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Greenhalgh DG. Current Thoughts on Burn Resuscitation. Adv Surg 2024; 58:1-17. [PMID: 39089770 DOI: 10.1016/j.yasu.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
The optimal treatment of burn shock is still unresolved. The problem of "fluid creep" continues despite modern devices that fail to improve outcomes over hourly urine output. Colloids, especially albumin, reduce fluid requirements. Albumin can be used either immediately at the start of resuscitation, or as a "rescue" when crystalloid use is excessive. Several studies confirm that when crystalloid resuscitation is "out of control" the majority of caregivers will add albumin to reduce fluid rates. A multi-center trial is underway comparing crystalloids with albumin to confirm the benefit of colloids. The next question is whether albumin or plasma is as the better colloid choice.
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Affiliation(s)
- David G Greenhalgh
- Burn Department, Shriners Children's Northern California, 2425 Stockton Boulevard, Sacramento, CA 95817, USA; Emeritus, Department of Surgery, University of California, Davis, CA, USA.
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2
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McHargue C, Aden J, Pham TN, Salinas J, Rizzo JA. Precursors to oliguria during major burn resuscitation: An analysis of a prospective observational trial at 5 major US burn centers. Burns 2024; 50:1513-1518. [PMID: 38548572 DOI: 10.1016/j.burns.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 03/01/2024] [Accepted: 03/05/2024] [Indexed: 06/14/2024]
Abstract
Currently, urine output is the leading variable used to tailor fluid resuscitation in patients with large TBSA burns. However, this metric often lags with respect to resuscitation. Our group sought to identify derangements in variables that precede development of oliguria (<30 cc/hr) that we hypothesize will aid in more efficient resuscitation. We performed a retrospective analysis of 146 adult patients admitted within 4 h of a large TBSA (>20%) burn. We then divided them into two cohorts: those who developed oliguria within 6 h of admission and those who did not. Patients who experienced early oliguria had a higher incidence of invasive SBP < 90 (p = 0.02) or DBP < 40 (p = 0.009), lower minimum bicarbonate level (p = 0.04), more full thickness burns (p = 0.004), and higher TBSA (p = 0.01). More female patients were found in the oliguric group (p = 0.003). Multivariate analysis was used to develop a model to predict development of oliguria. When evaluated together, minimum DBP, sex, TBSA (or percent full thickness burn), and maximum base deficit constituted the most parsimonious model that significantly predicted oliguria (AUC = 0.92). Interestingly, the model lost significance when DBP was omitted, highlighting the importance of diastolic pressure in the development of oliguria.
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Affiliation(s)
- Cody McHargue
- UW Medicine Regional Burn Center, Harborview Medical Center, 325 9th Ave, Seattle, WA 98104, USA.
| | - James Aden
- Brooke Army Medical Center, JBSA, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234, USA
| | - Tam N Pham
- UW Medicine Regional Burn Center, Harborview Medical Center, 325 9th Ave, Seattle, WA 98104, USA
| | - Jose Salinas
- United States Army Institute of Surgical Research, 3698 Chambers Pass STE B JBSA Ft. Sam Houston, TX 78234, USA
| | - Julie A Rizzo
- Brooke Army Medical Center, JBSA, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234, USA
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3
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Cartotto R, Johnson LS, Savetamal A, Greenhalgh D, Kubasiak JC, Pham TN, Rizzo JA, Sen S, Main E. American Burn Association Clinical Practice Guidelines on Burn Shock Resuscitation. J Burn Care Res 2024; 45:565-589. [PMID: 38051821 DOI: 10.1093/jbcr/irad125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
This Clinical Practice Guideline (CPG) addresses the topic of acute fluid resuscitation during the first 48 hours following a burn injury for adults with burns ≥20% of the total body surface area (%TBSA). The listed authors formed an investigation panel and developed clinically relevant PICO (Population, Intervention, Comparator, Outcome) questions. A systematic literature search returned 5978 titles related to this topic and after 3 levels of screening, 24 studies met criteria to address the PICO questions and were critically reviewed. We recommend that clinicians consider the use of human albumin solution, especially in patients with larger burns, to lower resuscitation volumes and improve urine output. We recommend initiating resuscitation based on providing 2 mL/kg/% TBSA burn in order to reduce resuscitation fluid volumes. We recommend selective monitoring of intra-abdominal and intraocular pressure during burn shock resuscitation. We make a weak recommendation for clinicians to consider the use of computer decision support software to guide fluid titration and lower resuscitation fluid volumes. We do not recommend the use of transpulmonary thermodilution-derived variables to guide burn shock resuscitation. We are unable to make any recommendations on the use of high-dose vitamin C (ascorbic acid), fresh frozen plasma (FFP), early continuous renal replacement therapy, or vasopressors as adjuncts during acute burn shock resuscitation. Mortality is an important outcome in burn shock resuscitation, but it was not formally included as a PICO outcome because the available scientific literature is missing studies of sufficient population size and quality to allow us to confidently make recommendations related to the outcome of survival at this time.
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Affiliation(s)
- Robert Cartotto
- Department of Surgery, Ross Tilley Burn Centre, Sunnybrook Heath Sciences Centre, University of Toronto, Canada
| | - Laura S Johnson
- Department of Surgery, Walter L. Ingram Burn Center, Grady Memorial Hospital, Emory University, Atlanta, GAUSA
| | - Alisa Savetamal
- Department of Surgery, Connecticut Burn Center, Bridgeport Hospital, Bridgeport, CT, USA
| | - David Greenhalgh
- Shriners Hospital for Children, Northern California, Sacramento, CA, USA
| | - John C Kubasiak
- Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Tam N Pham
- Department of Surgery, University of Washington Regional Burn Center, Harborview Medical Center, Seattle, WA, USA
| | - Julie A Rizzo
- Department of Trauma, Brooke Army Medical Center, Fort Sam Houston, San Antonio, TX, USA
- Uniformed Services University of Health Sciences, Bethesda, MD, USA
| | - Soman Sen
- Department of Surgery, Division of Burn Surgery, University of California, Davis, CA, USA
| | - Emilia Main
- Sunnybrook Health Sciences Centre, Toronto, Canada
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4
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Legrand M, Clark AT, Neyra JA, Ostermann M. Acute kidney injury in patients with burns. Nat Rev Nephrol 2024; 20:188-200. [PMID: 37758939 DOI: 10.1038/s41581-023-00769-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2023] [Indexed: 09/29/2023]
Abstract
Burn injury is associated with a high risk of acute kidney injury (AKI) with a prevalence of AKI among patients with burns of 9-50%. Despite an improvement in burn injury survival in the past decade, AKI in patients with burns is associated with an extremely poor short-term and long-term prognosis, with a mortality of >80% among those with severe AKI. Factors that contribute to the development of AKI in patients with burns include haemodynamic alterations, burn-induced systemic inflammation and apoptosis, haemolysis, rhabdomyolysis, smoke inhalation injury, drug nephrotoxicity and sepsis. Early and late AKI after burn injury differ in their aetiologies and outcomes. Sepsis is the main driver of late AKI in patients with burns and late AKI has been associated with higher mortality than early AKI. Prevention of early AKI involves correction of hypovolaemia and avoidance of nephrotoxic drugs (for example, hydroxocobalamin), whereas prevention of late AKI involves prevention and early recognition of sepsis as well as avoidance of nephrotoxins. Treatment of AKI in patients with burns remains supportive, including prevention of fluid overload, treatment of electrolyte disturbance and use of kidney replacement therapy when indicated.
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Affiliation(s)
- Matthieu Legrand
- Department of Anaesthesia and Perioperative Care, Division of Critical Care Medicine, University of California San Francisco, San Francisco, CA, USA.
| | - Audra T Clark
- Department of General Surgery, Division of Burn, Trauma, Critical Care, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Javier A Neyra
- Department of Internal Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Marlies Ostermann
- Department of Critical Care & Nephrology, King's College London, Guy's & St Thomas' Hospital, London, UK
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Haruta A, Mandell SP. Assessment and Management of Acute Burn Injuries. Phys Med Rehabil Clin N Am 2023; 34:701-716. [PMID: 37806692 DOI: 10.1016/j.pmr.2023.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
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.
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Affiliation(s)
- Alison Haruta
- Department of Burns, Trauma, Acute, and Critical Care Surgery, UT Southwestern, 5323 Harry Hines Boulevard, Dallas, TX 75390-9005, USA.
| | - Samuel P Mandell
- Department of Burns, Trauma, Acute, and Critical Care Surgery, UT Southwestern, 5323 Harry Hines Boulevard, Dallas, TX 75390-9005, USA
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Tejiram S, Tranchina SP, Travis TE, Shupp JW. The First 24 Hours: Burn Shock Resuscitation and Early Complications. Surg Clin North Am 2023; 103:403-413. [PMID: 37149377 DOI: 10.1016/j.suc.2023.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Resuscitation is required for the management of patients with severe thermal injury. Some of the initial pathophysiologic events following burn injury include an exaggerated inflammatory state, injury to the endothelium, and increased capillary permeability, which all culminate in shock. Understanding these processes is critical to the effective management of patients with burn injuries. Formulas predicting fluid requirements during burn resuscitation have evolved over the past century in response to clinical experience and research efforts. Modern resuscitation features individualized fluid titration and monitoring along with colloid-based adjuncts. Despite these developments, complications from over-resuscitation still occur.
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Affiliation(s)
- Shawn Tejiram
- The Burn Center, MedStar Washington Hospital Center, 110 Irving Street, Northwest Suite 3B-55, Washington, DC 20010, USA; Department of Surgery, Georgetown University School of Medicine, 3900 Reservoir Road NW, Washington, DC 20007, USA
| | - Stephen P Tranchina
- Georgetown University School, 3900 Reservoir Road NW, Washington, DC 20007, USA
| | - Taryn E Travis
- The Burn Center, MedStar Washington Hospital Center, 110 Irving Street, Northwest Suite 3B-55, Washington, DC 20010, USA; Department of Surgery, Georgetown University School of Medicine, 3900 Reservoir Road NW, Washington, DC 20007, USA; Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, 3900 Reservoir Road NW, Washington, DC 20007, USA
| | - Jeffrey W Shupp
- The Burn Center, MedStar Washington Hospital Center, 110 Irving Street, Northwest Suite 3B-55, Washington, DC 20010, USA; Department of Surgery, Georgetown University School of Medicine, 3900 Reservoir Road NW, Washington, DC 20007, USA; Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, 3900 Reservoir Road NW, Washington, DC 20007, USA; Department of Biochemistry and Molecular & Cellular Biology, Georgetown University Medical Center, 37th and O Street, Northwest, Washington, DC 20057, USA.
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7
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Rizzo JA, Liu NT, Coates EC, Serio-Melvin ML, Aden JK, Stallings JD, Foster KN, AbdelFattah KR, Pham TN, Salinas J. The Battle of the Titans-Comparing Resuscitation Between Five Major Burn Centers Using the Burn Navigator. J Burn Care Res 2023; 44:446-451. [PMID: 35880437 DOI: 10.1093/jbcr/irac095] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
The goal of burn resuscitation is to provide the optimal amount of fluid necessary to maintain end-organ perfusion and prevent burn shock. The objective of this analysis was to examine how the Burn Navigator (BN), a clinical decision support tool in burn resuscitation, was utilized across five major burn centers in the United States, using an observational trial of 300 adult patients. Subject demographics, burn characteristics, fluid volumes, urine output, and resuscitation-related complications were examined. Two hundred eighty-five patients were eligible for analysis. There was no difference among the centers on mean age (45.5 ± 16.8 years), body mass index (29.2 ± 6.9), median injury severity score (18 [interquartile range: 9-25]), or total body surface area (TBSA) (34 [25.8-47]). Primary crystalloid infusion volumes at 24 h differed significantly in ml/kg/TBSA (range: 3.1 ± 1.2 to 4.5 ± 1.7). Total fluids, including colloid, drip medications, and enteral fluids, differed among centers in both ml/kg (range: 132.5 ± 61.4 to 201.9 ± 109.9) and ml/kg/TBSA (3.5 ± 1.0 to 5.3 ± 2.0) at 24 h. Post-hoc adjustment using pairwise comparisons resulted in a loss of significance between most of the sites. There was a total of 156 resuscitation-related complications in 92 patients. Experienced burn centers using the BN successfully titrated resuscitation to adhere to 24 h goals. With fluid volumes near the Parkland formula prediction and a low prevalence of complications, the device can be utilized effectively in experienced centers. Further study should examine device utility in other facilities and on the battlefield.
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Affiliation(s)
- Julie A Rizzo
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas, USA.,Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
| | - Nehemiah T Liu
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | - Elsa C Coates
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | | | - James K Aden
- Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | | | - Kevin N Foster
- Arizona Burn Center - Valleywise Health, Phoenix, Arizona, USA
| | | | - Tam N Pham
- UW Medicine Regional Burn Center, Harborview Medical Center, Seattle, Washington, USA
| | - Jose Salinas
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
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Shupp JW, Holmes JH, Moffatt LT, Phelan HA, Sousse L, Romanowski KS, Jeschke M, Kowalske KJ, Badger K, Allely R, Cartotto R, Burmeister DM, Kubasiak JC, Wolf SE, Wallace KF, Gillenwater J, Schneider DM, Hultman CS, Wiechman SA, Bailey JK, Powell HM, Travis TE, Supp DM, Carney BC, Johnson LS, Johnson LS, Chung KK, Chung KK, Kahn SA, Gibson ALF, Christy RJ, Carter JE, Carson JS, Palmieri TL, Kopari NM, Blome-Eberwein SA, Hickerson WL, Parry I, Cancio JM, Suman O, Schulman CI, Lamendella R, Hill DM, Wibbenmeyer LA, Nygaard RM, Wagner AL, Carter ADW, Greenhalgh DG, Lawless MB, Carlson DL, Harrington DT. Proceedings of the 2021 American Burn Association State and Future of Burn Science Meeting. J Burn Care Res 2022; 43:1241-1259. [PMID: 35988021 DOI: 10.1093/jbcr/irac092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Periodically, the American Burn Association (ABA) has convened a State of the Science meeting on various topics representing multiple disciplines within burn care and research. In 2021 at the request of the ABA President, meeting development was guided by the ABA's Burn Science Advisory Panel (BSAP) and a subgroup of meeting chairs. The goal of the meeting was to produce both an evaluation of the current literature and ongoing studies, and to produce a research agenda and/or define subject matter-relevant next steps to advance the field(s). Members of the BSAP defined the topics to be addressed and subsequently solicited for nominations of expert speakers and topic leaders from the ABA's Research Committee. Current background literature for each topic was compiled by the meeting chairs and the library then enhanced by the invited topic and breakout discussion leaders. The meeting was held in New Orleans, LA on November 2nd and 3rd and was formatted to allow for 12 different topics, each with two subtopics, to be addressed. Topic leaders provided a brief overview of each topic to approximately 100 attendees, followed by expert-lead breakout sessions for each topic that allowed for focused discussion among subject matter experts and interested participants. The breakout and topic group leaders worked with the participants to determine research needs and associated next steps including white papers, reviews and in some cases collaborative grant proposals. Here, summaries from each topic area will be presented to highlight the main foci of discussion and associated conclusions.
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Closed-Loop Controlled Fluid Administration Systems: A Comprehensive Scoping Review. J Pers Med 2022; 12:jpm12071168. [PMID: 35887665 PMCID: PMC9315597 DOI: 10.3390/jpm12071168] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/14/2022] [Accepted: 07/15/2022] [Indexed: 02/07/2023] Open
Abstract
Physiological Closed-Loop Controlled systems continue to take a growing part in clinical practice, offering possibilities of providing more accurate, goal-directed care while reducing clinicians’ cognitive and task load. These systems also provide a standardized approach for the clinical management of the patient, leading to a reduction in care variability across multiple dimensions. For fluid management and administration, the advantages of closed-loop technology are clear, especially in conditions that require precise care to improve outcomes, such as peri-operative care, trauma, and acute burn care. Controller design varies from simplistic to complex designs, based on detailed physiological models and adaptive properties that account for inter-patient and intra-patient variability; their maturity level ranges from theoretical models tested in silico to commercially available, FDA-approved products. This comprehensive scoping review was conducted in order to assess the current technological landscape of this field, describe the systems currently available or under development, and suggest further advancements that may unfold in the coming years. Ten distinct systems were identified and discussed.
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