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

Endothelial dysfunction is dampened by early administration of fresh frozen plasma in a rodent burn shock model

BACKGROUND

Endothelial dysfunction has been implicated in the pathogenesis of burn shock affecting patients with large thermal injury. In response to injury, glycocalyx components like Syndecan-1 (SDC-1) are shed into circulation and have been used as markers of endothelial damage. Previous work in our laboratory has shown that plasma inclusive resuscitation (PIR) with fresh frozen plasma (FFP) ameliorates endothelial damage. However, there remains a paucity of information regarding optimal timing and dosing of PIR as well as organ-specific endothelial responses to shock. We aimed to examine the impact of PIR on endothelial dysfunction using clinically translatable timing and dosing.

METHODS

Sprague-Dawley rats were used to create thermal burns. Rats were subjected to 40% total body surface area scald burns and were resuscitated with lactated Ringer's (LR) only, LR plus albumin, and LR plus early 1 mL boluses of FFP at 0, 2, 4, and 8 hours postinjury. A late group also received LR plus FFP starting at hour 10 postinjury. Syndecan-1 levels were quantified by enzyme-linked immunosorbent assay, and quantitative real-time polymerase chain reaction analysis characterized transcription of glycocalyx components and inflammatory cytokines in the lung and spleen. Evan's blue dye was used to quantify amount of vascular leakage.

RESULTS

Lactated Ringer's plus early FFP reduced Evan's blue dye extravasation when compared with LR only groups, while late FFP did not. When comparing LR only versus LR plus early FFP, SDC-1 levels were reduced in the LR plus early FFP group at hours 8, 12, and 24 (5.23 vs. 2.07, p < 0.001; 4.49 vs. 2.05, p < 0.01; and 3.82 vs. 2.08, p < 0.05, respectively). Lactated Ringer's only groups had upregulation of Exostosin-1 and SDC-1 in the lung compared with LR plus early FFP groups ( p < 0.01 and p < 0.05) and upregulation of cytokines interluekin-10 and interferon γ ( p < 0.001 and p < 0.001).

CONCLUSION

Early administration of LR plus FFP reduces the magnitude of SDC-1 shedding and dampens the cytokine response to injury. The upregulation of glycocalyx components as a response to endothelial injury is also decreased in the lung and spleen by LR plus early FFP administration.

Lower Admission Prealbumin and Albumin Levels in Unhoused Burn Patients Is a Marker for Poorer Outcomes

Unhoused (UH) individuals experience burn injuries at a higher rate than domiciled individuals, and have poorer outcomes following injuries. One such mechanism proposed for worsened outcomes is secondary to poor nutrition. Access to proper nutrition and food insecurity are major barriers. Malnutrition has been shown to decrease wound tensile strength, increase infection rates, and prolong healing. The purpose of this study was to understand if albumin and prealbumin could help determine outcomes in UH patients and identify at-risk patients earlier in their hospital course. A retrospective chart review was conducted of UH patients from 2015 through 2023 at a large urban safety net hospital. Data collected included admission laboratory values including albumin and prealbumin. Outcomes studied included length of stay (LOS), Intensive Care Unit (ICU) days, ventilator days, and mortality. Data analysis for the effect of albumin and prealbumin included a zero-truncated negative binomial model for LOS, a negative binomial hurdle model for ICU LOS and ventilator days, and logistic regression for mortality. Three hundred and eighty-five patients met inclusion criteria and of these, 366 had albumin and 361 had prealbumin information. Adjusting for age, gender, and total body surface area, the fewest days in the hospital and lowest odds of admission to the ICU occurred for those with admission albumin values of approximately 3.4-3.5 g/dL. Each unit (g/dL) decrease in albumin was associated with 3.19 times the odds of death (95% CI: 1.42, 7.69). Each unit (mg/dL) decrease in prealbumin was associated with 1.19 times the odds of death (95% CI: 1.06, 1.35). Decreased admission albumin and prealbumin levels are associated with worse burn outcomes in UH patients. These nutritional biomarkers may aid in determining which UH patients are suffering from food insecurity at injury onset. Obtaining these values on admission may help burn providers target nutritional goals in their most vulnerable patients.

Current Thoughts on Burn Resuscitation

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.

A Meta-Analysis of the Mortality and the Prevalence of Burn Complications in Western Populations

Management of burn injuries is complex, with highly variable outcomes occurring among different populations. This meta-analysis aims to assess the outcomes of burn therapy in North American and European adults, specifically mortality and complications, to guide further therapeutic advances. A systematic review of PubMed, Web of Science, and Cochrane was performed. Random-effect meta-analysis of proportions was conducted to assess the overall prevalence of the defined outcomes. In total, 54 studies were included, pooling 60 269 adult patients. A total of 53 896 patients were in North America (NA, 89.4%), and 6373 were in Europe (10.6%). Both populations experienced similar outcomes. The overall pooled prevalence of mortality was 13% (95% CI, 8%-19%) for moderate burns, 20% (95% CI, 12%-29%) for severe burns in the NA region, and 22% (95% CI, 16%-28%) for severe burns in Europe. Infectious complications were the most common across both regions. European studies showed an infection rate for patients with moderate and severe burns at 8% and 76%, respectively, while NA studies had rates of 35% and 54%. Acute kidney injury (39% vs 37%) and shock (29% vs 35%) were the next most common complications in European and NA studies, respectively. The length of stay was 27.52 days for patients with severe burns in Europe and 31.02 days for patients with severe burns in NA. Burn outcomes are similar between Western populations. While outcomes are reasonably good overall, infectious complications remain high. These findings encourage the development of further therapeutic strategies disclosing respective costs to enable cost/efficiency evaluations in burn management.

Effect of fluid resuscitation with albumin on mortality in patients with severe burns: A nationwide inpatient data analysis

The present study aimed to evaluate the effect of albumin administration on mortality in patients with severe burns. We retrospectively analyzed data from the Diagnosis Procedure Combination Database, a nationwide inpatient database in Japan. We identified patients in the database aged ≥ 15 years who were admitted with severe burns (burn index ≥15) from April 2014 to March 2021. We included patients who received albumin within 2 days of admission in the albumin group and those who did not in the control group. The outcome was the 28-day mortality. Eligible patients (n = 2492) were categorized into an albumin group (n = 1128) or a control group (n = 1364). One-to-one propensity score matching generated 530 pairs of patients with and without albumin administration. The 28-day mortality did not differ significantly between the two groups (albumin vs. control, 21.7 % vs. 22.8 %; risk difference, -1.1 %; 95 % confidence interval, -6.1 % to +3.9 %). These results suggest that albumin administration within 2 days of admission in patients with severe burns may not be associated with mortality during the acute phase.

Use of Intravenous Albumin: A Guideline From the International Collaboration for Transfusion Medicine Guidelines

BACKGROUND

Albumin is used commonly across a wide range of clinical settings to improve hemodynamics, to facilitate fluid removal, and to manage complications of cirrhosis. The International Collaboration for Transfusion Medicine Guidelines developed guidelines for the use of albumin in patients requiring critical care, undergoing cardiovascular surgery, undergoing kidney replacement therapy, or experiencing complications of cirrhosis.

STUDY DESIGN AND METHODS

Cochairs oversaw the guideline development process and the panel included researchers, clinicians, methodologists, and a patient representative. The evidence informing this guideline arises from a systematic review of randomized clinical trials and systematic reviews, in which multiple databases were searched (inception through November 23, 2022). The panel reviewed the data and formulated the guideline recommendations using Grading of Recommendations Assessment, Development, and Evaluation methodology. The guidelines were revised after public consultation.

RESULTS

The panel made 14 recommendations on albumin use in adult critical care (three recommendations), pediatric critical care (one recommendation), neonatal critical care (two recommendations), cardiovascular surgery (two recommendations), kidney replacement therapy (one recommendation), and complications of cirrhosis (five recommendations). Of the 14 recommendations, two recommendations had moderate certainty of evidence, five recommendations had low certainty of evidence, and seven recommendations had very low certainty of evidence. Two of the 14 recommendations suggested conditional use of albumin for patients with cirrhosis undergoing large-volume paracentesis or with spontaneous bacterial peritonitis. Twelve of 14 recommendations did not suggest albumin use in a wide variety of clinical situations where albumin commonly is transfused.

INTERPRETATION

Currently, few evidence-based indications support the routine use of albumin in clinical practice to improve patient outcomes. These guidelines provide clinicians with actionable recommendations on the use of albumin.

American Burn Association Clinical Practice Guidelines on Burn Shock Resuscitation

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.

The combined risk predictive power of frailty and hypoalbuminemia in free tissue flap reconstruction: A cohort study of 34,571 patients from the NSQIP database

INTRODUCTION

Significant morbidity and mortality are hallmarks of the functional decline seen in physically frail patients. The modified frailty index 5 (mFI-5) represents a risk predictor score that has been validated as a comorbidity-based scale in surgery. Serum albumin levels of <3.5 g/dL (hypoalbuminemia) have also been implicated with poor postoperative outcomes. However, the association between these two parameters remains to be investigated. We aimed to elucidate the interdependence of preoperative albumin levels and frailty, as evaluated by the mFI-5 score, and its reliability to prognosticate postoperative results in free flap reconstruction (FFR).

METHODS

We conducted a multicenter, retrospective cohort study and accessed the ACS National Surgical Quality Improvement Program (ACS-NSQIP) from 2008 to 2021. We identified all adult patients (≥18 years of age) who underwent a FFR. We extracted perioperative data and lab values including albumin. Multivariable linear and logistic regression analyses were performed to identify independent risk predictors. Main outcomes involved mortality, length of hospital stay, reoperation, medical and surgical complications, and discharge destination within the 30-day postoperative period.

RESULTS

A total of 34,571 patients were included in the study, with an average age of 53.9 years (standard deviation [SD] 12.2) and an average body mass index (BMI) of 28.8 (SD 6.1). Of these patients, 7484 were male (21.6%), whereas 22,363 (64.7%) had no frailty (mFI = 0). Additionally, 9466 patients had a frailty score of 1 (27.4%), 2505 had a score of 2 (7.2%), 226 had a score of 3 (0.7%), and 11 had a score of 4 or higher (0.0%). Albumin levels were available for 16,250 patients (47.0%), and among them, 1334 (8.2%) had hypoalbuminemia. Regression analyses showed that higher mFI scores were independent predictors of any, surgical, and medical complications, as well as increased rates of reoperations, unplanned readmissions, and prolonged hospital stays. Hypoalbuminemia independently predicted any, surgical, and medical complications, and higher mortality, reoperation, and longer hospital stay. When both frailty and albumin levels (mFI-5 and albumin) were considered together, this combined assessment was found to be a more accurate predictor of all major outcomes (any, medical and surgical complications, mortality, and reoperation). Further, our analysis identified a weak negative correlation between serum albumin levels and mFI scores (Spearman R: -.1; p < .0001).

CONCLUSION

In conclusion, this cohort study highlights the association of hypoalbuminemia with adverse postoperative outcomes, including those not directly related to frailty. Simultaneously, higher mFI scores independently predicted outcomes not associated with hypoalbuminemia. Stemming from these findings, we recommend considering both serum albumin levels and frailty in patients receiving FFR. This perioperative algorithm may help provide more individualized planning including multidisciplinary care and pre and posthabilitation.

Fluid Resuscitation and Cardiovascular Support in Acute Burn Care

Acute burn injury creates a complex and multifactorial local response which may have systemic sequelae such as hypovolemia, hypothermia, cardiovascular collapse, hypercoagulability, and multi-system organ failure. Understanding the underlying pathophysiology of burn shock, the initial burn triage and assessment, calculation of fluid requirements, and the means of tailoring ongoing interventions to optimize resuscitation are critical for overcoming the wide spectrum of derangements which this condition creates. As a result, this article discusses the various key points in order to garner a greater understanding of these nuances and the optimal pathway to take when tackling these challenging issues.

A Retrospective Cohort Study of Burn Casualties Transported by the US Army Burn Flight Team and US Air Force Critical Care Air Transport Teams

INTRODUCTION

The US Army Burn Center, the only burn center in the Department of Defense provides comprehensive burn care. The Burn Flight Team (BFT) provides specialized burn care during transcontinental evacuation. During Operations Iraqi and Enduring Freedom, burn injuries accounted for approximately 5% of all injuries in military personnel. To augment BFT capacity, US Air Force Critical Care Air Transport Teams (CCATTs) mobilized to transport burn patients. The purpose of this study was to describe critically ill, burn injured patients transported to the US Army Burn Center by BFT or CCATT, to compare and contrast characteristics, evacuation procedures, in-flight treatments, patient injuries/illnesses, and outcomes between the two groups.

MATERIALS AND METHODS

We conducted a retrospective cohort study of CCATT and BFT patients, admitted to the burn ICU between January 1, 2001 and September 30, 2018. Patients with total body surface area burned (TBSA) >30% were evacuated by BFT, while CCATT evacuated patients with ≤ 30% TBSA.

RESULTS

Ninety-seven patients met inclusion criteria for this study. Of these, 40 (41%) were transported by the BFT and 57 (59%) were transported by CCATTs. Compared with patients transported by CCATTs, patients transferred by the BFT had higher median TBSA and full-thickness burn size, higher prevalence of chest, back and groin burns, and higher prevalence of inhalation injury. BFT patients had increased hospital days (62 vs. 37; P = .08), ICU days (29 vs. 12; P = .003) and ventilator days (14 vs. 6; P  < .001). TBSA was the only variable significantly associated with ARDS (aOR = 1.04; 95% CI: 1.01, 1.08; P = 0.04), renal failure (aOR = 1.07; 95% CI: 1.03, 1.11; P = .002), and mortality (aOR = 1.08; 95% CI: 1.03, 1.13; P = .001).

CONCLUSIONS

Evacuation by the BFT was associated with increased ICU and ventilator days, increased mortality, and a greater risk for developing renal failure. The severity of injury/TBSA likely accounted for most of these differences.

Effect of Hydroxyethyl starch (HES) versus 5% albumin solution on intra-abdominal pressure in severe burn patients: A prospective randomized clinical trial

INTRODUCTION

Massive burn patients are at risk of developing intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) as a complication of resuscitation.

OBJECTIVE

This study aimed to evaluate the effect of Hydroxyethyl starch (HES) versus 5% albumin solution on intra-abdominal pressure (IAP) in massive burn patients.

METHODS

This was a prospective randomized clinical trial carried on at Ain Shams University (ASU) burn unit for 2 years. Where adult patients with burns more than 20% of TBSA were equally randomized into HES group or albumin group.

RESULTS

Fifty-two patients were equally randomized into 2 groups. We found no difference in age, sex, weight, type of burn, and TBSA between the two groups. The mean total resuscitation fluid volume in the first 48 h was 213 ml/kg and 206.2 ml/kg for the HES group and the albumin group respectively (p = 0.674). IAP statistically was non-significantly higher in the HES group. We found no statistical difference between the two groups as regards the renal function tests.

CONCLUSION

Both HES and 5% albumin solution are effective and safe colloids for burn resuscitation. As regards the IAP, it seems that both 5% albumin and HES have comparable effect regarding IAH in severely burn patients. Both HES and 5% albumin were partially equal in terms of renal involvement and vital data stability.

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 surgery]

Burn injuries represent a special type of injury that requires special expertise. Both in adequate wound treatment and in intensive medical care, there are various special features that must be considered and due to which treatment by experienced medical personnel is necessary. In the clinical, but also in the preclinical course, the most important points in the treatment of the burn injury should be known to be able to guarantee adequate treatment. In this context, in addition to the knowledge of the different degrees of burns, the estimation of the burned body surface area (VKOF) is essential. Intensive medical treatment as well as surgical therapy of deep burn wounds should then be performed in a burn center. The article provides an overview of the classifications of burn injuries, the management of wound care, the various therapeutic options, both conservative and surgical, and the special features of burn disease.

Implications of the Regulation of Endothelial Glycocalyx Breakdown and Reconstitution in Severe Burn Injury

INTRODUCTION

Effective initial fluid resuscitation is the cornerstone intervention in the setting of severe burn injury. Critically, few major advances in burn resuscitation have been made since the 1970s, and since that time there has been only modest improvement in overall morbidity and mortality. Recently, investigations regarding the dynamic changes of vascular endothelium, and more specifically the vascular endothelial glycocalyx, in the setting of severe burn injury and resuscitation have offered insight into the possibility of more tightly controlling fluid shifts and understanding the consequences thereof during this critical period.

METHODS

We conducted a literature search of the PubMed database using the terms "burn", and "glycocalyx" limited to studies published in the English language over the past 10 y. A total of 31 articles were initially identified. Abstracts and full text were manually reviewed to identify suitable articles. Of the identified articles, 10 were deemed relevant and included within this review, along with additional articles necessary to provide background on glycocalyx structure and function as well as principles of burn injury management.

RESULTS

Glycocalyx shedding is a process known to occur early in the setting of severe burn injury and resuscitation. The degree of shedding tends to increase with age and severity of injury. Though the role and regulation of this shedding is incompletely understood, it has direct consequences on vascular unction and permeability and likely coagulation as well.

CONCLUSIONS

Here in this research review, we examine what is known regarding the dynamic breakdown and reconstitution of the glycocalyx during burn injury and how it may be impacted by fluid resuscitation strategies. We further explore the need to more completely understand this mechanism and the consequences of its manipulation.

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.

Medical and Surgical Care of Critical Burn Patients: A Comprehensive Review of Current Evidence and Practice

Critically ill burn patients pose several unique challenges to care providers. The concepts of fluid resuscitation, nutritional management, organ support and wound care are rapidly evolving. There is a pressing need to review emerging evidence and incorporate these into practice for the effective management of burn patients. We have searched the PubMed and Google Scholar databases to review the current evidence on the acute care management of adult as well as paediatric burn patients. The rationales for current practices have been integrated into the review. The management of critically ill burn patients requires an in-depth knowledge of the pathophysiology of burn injury, a tailored approach for timely resuscitation, timely diagnosis of organ specific problems, and comprehensive wound care. This review will help the doctors and healthcare providers involved in the management of critical burn patients in their day-to-day practice.

Choosing wisely in burn care

BACKGROUND

The Choosing Wisely Campaign was launched in 2012 and has been applied to a broad spectrum of disciplines in almost thirty countries, with the objective of reducing unnecessary or potentially harmful investigations and procedures, thus limiting costs and improving outcomes. In Canada, patients with burn injuries are usually initially assessed by primary care and emergency providers, while plastic or general surgeons provide ongoing management. We sought to develop a series of Choosing Wisely statements for burn care to guide these practitioners and inform suitable, cost-effective investigations and treatment choices.

METHODS

The Choosing Wisely Canada list for Burns was developed by members of the Canadian Special Interest Group of the American Burn Association. Eleven recommendations were generated from an initial list of 29 statements using a modified Delphi process and SurveyMonkey™.

RESULTS

Recommendations included statements on avoidance of prophylactic antibiotics, restriction of blood products, use of adjunctive analgesic medications, monitoring and titration of opioid analgesics, and minimizing 'routine' bloodwork, microbiology or radiological investigations.

CONCLUSIONS

The Choosing Wisely recommendations aim to encourage greater discussion between those involved in burn care, other health care professionals, and their patients, with a view to reduce the cost and adverse effects associated with unnecessary therapeutic and diagnostic procedures, while still maintaining high standards of evidence-based burn care.

Evaluating the role of clinical pharmacist in the detection and reduction of medication errors in a specialized burn unit

OBJECTIVE

This study evaluated the frequency and types of medication errors and the role of clinical pharmacist in the reduction of medication errors in a burn unit.

METHODS

The clinical pharmacist monitored medication use process in all patients admitted to the burn unit in the 4-month interventional study. Direct observation and chart review methods were used to detect medication errors. Medication errors were classified according to the classification of American Society of Health-system Pharmacists. The seriousness of medication errors was categorized based on the National Coordinating Council for Medication Error Reporting and Prevention index.

RESULTS

During the study, 1653 drugs were prescribed to 94 patients. Totally, 259 medication errors were identified. The rates of medication errors were 2.75 errors/patient, 0.16 errors/ordered medication, and 0.98 errors/prescription. The most common type of errors was prescribing error (61.8%) followed by dispensing error (14.7%). Regarding the seriousness of medication errors, 1.9%, 21.6%, 45.9%, 30.1%, and 0.4% of errors were in the categories B, C, D, E, and F, respectively. Antibiotics had the highest rate of errors. Of all detected medication errors, 64.5% were intercepted or corrected by the clinical pharmacist interventions.

CONCLUSION

Medication errors were not rare in the burn unit. Providing clinical pharmacy services to burn patients to reduce the incidence of medication errors is highly recommended.

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.

Different Depths May Not Determine the Fluid Resuscitation Volume in Early-stage Management of Severe Burns: a Model-Comparison Retrospective Analysis of Fluid Volume Determining Factors

BACKGROUND

Large-volume fluid resuscitation remains irreplaceable in the early-stage management of severe burns. We aimed to explore the relationship between fluid volume and other indicators.

METHOD

Data of severe burn patients with successful resuscitation in the early stage was collected. Correlation and linear regression analyses were performed. Multiple linear regression models, related goodness-of-fit assessment (adjusted R-square and Akaike Information Criterion), scatter plots and paired t-test for two models, and a likelihood ratio test were performed.

RESULTS

96 patients were included. The median of total burn area (TBA) was 70%TBSA, with full thickness burn area (FTBA)/TBA of 0.4, a resuscitation volume of 1.93 mL/kg/%TBSA. Among volume-correlated indicators, two linear regression models were established (Model 1: TBA × weight and tracheotomy; and Model 2: FTBA × weight, partial thickness burn area (PTBA) × weight, and tracheotomy). For these models, close values of Akaike Information Criterion, adjusted R-squares, outliers of the prediction range, and the result of paired t-test, all suggest similarity between two models estimations, while the likelihood ratio test for coefficients of FTBA × weight and PTBA × weight showed a statistical difference.

CONCLUSION

inhalational injury and decompression surgery only correlated with volume, while Tracheotomy, TBA × weight, FTBA × weight, and PTBA × weight correlated with and were accepted in linear models of volume. Although FTBA and PTBA differed statistically, there may be no need to distinguish them when estimating the resuscitation volume requirements in this patient set. Further study about different depths fluid should be conducted.

[Use of albumin : State of the art]

The Saline versus Albumin Fluid Evaluation (SAFE) study has demonstrated that the use of albumin as an infusion solution in volume therapy can be regarded as safe. An exception is hypo-oncotic albumin in traumatic brain injury. While clear indications of albumin exist for some patients with liver cirrhosis, large studies that demonstrate a clinically relevant advantage beyond hemodynamic effects and would therefore justify wider use in many other areas are still lacking. In large-volume paracentesis, spontaneous bacterial peritonitis, but also in hepatorenal syndrome, use of albumin is recommended and established due to clinical benefit in randomized controlled trials. In septic shock, use of albumin may be considered, with two large studies addressing this issue in Germany and Italy being still in the recruitment phase. For volume therapy, albumin can be used primarily when other measures for hemodynamic stabilization have been exhausted. This applies to volume resuscitation in hypovolemia as well as in conservative fluid management in the so-called "de-resuscitation" phase. The extent to which the correction of severe hypoalbuminemia with exogenous albumin can improve the impaired outcome of these patients is also part of ongoing studies. On the way to a more individualized medicine, hypoalbuminemia may serve as a parameter in future decision making for or against the use of albumin in volume therapy.

Variation in definitions of burn wound infection limits the validity of systematic review findings in burn care: A systematic review of systematic reviews

INTRODUCTION

Systematic reviews (SR) of high-quality randomised controlled trials can identify effective treatments for burn wound infections (BWIs). Clinical heterogeneity in outcome definitions can prevent valid evidence synthesis, which may limit the reliability of the findings of SRs affected by this heterogeneity. This SR aimed to investigate whether there is variation BWI definitions across studies in SRs of burn care interventions and its impact on identification of effective treatments for patients with burn injuries.

METHODS

A systematic search of five databases was conducted. Included SRs were: in English, published from January 2010 to October 2018, assessed intervention effects for patients with a burn injury, and reported data about BWI.

RESULTS

Twenty-nine SRs, which included 248 studies reporting BWI outcomes, were included in our final dataset. Three SRs used a definition of BWI to select studies for inclusion. Fourteen reported BWI definitions from included studies in the review results. There was heterogeneity of BWI definition in their included studies; across 29 SRs, 32 different BWI indicators were used, with the median across SRs ranging from 1 to 7 (range 1-14). Fourteen SRs accounted for BWI definition heterogeneity in their conclusions, indicating that the issue impacted whether a conclusion could be drawn, and limited the validity of the SR findings.

CONCLUSIONS

There is variation in BWI definition across SRs and within the studies included in SRs of interventions assessing BWI outcomes. This heterogeneity has prevented conclusions about intervention effects being drawn, and only half of the SR authors have accounted for it in their findings. Reviews that have collated this data without reference to the heterogeneity should be viewed with caution, since it may limit the validity of evidence for the identification of effective treatments for BWI. The use of a newly developed core indicator set to support consistent reporting of indicators and standardisation of BWI outcome reporting will enable effective evidence synthesis.

Effect of the infusion ration between frozen plasma and plasma substitutes on the prognosis of adult patients with major burn in shock stage

OBJECTIVES

In recent years, it has been reported that the anti-shock effect of plasma substitutes in adult patients with major burn in shock stage is not good. However, due to the shortage of clinical frozen plasma supply, it is impossible to guarantee that frozen plasma is used as colloidal solution for anti-shock treatment. The purpose of this study is to explore the effect of the infusion ration between frozen plasma and plasma substitutes on the prognosis of adult patients with major burn in shock stage.

METHODS

This study enrolled 586 adult patients with major burn by selecting the hospitalization burn patients, who had been hospitalized at the Jiangxi province burn center from September 2014 to April 2019. The patients with the infusion ratio of frozen plasma to plasma substitutes ≥2꞉1 at 48 hours after admission were included in the experimental group, otherwise they were included in the control group. The basic clinical data and clinical prognosis indicator in the 2 groups were compared. Logistic univariate regression analysis was used to screen the influential factors of 30-day mortality in adult patients with major burn, and logistic multivariate regression analysis was used to obtain independent risk and protective factors; Kaplan-Meier method was used to draw the survival curve of the 2 groups, and log-rank test was used to compare the 30-day survival rate of the 2 groups.

RESULTS

There were significant differences in the infusion volume of frozen plasma and plasma substitutes between the 2 groups at 48 hours after admission (both P<0.05). The duration of mechanical ventilation in the experimental group was shorter than that in the control group, the percentage of continuous renal replacement therapy (CRRT) in the experimental group was lower than that in the control group, and the in-hospital mortality and 30-day mortality in the experimental group were lower than those in the control group, the differences were statistically significant (all P<0.05). The percentage of burn area and total body surface area (TBSA) was an independent risk factor for 30-day mortality of adult patients with major burn (OR=1.228, 95% CI 1.010 to 1.439, P=0.039), while the infusion ration between of frozen plasma and plasma substitutes 48 hours after admission was an independent protective factor (OR=0.016, 95% CI 0.001 to 0.960, P=0.023). The 30-day survival rate of the experimental group was significantly higher than that in the control group (P<0.001).

CONCLUSIONS

Infusion ration between frozen plasma to plasma substitutes at 48 hours after admission is an independent protective factor for 30-day mortality of adult patients with major burn. In the early stage of adult patients with major burn, frozen plasma should be used as the anti-shock therapy as far as possible (frozen plasma꞉plasma substitute ≥2꞉1) to improve the prognosis and reduce the of 30-day mortality.

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.

[Standards in medical treatment of burns]

Thermal injuries occur in every age group and are caused by flames, fluids, steam and direct contact. They are often trivialized but should actually be treated immediately to reduce secondary complications, such as infections and hypertrophic scars. Besides the pain, large wound areas are given priority. Surgical treatment is necessary if at least second degree (IIb) deep dermal burns are present. In this case the reconstructive surgeon has various techniques in the therapeutic armamentarium. Furthermore, in cases of severe burns a perioperative intensive care monitoring and treatment are obligatory as massive systemic inflammatory response syndrome (SIRS), shock, sepsis, organ failure, fluid resuscitation and complications, such as delirium and exacerbation of pain have been proven to negatively influence the outcome.

High Versus Low Volume Fluid Resuscitation Strategies in a Porcine Model (Sus scrofa) of Combined Thermal and Traumatic Brain Injury

BACKGROUND

Combined burn and traumatic brain injury (TBI) treatment priorities may not align due to opposing fluid resuscitation paradigms used in treating burns and TBI. We developed a porcine model of combined thermal injury/TBI and compared an "aggressive" fluid resuscitation strategy using the Parkland formula and a "restrictive" resuscitation strategy using the modified Brooke formula.

METHODS

Twenty-eight swine were deeply anesthetized and received a 40% total body surface area full-thickness burn injury and TBI. Swine were then randomized to receive restrictive or aggressive resuscitation for 8 h after which time animals were euthanized and necropsy was performed. Volume of brain injury was assessed after analyzing segmental slices of brain tissue.

RESULTS

There were no differences between the restrictive and aggressive resuscitation groups in blood pressure, heart rate, central venous pressure, intra-cranial pressure (ICP), or serum lactate levels after 8 h of resuscitation. Urine output was higher in the aggressive resuscitation group. The restrictive group had a significantly higher serum blood urea nitrogen (BUN) compared with baseline and compared with the aggressive group. There was no significant difference in size of brain injury between groups.

CONCLUSIONS

Both restrictive and aggressive resuscitation demonstrated adequate resuscitation at 8 h postinjury. Increased serum BUN in the restrictive group may be an indicator of early acute kidney injury, despite adequate urine output. Resuscitation strategy did not appear to affect ICP or the size of brain injury.

Nurses Can Resuscitate

Fluid resuscitation in the first 48 hours postburn is crucial in the management of burn shock. The primary purpose of this study was to evaluate nurses' adherence to a nurse-driven fluid resuscitation protocol at one adult burn center. Their secondary goal was to establish that the use of a nursing-driven protocol did not result in over resuscitation. Following implementation of a nurse-driven burn resuscitation protocol, a 48-hour data resuscitation data collection tool was developed by the burn physicians and nurses. All resuscitations were reviewed in real-time and in burn leadership meeting to identify opportunities for improvement. Follow-up with nursing staff was done in real time by the clinical nurse specialist following each burn resuscitation. Twenty-two patients requiring formal fluid resuscitation were included in the review. Patients had a median age of 36.5(IQR: 38.74) years and were predominantly male. They found that in the first 24 hours that patients received 3.47 ml/kg/hr and then in the next 24 hours they received an average of 2.68 ml/kg/hr. All 22 patients' resuscitation was initiated using the Parkland formula in the emergency department, and nurses were successful in consistently adjusting fluid infusions consistent with the protocol. Using a multidisciplinary approach and preparatory and real-time education processes, burn nurses can successfully guide burn resuscitation. Providing education and follow-up in real time can improve the process.

Challenges in anaesthesia and pain management for burn injuries

Burn-injured patients provide unique challenges to those providing anaesthesia and pain management. This review aims to update both the regular burn anaesthetist and the anaesthetist only occasionally involved with burn patients in emergency settings. It addresses some aspects of care that are perhaps contentious in terms of airway management, fluid resuscitation, transfusion practices and pharmacology. Recognition of pain management failures and the lack of mechanism-specific analgesics are discussed along with the opioid crisis as it relates to burns and nonpharmacological methods in the management of distressed patients.

Initial management of severe burn injury

PURPOSE OF REVIEW

Patients with severe burn injuries pose significant challenges for the intensivist. Though average burn sizes have decreased over time, severe burn injuries involving greater than 20% of the total body surface area still occur. Verified burn centers are limited, making the management of severely burn injured patients at nonspecialized ICUs likely. Current practices in burn care have increased survivability even from massive burns. It is important for intensivists to be aware of the unique complications and therapeutic options in burn critical care management. This review critically discusses current practices and recently published data regarding the evaluation and management of severe burn injury.

RECENT FINDINGS

Burn patients have long, complex ICU stays with accompanying multiorgan dysfunction. Recent advances in burn intensive care have focused on acute respiratory distress syndrome from inhalation injury, acute kidney injury (AKI), and transfusion, resulting in new strategies for organ failure, including renal replacement therapy and extracorporeal life support.

SUMMARY

Initial evaluation and treatment of acute severe burn injury remains an ongoing area of study. This manuscript reviews current practices and considerations in the acute management of the severely burn injured patient.

Management of severe thermal burns in the acute phase in adults and children

OBJECTIVES

To provide recommendations to facilitate the management of severe thermal burns during the acute phase in adults and children.

DESIGN

A committee of 20 experts was asked to produce recommendations in six fields of burn management, namely, (1) assessment, admission to specialised burns centres, and telemedicine; (2) haemodynamic management; (3) airway management and smoke inhalation; (4) anaesthesia and analgesia; (5) burn wound treatments; and (6) other treatments. At the start of the recommendation-formulation process, a formal conflict-of-interest policy was developed and enforced throughout the process. The entire process was conducted independently of any industry funding. The experts drew up a list of questions that were formulated according to the PICO model (Population, Intervention, Comparison, and Outcomes). Two bibliography experts per field analysed the literature published from January 2000 onwards using predefined keywords according to PRISMA recommendations. The quality of data from the selected literature was assessed using GRADE® methodology. Due to the current paucity of sufficiently powered studies regarding hard outcomes (i.e. mortality), the recommendations are based on expert opinion.

RESULTS

The SFAR guidelines panel generated 24 statements regarding the management of acute burn injuries in adults and children. After two scoring rounds and one amendment, strong agreement was reached for all recommendations.

CONCLUSION

Substantial agreement was reached among a large cohort of experts regarding numerous strong recommendations to optimise the management of acute burn injuries in adults and children.

Establishing a hospital transfusion management system promotes appropriate clinical use of human albumin in Japan: a nationwide retrospective study

BACKGROUND

Despite international recommendations to establish hospital transfusion management systems to promote appropriate use of blood products, the general efficacy of establishing such systems has not been proven. This study aimed to validate the effect of establishing such systems for promoting the appropriate use of human albumin.

METHODS

In this retrospective observational study, we used a Japanese Diagnosis Procedure Combination (DPC) database from fiscal year 2012 to 2016, which included inpatient records from approximately 1200 hospitals for payment processes in the national medical insurance system. From this existing database, containing approximately 8 million inpatient records per year, we selected patients with emergency due to "bleeding," "sepsis," and "burn injury," by using the International Classification of Diseases and Injuries 10th revision (ICD-10) codes, and hospitals that had one or more patients for each disease group in each fiscal year. We conducted multivariable logistic regression analysis to estimate the relationship between human albumin administration and the state of the hospital transfusion management system. We evaluated temporal trends of mortality rate and length of stay as an indicator of care quality.

RESULTS

Overall, 139,853 eligible patients admitted to 682 hospitals were selected. The results of the multivariable logistic regression analysis show that patients who were admitted to hospitals with an established hospital transfusion department introducing good practice criteria of blood products were less likely to be administered human albumin compared with those who were admitted to hospitals not introducing it, by approximately 30% for each of the three disease groups; adjusted odds ratios (95% confidential intervals) were 0.70 (0.59-0.83), 0.75 (0.69-0.81), and 0.71 (0.58-0.87) in the "bleeding," "sepsis," and "burn injury" groups, respectively. The temporal trends evaluation shows that there were no increasing trends of mortality rate and average length of stay against decreasing trends of human albumin administration in any disease groups.

CONCLUSIONS

Establishing a hospital transfusion department responsible for promoting appropriate clinical use of blood products could reduce human albumin administration for critically ill patients without loss of care quality. These findings provide support for policy makers and hospital managers to consider establishing such systems.

Resuscitation with albumin using BET formula keeps at bay fluid administration in burned patients. An observational study

BET (Biological Engineering Technology) formula uses fluids with high albumin concentration to resuscitate burn patients. It estimates fluid resuscitation as a function of Body Burned Surface Area (BBSA) (ml/h = BBSA (m²) × 220) and administers it through a combination of lactated ringer and 20% Albumin starting at a 1:1 relationship. The proportion of albumin is decreased every 8 h, and infusion rate is modified according to urinary output. The study's purpose was to review resuscitation related variables of all burned patients treated in our unit using BET formula. We retrospectively analyzed all patients admitted to our critical care burn unit during a five year period. Only those admitted within the first 12 h post-burn injury were considered. 40 patients met all inclusion criteria. Resuscitation volume during the first 24 h was 2.58 ml/kg/%BBSA, significantly less than Parkland's estimation (4 ml/kg/%BBSA; P < 0.05). Patients were successfully resuscitated showing a significant base excess increase and lactate clearance during the resuscitation period (base excess 120%; lactate 29%; P < 0.05). Burn related complications where: ARDS 27%, renal dysfunction 53%, wound deepening 20%, abdominal compartment syndrome 4.5%. In conclusion, BET formula is capable of resuscitating burn patients successfully, limiting fluid administration.

Early hypoalbuminemia is associated with 28-day mortality in severely burned patients: A retrospective cohort study

BACKGROUND

Hypoalbuminemia is a frequent condition in the first 24 h after a severe burn injury and is associated with worse outcomes.

METHODOLOGY

We investigated the relation between very early hypoalbuminemia (<6 h after admission) and clinical outcome in a retrospective cohort admitted to our unit for severe burn injuries between 2012 and 2017.

RESULTS

73 severely burned patients were included, with a delay of admission of 3 (2-4) h. In a context of early exogenous supply of albumin, admission and 4H Albuminemia (Alb4 h) were significantly lower in deceased patients (respectively, 34 (29-37) vs 27 (23-30) g/l; p = 0.009 and 27 (24-32) vs 21 (17-27) g/l; p = 0.022) whereas albuminemia ≥6 h were not. The best threshold value of Alb4 h to discriminate 28-day mortality was 23 g/l. Patients with an Alb4 h < 23 g/l had a higher 28-day mortality than patients with an Alb4 h ≥ 23 g/l (42% vs 11%; p = 0.003); adjusted OR = 4.47 (95% CI 1.15-17.36); p = 0.03.

CONCLUSION

In severely burned patients receiving early albumin supply, early hypoalbuminemia is associated with higher mortality whereas later albuminemia (≥6 h) is not. Exploration of whether early albumin infusion (8-12 h post injury) may alter clinical outcome is warranted.

Perioperative in Intensive Medicine of reconstructive surgery and burned patients

Burned patients may need prolonged admissions in the Intensive Care Service, both for initial care and for the pre and postoperative treatment of the multiple surgeries they require. The initial resuscitation of critically burned patients requires adequate monitoring to calculate the fluid therapy necessary to replenish the losses and ensure tissue perfusion, but without excesses that increase interstitial edema. In addition, monitoring can evaluate the systemic inflammatory response that can lead to shock and organic dysfunctions. After this initial phase we will find a critical patient who requires multiple reinterventions in non-optimal situations, so he will need special care over a long period of time. In addition, the Intensive Care Service offers specific postoperative care for reconstructive surgery and the transplantation of composite tissues (upper limb and face) in which its success depends on a rigorous control through adequate monitoring and treatment.

Barriers and facilitators to adopting high value practices and de-adopting low value practices in Canadian intensive care units: a multimethod study

OBJECTIVE

To compare and contrast illustrative examples of the adoption of high value practices and the de-adoption of low value practices.

DESIGN

(1) Retrospective, population-based audit of low molecular weight heparin (LMWH) for venous thromboembolism (VTE) prophylaxis (high value practice) and albumin for fluid resuscitation (low value practice) and (2) cross-sectional survey of healthcare providers.

SETTING

Data were collected from nine adult medical-surgical intensive care units (ICUs) in two large Canadian cities. Patients are managed in these ICUs by a group of multiprofessional and multidisciplinary healthcare providers.

PARTICIPANTS

Participants included 6946 ICU admissions and 309 healthcare providers from the same ICUs.

MAIN OUTCOME MEASURES

(1) The use of LMWH for VTE prophylaxis (per cent ICU days) and albumin for fluid resuscitation (per cent of patients); and (2) provider knowledge of evidence underpinning these practices, and barriers and facilitators to adopt and de-adopt these practices.

RESULTS

LMWH was administered on 38.7% of ICU days, and 20.0% of patients received albumin.Most participants had knowledge of evidence underpinning VTE prophylaxis and fluid resuscitation (59.1% and 84.2%, respectively). Providers perceived these practices to be followed. The most commonly reported barrier to adoption was insufficient knowledge/understanding (32.8%), and to de-adoption was clinical leader preferences (33.2%). On-site education was the most commonly identified facilitator for adoption and de-adoption (67.8% and 68.6%, respectively).

CONCLUSIONS

Despite knowledge of and self-reported adherence to best practices, the audit demonstrated opportunity to improve. Provider-reported barriers and facilitators to adoption and de-adoption are broadly similar.

Predictors of Early Onset Multiple Organ Dysfunction in Major Burn Patients with Ventilator Support: Experience from A Mass Casualty Explosion

Organ dysfunction is common in patients with major burns and associated with poor outcomes. The risk factors for early onset multiple organ dysfunction syndrome (MODS) in major burn patients with invasive ventilator support has rarely been evaluated before. In this study, major burn patients with invasive ventilator support from 499 victims suffered in a mass casualty color dust explosion were retrospectively enrolled. The development of early MODS that occurred within 5 days after burn injury was determined and the risk factors associated with early MODS were analyzed. A total of 88 patients from five medical centers were included. Their mean total body surface area (TBSA) was 60.9 ± 15.8%, and 45 (51.1%) patients had early MODS. Hematologic failure was the most common organ failure (68.6%), followed by respiratory failure (48.9%). Independent clinical factors associated with early MODS included TBSA ≥55% (OR: 3.83; 95% CI: 1.29-11.37) and serum albumin level <2.1 g/dL upon admission (OR: 3.43; 95% CI: 1.01-11.57). Patients with early MODS had prolonged ventilator dependence and longer ICU admission than those without early MODS. Our results showed that early MODS in major burn patients with invasive ventilator support is very common and can be predicted early on admission.

Systematic Reviews in Burns Care: Poor Quality and Getting Worse

The objective of this article is to investigate adherence to reporting standards and methodological quality in systematic reviews on burns care published in peer-reviewed journals to determine their utility for guiding evidence-based burns care. PubMed, Embase, Database of Abstracts of Reviews of Effects, Cochrane Database of Systematic Reviews, and the Joanna Briggs Institute (JBI) Database of Systematic Reviews and Implementation Reports were searched from 2009. Any systematic review on any question on therapeutic interventions in burns care was eligible for inclusion. Critical appraisal and data extraction were performed using the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) tool and the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist by two independent reviewers. The overall quality of the 44 included burns care systematic reviews was low, with an average methodological quality of 55% and an average compliance with reporting guidelines of 70%. Correlation analysis showed that adherence to reporting guidelines has been relatively stable, but methodological quality has deteriorated (r = -.32, P < .05). Cochrane reviews had lower citation rates than reviews published in other journals, whereas reviews that included meta-analyses had more citations. Quality did not have a significant effect on citation rate. Health professionals working in burns should be able to expect that systematic reviews published in their field are of a high standard. Unfortunately, this is not the case. To address this problem, established guidelines on the conduct and reporting of systematic reviews should be adhered to by researchers and editors.

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.

Poor methodological quality and reporting standards of systematic reviews in burn care management

The methodological and reporting quality of burn-specific systematic reviews has not been established. The aim of this study was to evaluate the methodological quality of systematic reviews in burn care management. Computerised searches were performed in Ovid MEDLINE, Ovid EMBASE and The Cochrane Library through to February 2016 for systematic reviews relevant to burn care using medical subject and free-text terms such as 'burn', 'systematic review' or 'meta-analysis'. Additional studies were identified by hand-searching five discipline-specific journals. Two authors independently screened papers, extracted and evaluated methodological quality using the 11-item A Measurement Tool to Assess Systematic Reviews (AMSTAR) tool and reporting quality using the 27-item Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Characteristics of systematic reviews associated with methodological and reporting quality were identified. Descriptive statistics and linear regression identified features associated with improved methodological quality. A total of 60 systematic reviews met the inclusion criteria. Six of the 11 AMSTAR items reporting on 'a priori' design, duplicate study selection, grey literature, included/excluded studies, publication bias and conflict of interest were reported in less than 50% of the systematic reviews. Of the 27 items listed for PRISMA, 13 items reporting on introduction, methods, results and the discussion were addressed in less than 50% of systematic reviews. Multivariable analyses showed that systematic reviews associated with higher methodological or reporting quality incorporated a meta-analysis (AMSTAR regression coefficient 2.1; 95% CI: 1.1, 3.1; PRISMA regression coefficient 6·3; 95% CI: 3·8, 8·7) were published in the Cochrane library (AMSTAR regression coefficient 2·9; 95% CI: 1·6, 4·2; PRISMA regression coefficient 6·1; 95% CI: 3·1, 9·2) and included a randomised control trial (AMSTAR regression coefficient 1·4; 95%CI: 0·4, 2·4; PRISMA regression coefficient 3·4; 95% CI: 0·9, 5·8). The methodological and reporting quality of systematic reviews in burn care requires further improvement with stricter adherence by authors to the PRISMA checklist and AMSTAR tool.

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.

Acute Fluid Management of Large Burns: Pathophysiology, Monitoring, and Resuscitation

This article reviews the pathophysiology of large burn injury and the extreme fluid shifts that occur in the hours and days after this event. The authors focus on acute fluid management, monitoring of hemodynamic status, and end points of resuscitation. Understanding the need and causes for fluid resuscitation after burn injury helps the clinician develop an effective plan to balance the competing goals of normalized tissue perfusion and limited tissue edema. Thoughtful, individualized treatment is the best answer and the most effective compromise.

Patient Safety in Burn Care: Application of Evidence-based Medicine to Improve Outcomes

This article reviews 5 areas in burn care that increasingly use evidence-based medicine to optimize quality and safety: resuscitation protocols, transfusion practices, vascular access, venous thromboembolic prophylaxis, and rational use of antibiotics.