' ability to improve intravascular colloid osmotic pressure, expand intravascular volume, reduce resuscitation requirements, and limit edema in unburned tissue following a major burn. Fresh frozen plasma appears to be a useful and effective immediate burn resuscitation fluid but its benefits must be weighed against its costs, and risks of viral transmission and acute lung injury. Albumin, in contrast, is less expensive and safer and has demonstrated ability to reduce resuscitation requirements and possibly limit edema-related morbidity.

Strategies for Intravenous Fluid Resuscitation in Trauma Patients

Intravenous fluid management of trauma patients is fraught with complex decisions that are often complicated by coagulopathy and blood loss. This review discusses the fluid management in trauma patients from the perspective of the developing world. In addition, the article describes an approach to specific circumstances in trauma fluid decision-making and provides recommendations for the resource-limited environment.

Resuscitation using less fluid has no negative impact on hydration status in children with moderate sized scalds: a prospective single-centre UK study

BACKGROUND

After a burn, optimal fluid resuscitation is critical for positive patient outcome. Although national guidelines advocate using resuscitation fluids of 4mL per kg body weight and percent body surface area (%BSA) for paediatric burns of >10% BSA, evidence in adults suggest that such volumes lead to over-resuscitation and related complications. Our aim was to investigate whether children managed with biosynthetic dressings (Biobrane™) and reduced fluid volumes remain well hydrated, as determined by clinical and laboratory parameters.

METHODS

At a single UK Burn Centre, children with scalds of 10-19%BSA managed with Biobrane were given 80% maintenance fluids and no formal burn resuscitation (permissive hypovolaemia [PH] group). Urine output (UO), serum sodium, urea, and creatinine were used as 24h markers of hydration and concentrations compared to those in a patient cohort treated within the same centre when traditional resuscitation was used (TR group).

RESULTS

Serum sodium concentrations and UO in the PH group were similar to those in the TR group (median sodium: PH=136, TR=136, P=1.00; median UO: PH=1.5, TR=1.8, P=0.25). Urea concentrations were lower and creatinine concentrations higher in the TR group compared to the PH group (median urea: PH=3.2, TR=2.3, P=0.04; median creatinine: PH=21, TR=30, P<0.001). A higher proportion of TR patients than PH patients fell outside the reference ranges for urea (61% vs. 23%; P=0.04) and creatinine (44% vs. 8%; P=0.03).

CONCLUSION

Based on markers of hydration, children with moderate-sized scalds managed with Biobrane can be safely managed with less fluid.

Hold the Pendulum: Rates of Acute Kidney Injury are Increased in Patients Who Receive Resuscitation Volumes Less than Predicted by the Parkland Equation

OBJECTIVE

To determine whether restrictive fluid resuscitation results in increased rates of acute kidney injury (AKI) or infectious complications.

BACKGROUND

Studies demonstrate that patients often receive volumes in excess of those predicted by the Parkland equation, with potentially detrimental sequelae. However, the consequences of under-resuscitation are not well-studied.

METHODS

Data were collected from a multicenter prospective cohort study. Adults with greater than 20% total burned surface area injury were divided into 3 groups on the basis of the pattern of resuscitation in the first 24 hours: volumes less than (restrictive), equal to, or greater than (excessive) standard resuscitation (4 to 6 cc/kg/% total burned surface area). Multivariable regression analysis was employed to determine the effect of fluid group on AKI, burn wound infections (BWIs), and pneumonia.

RESULTS

Among 330 patients, 33% received restrictive volumes, 39% received standard resuscitation volumes, and 28% received excessive volumes. The standard and excessive groups had higher mean baseline APACHE scores (24.2 vs 16, P < 0.05 and 22.3 vs 16, P < 0.05) than the restrictive group, but were similar in other characteristics. After adjustment for confounders, restrictive resuscitation was associated with greater probability of AKI [odds ratio (OR) 3.25, 95% confidence interval (95% CI) 1.18-8.94]. No difference in the probability of BWI or pneumonia among groups was found (BWI: restrictive vs standard OR 0.74, 95% CI 0.39-1.40, excessive vs standard OR 1.40, 95% CI 0.75-2.60, pneumonia: restrictive vs standard, OR 0.52, 95% CI 0.26-1.05; excessive vs standard, OR 1.12, 95% CI 0.58-2.14).

CONCLUSIONS

Restrictive resuscitation is associated with increased AKI, without changes in infectious complications.

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.

In view of standardization Part 2: Management of challenges in the initial treatment of burn patients in Burn Centers in Germany, Austria and Switzerland

INTRODUCTION

Initial therapy of severe burns in specialized burn trauma centers is a challenging task faced by the treating multi-professional and interdisciplinary team. A lack of consistent operating procedures and varying structural conditions was recently demonstrated in preliminary data of our group. These results raised the question on how specific treatment measures in acute burn care are met in the absence of standardized guidelines.

MATERIAL AND METHODS

A specific questionnaire containing 57 multiple-choice questions was sent to all 22 major burn centers in Germany, Austria and Switzerland. The survey included standards of airway management and ventilation, fluid management and circulation, body temperature monitoring and management, topical burn wound treatment and a microbiological surveillance. Additionally, the distribution of standardized course systems was covered.

RESULTS

17 out of 22 questionnaires (77%) were returned completed. Regarding volume resuscitation, results showed a similar approach in estimating initial fluid while discrepancies persisted in the use of colloidal fluid and human albumin. Elective tracheostomy and the need for bronchoscopy with suspected inhalation injury were the most controversial issues revealed by the survey. Topical treatment of burned body surface also followed different principles regarding the use of synthetic epidermal skin substitutes or enzymatic wound debridement. Less discrepancy was found in basic diagnostic measures, body temperature management, estimation of the extent of burns and microbiological surveillance.

CONCLUSION

While many burn-related issues are clearly not questionable and managed in a similar way in most participating facilities, we were able to show that the most contentious issues in burn trauma management involve initial volume resuscitation, management of inhalation trauma and topical burn wound treatment. Further research is required to address these topics and evaluate a potential superiority of a regime in order to increase the level of evidence.