Burn State of the Science: Fluid Resuscitation. J Burn Care Res. 2017;38:e596-e604. [PMID: 28328669 DOI: 10.1097/bcr.0000000000000541]

Impact of a newly implemented burn protocol at Tri-Service General Hospital: Outcome analysis of 20-year experience

PURPOSE

To share our 20-year experience in major burn management and the impact of a newly implemented burn protocol since 2015 at Tri-Service General Hospital (TSGH).

MATERIALS AND METHODS

We performed a retrospective cohort study of severely burned patients who were admitted to the intensive care unit (ICU) at TSGH from January 2003 to September 2023. Data regarding demographics, complications, and mortality were collected and analyzed. We compared the patient data before (pre-implementation) and after 2015 (post-implementation), when the new major burn management protocol was introduced.

RESULTS

No statistically significant differences were observed in the mean total body surface area of the burns between the groups. The post-implementation group had younger age (34.62 vs 45.06, P < 0.001) and lower rate of inhalation injury (60.8 % vs 82.5 %, P = 0.005). No statistically significant difference was observed in the ICU stays between the groups. The post-implementation group had a statistically significant lower all-cause mortality (8.1 % vs 47.6 %, P < 0.0001) and lower rate of renal replacement therapy (RRT) (20.3 % vs 42.9 %, P = 0.004) but earlier initiation of RRT.

CONCLUSION

The new TSGH Burns Protocol revolutionized the care of major burns by introducing tailored, multidisciplinary burn management and improved patient outcomes.

Ethnicity does not change burn resuscitation and time to first excision

Health and racial disparities can limit access to preventative, trauma, and chronic disease care but have not been addressed in burn resuscitation. Over- and under-resuscitation contribute to increased overall hospital costs, and morbidity and mortality rates. The primary objective of this study was to identify potential racial disparities that may exist during the initial fluid resuscitation after burn injury. This was a retrospective review of all burn patients > 14 years of age admitted between January 1, 2020 and December 31, 2022 to a county safety net hospital. Patients were excluded if they transitioned to comfort care within 24 hours of admission. Data collected included baseline demographics, relevant burn injury information, and laboratory parameters. Outcomes included hospital and ICU length of stay, duration of mechanical ventilation, payor status, and mortality. Patients were divided into white (59 %) vs. African American-Hispanic (AA-HIS) (41 %) and included 105 patients. The median age (IQR) was 44.5(30) for whites vs 34(36) for AA-HIS. There were no statistically significant differences in severity of burn injury, cause of burn injury, rates of inhalation injury, or ICU or hospital lengths of stay. In both groups 55 % of the patients required mechanical ventilation while 18 % required renal replacement therapy. Overall mortality was not higher in the AA-HIS group at 32.6 % vs 17.7 % (p = 0.081). There were no differences in amount of fluid administered, urine output, laboratory values during resuscitation, or patient outcomes between the groups. The use of protocols for burn resuscitation can be instrumental in protecting against racial and ethnic disparities.

Update burn surgery: overview of current multidisciplinary treatment concepts

The treatment of severe burn injuries is an essential part of plastic-reconstructive surgery. Severe burned patients are treated in burn centers, which have highly specialized technical and personnel equipment. In addition to clear recommendations for prehospital management, intensive care therapy is usually required for extensive burn wounds. Shock therapy in burns primarily involves balanced fluid resuscitation according to hemodynamic monitoring, vasopressor support, pain management, temperature regulation, oxygen therapy, and comprehensive supportive care to stabilize the patient's condition. Surgical treatment is still based on wound debridement and the gold standard of autologous split-thickness skin grafting. Besides skin transplantation, surgical management of burns may also involve the application of various topical therapies to promote wound healing, reduce pain, and prevent infection. These therapies may include antimicrobial dressings, skin substitutes, growth factors, or specialized wound care products. Once the acute treatment has been completed, multidisciplinary rehabilitation treatment takes place, which begins in the acute hospital and continues in the outpatient and inpatient rehabilitation areas. Surgical treatment of the secondary complications of burns and scars is also an important component of burn care. Comprehensive knowledge of the various components and players involved in the care of severely burned patients is, therefore, required in order to achieve the best possible outcome for the patient.

Research progress and considerations on oral rehydration therapy for the prevention and treatment of severe burn shock: A narrative review

Severe burns are a significant cause of life-threatening conditions in both peacetime and wartime. Shock is a critical complication during the early stages of burn injury, contributing substantially to mortality and long-term disability. Effective fluid resuscitation is crucial for preventing and treating shock, with prompt administration being vital. However, timely intravenous fluid resuscitation is often challenging, and errors in resuscitation significantly contribute to mortality. Therefore, exploring a more rapid and effective non-invasive method of fluid resuscitation is necessary. Oral rehydration therapy (ORT) has shown considerable potential in this regard. This paper reviews ORT's historical development and current research progress, discussing its application in early anti-shock treatment for burns. While ORT is generally safe, potential complications like diarrhoea, vomiting, and abdominal discomfort must be noted, particularly if the rehydration rate is too rapid or if gastrointestinal issues exist. Careful patient assessment and monitoring are essential during ORT administration. Based on a comprehensive review of relevant research, we present provisional guidelines for ORT in burn patients. These guidelines aim to inform clinical practice but should be applied cautiously due to limited clinical evidence. Implementation must be tailored to the patient's condition under healthcare supervision, with adjustments according to evolving circumstances: ① Initiation timing: Start as soon as possible, and the ideal start time is usually within 6 h after injury. ② Rate of application: Employing a fractional administration approach, wherein small quantities of approximately 150-250 millilitres are provided for each instance and the initial fluid rate of oral rehydration can be simplified to 100 mL/kg/24 h. ③ Composition combination: In addition to essential salts and glucose, the oral rehydration solution can incorporate various anti-inflammatory and cellular protection constituents.

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.

Routinely collected burn clinical data in Canada: Determining the knowledge gap

Unlike other developed countries that hold national burn registries to monitor burn injury and care, Canada relies on single-centre secondary datasets and administrative databases as surveillance mechanisms. The objective of this study was to determine the knowledge gap faced in Canada for not having a dedicated burn registry. A comprehensive scoping review was conducted to identify the burn literature that has arisen from secondary datasets in Canada. Literature of all study designs was included with the exception of case reports and cases series. Once data extraction was concluded, a thematic framework was constructed based on the information that arose from nations that hold national burn registries. Eighty-eight studies were included. Twelve studies arose from national datasets, and 18 from provincial databases, most of which were from Ontario and British Columbia. Only seven studies were conducted using a combination of Canadian units' single-centre datasets. The majority of included studies (58%) resulted from non-collaborative use of single-centre secondary datasets. Research efforts were predominantly conducted by burn units in Ontario, British Columbia, Manitoba and Alberta. A significant number of the included studies were outdated and several provinces/territories had no published burn data whatsoever. Efforts should be made towards the development of systems to surveil burn injury and care in Canada. This study supports the development of a nation-wide burn registry to bridge this knowledge gap.

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.

An Introduction to Burn Care: The Sequel

GENERAL PURPOSE

To review burn care, with an emphasis on burn-specific issues and treatment.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will:1. Select the appropriate treatment guidelines for patients who have burn injuries.2. Identify common complications of major burns.3. Choose the recommended pharmacologic approaches to burn care.

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.

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.

Military Burn Care and Burn Disasters

Mass-casualty incidents can occur because of natural disasters; industrial accidents; or intentional attacks against civilian, police, or in case of combat, military forces. Depending on scale and type of incident, burn casualties often with a variety of concomitant injuries can be anticipated. The treatment of life-threatening traumatic injuries should take precedent but the stabilization, triage, and follow-on care of these patients will require local, state, and often regional coordination and support.

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.

Adherence to Burn Resuscitation Guidelines Reduces Resuscitation Fluids and Mortality

In our province, regional recommendations for optimal fluid resuscitation were published in 2011 to improve the management of acute burn patients prior to transfer to a specialized burn center. The purpose of this study was to determine compliance with these provincial burn resuscitation guidelines and their subsequent impact on patient outcomes. A retrospective review of patients transferred to the provincial burn center after being initially managed at peripheral sites was performed from 2011 to 2019. Patients were included if their burn injury was greater than 20% TBSA and they were transferred within 24 hours postburn injury. Charts were reviewed for the amount of fluid patients received and resuscitation associated outcomes. A total of 72 patients met the inclusion criteria, 37 of which were treated in accordance with the 2011 guidelines. For patients that followed the 2011 provincial guidelines, they received on average 3.2 cc/kg/TBSA of fluid during the first 24 hours postburn injury. Significantly more fluids were given when guidelines were not followed with an average of 4.4 cc/kg/TBSA (P = .03). Mortality rates were found to be significantly lower during the primary admission with guidelines compliance (16.2% vs 2.7%, P = .04). No significant differences were found between the remaining evaluated complications including abdominal compartment syndrome (8.1% vs 2.7%) and need for escharotomy (35.2% vs 21.6%). The use of clinical practice guidelines decreased excess IV fluid administration in additional to decreasing mortality rates for patients initially assessed in peripheral low volume centers.

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.

The Potential of Arterial Pulse Wave Analysis in Burn Resuscitation: A Pilot In Vivo Study

While urinary output (UOP) remains the primary endpoint for titration of intravenous fluid resuscitation, it is an insufficient indicator of fluid responsiveness. Although advanced hemodynamic monitoring (including arterial pulse wave analysis (PWA)) is of recent interest, the validity of PWA-derived indices in burn resuscitation extremes has not been established. The goal of this paper is to test the hypothesis that PWA-derived cardiac output (CO) and stroke volume (SV) indices as well as pulse pressure variation (PPV) and systolic pressure variation (SPV) can play a complementary role to UOP in burn resuscitation. Swine were instrumented with a Swan-Ganz catheter for reference CO and underwent a 40% total body surface area burns with varying resuscitation paradigms, and were monitored for 24 hours in an ICU setting under mechanical ventilation. The longitudinal changes in PWA-derived indices were investigated, and resuscitation adequacy was compared as determined by UOP versus PWA indices. The results indicated that PWA-derived indices exhibited trends consistent with reference CO and SV measurements: CO and SV indices were proportional to reference CO and SV, respectively (CO: post-calibration limits of agreement (LoA)=+/-24.7 [ml/min/kg], SV: post-calibration LoA=+/-0.30 [ml/kg]) while PPV and SPV were inversely proportional to reference SV (PPV: post-calibration LoA=+/-0.32 [ml/kg], SPV: post-calibration LoA=+/-0.31 [ml/kg]). The results also indicated that PWA-derived indices exhibited notable discrepancies from UOP in determining adequate burn resuscitation. Hence, it was concluded that the PWA-derived indices may have complementary value to UOP in assessing and guiding burn resuscitation.

The Effect and Evaluation of the Third Military Medical University Fluid Resuscitation Formula

Background

The clinical efficacy of the third Military Medical University formula (TMMU formula) for fluid resuscitation stage was evaluated to improve the treatment level of adult patients with extensive burns during the shock stage.

Methods

Retrospective analysis of the data of 55 patients undergoing fluid resuscitation according to the TMMU formula within six hours after burn injury. The following indicators were collected: (1) demographic and injury information; (2) fluid resuscitation information; (3) efficiency information, including cardiovascular function, liver function, renal function, coagulation function evaluation indicators, blood concentration, and average urine output index.

Results

(1) In the first and second 24 hours after injury, the median fluid rehydration coefficient was 1.68 ml/kg·(%) TBSA and 1.15 ml/kg·(%) TBSA, the median ratio of crystal to colloid was 2.24 and 1.67, and the median urine output index was 0.75 ml/kg·h and 1.05 ml/kg·h, respectively. (2) The actual fluid volume during patient resuscitation is higher than the formula calculated volume, and this difference is more obvious in patients with burn area ≥80%. (3) In the second 24 hours, the value of the actual total fluid volume minus the formula total volume in the group with crystal to colloid ratio ≤2 was significantly lower than that in the ratio >2 group. (4) At 24 and 48 hours after injury, the cardiovascular function, liver function, renal function, and coagulation function were better than those before fluid resuscitation.

Conclusions

Early application of the TMMU formula for fluid resuscitation in adult patients with extensive burns is safe and effective, but the actual input volume often exceeds the volume calculated by the formula, especially in the second 24 hours after burn injury and in patients with larger burn areas. Increasing the colloid input volume can help reduce the total amount of fluid used for resuscitation.

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.

Developing a national trauma research action plan: Results from the Burn Research Gap Delphi Survey

BACKGROUND

The 2016 National Academies of Science, Engineering and Medicine call for a national integrated, military-civilian trauma action plan to achieve zero preventable deaths and disability after injury included a proposal to establish a National Trauma Research Action Plan to "strengthen trauma research and ensure that the resources available for this research are commensurate with the importance of injury and the potential for improvement in patient outcomes." The Department of Defense funded the Coalition for National Trauma Research to generate a comprehensive research agenda spanning the continuum of trauma/burn care from prehospital to rehabilitation. The Burn/Reconstructive Surgery group represents one focus area for this research agenda development.

METHODS

Experts in burn and reconstructive surgery research identified gaps in knowledge, generated research questions and prioritized questions using a consensus driven Delphi survey approach. Participants were identified using established Delphi recruitment guidelines to ensure heterogeneity and generalizability with military and civilian representatives. Literature reviews informed the panel. Panelists were encouraged to use a PICO format to generate research questions: Patient/Population; Intervention; Compare/Control; Outcome. Participants ranked the priority of each question on a nine-point Likert scale, which was categorized to represent low, medium, and high priority items. Consensus was defined based on ≥60% panelist agreement.

RESULTS

Subject matter experts generated 949 research questions in 29 Burn & 26 Reconstruction topics. Five hundred ninety-seven questions reached consensus. Of these, 338 (57%) were high-priority, 180 (30%), medium-priority, and 78 (13%) low-priority questions.

CONCLUSION

Many high-priority questions translate to complex wound management and outcomes. Panel recognition that significant gaps in knowledge exist in understanding functional outcomes after injury underscores the importance of long-term recovery metrics even when studying acute injury or interventions such as resuscitation or inhalation injury. Funding agencies and burn/reconstructive surgery researchers should consider these gaps when they prioritize future research.

LEVEL OF EVIDENCE

Expert consensus, Level IV.

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.

Collective Variational Inference for Personalized and Generative Physiological Modeling: A Case Study on Hemorrhage Resuscitation

OBJECTIVE

Individual physiological experiments typically provide useful but incomplete information about a studied physiological process. As a result, inferring the unknown parameters of a physiological model from experimental data is often challenging. The objective of this paper is to propose and illustrate the efficacy of a collective variational inference (C-VI) method, intended to reconcile low-information and heterogeneous data from a collection of experiments to produce robust personalized and generative physiological models.

METHODS

To derive the C-VI method, we utilize a probabilistic graphical model to impose structure on the available physiological data, and algorithmically characterize the graphical model using variational Bayesian inference techniques. To illustrate the efficacy of the C-VI method, we apply it to a case study on the mathematical modeling of hemorrhage resuscitation.

RESULTS

In the context of hemorrhage resuscitation modeling, the C-VI method could reconcile heterogeneous combinations of hematocrit, cardiac output, and blood pressure data across multiple experiments to obtain (i) robust personalized models along with associated measures of uncertainty and signal quality, and (ii) a generative model capable of reproducing the physiological behavior of the population.

CONCLUSION

The C-VI method facilitates the personalized and generative modeling of physiological processes in the presence of low-information and heterogeneous data.

SIGNIFICANCE

The resulting models provide a solid basis for the development and testing of interpretable physiological monitoring, decision-support, and closed-loop control algorithms.

Burn-Induced Coagulopathies: a Comprehensive Review

Burn-induced coagulopathy is not well understood, and consensus on diagnosis, prevention, and treatments are lacking. In this review, literature on burn-induced (and associated) coagulopathy is presented along with the current understanding of the effects of burn injury on the interactions among coagulation, fibrinolysis, and inflammation in the acute resuscitative phase and reconstructive phase of care. The role of conventional tests of coagulopathy and functional assays like thromboelastography or thromboelastometry will also be discussed. Finally, reported methods for the prevention and treatment of complications related to burn-induced coagulopathy will be reviewed.

The Effect of Burn Resuscitation Volumes on the Gut Microbiome in a Swine Model

INTRODUCTION

While recent reports underscore the significance of the gut microbiome (GM) in health and disease, its importance in burn outcomes remains unclear. Moreover, aggressive intravenous (IV) fluid resuscitation of patients may alter intestinal flora. Herein, we describe GM changes following a large burn in swine randomized to different volumes of IV Lactated Ringers' (LR).

METHODS

Anesthetized Yorkshire swine sustained 40% total body surface area full-thickness burns and were randomized to different volumes of IV LR: none (n = 5), 15 mL/kg/d (low; n = 6), or 80 mL/kg/d (high; n = 6). At baseline and days 1 and 2, fecal swabs were collected for 16s rDNA sequencing. Proximal jejunum was collected immediately after euthanasia (day 2) for western blot, histopathology, and cytokine analyses.

RESULTS

Burns produced significant shifts in β-diversity and non-significant reductions in α-diversity that did not recover regardless of treatment group. Burn-induced increases in Proteobacteria and decreases in Firmicutes were attenuated by IV fluids in a dose-dependent manner, and also correlated with α-diversity. IV fluids caused a dose-dependent increase in Bacteroides and prevented a transient increase in the opportunistic pathogen Haemophilus parainfluenzae. While high volumes of IV fluids increased intestinal Hsp70 levels (P = 0.0464), they reduced SGLT1 (P = 0.0213) and caspase3 (P = 0.0139) levels. IV fluids elicited a non-specific cytokine response; however, Bacteroidetes levels correlated with intestinal IL18 levels (P = 0.0166, R = 0.4201).

CONCLUSIONS

We present the first report on the gut microbiome in a porcine burn model, and present data to suggest that IV fluids may influence GM and gut functional proteins following a burn. Overall, burn-induced GM diversity shifts may expose diagnostic and/or therapeutic targets to improve outcomes.

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.

Витамин С при критических состояниях: от эксперимента к клинике (часть 2)

Витамин С (аскорбиновая кислота) играет важную физиологическую роль в многочисленных метаболических функциях. Он также является кофактором в синтезе важных веществ, в частности катехоламинов и вазопрессина. Снижение уровня аскорбиновой кислоты отмечено при различных заболеваниях и часто сопровождает тяжелое состояние больного. Целью этой статьи является обзор современных представлений о применении высоких доз витамина С при критических состояниях у хирургических больных. Для поиска литературных источников использовалась база Medline на платформе Pubmed по ключевым словам: витамин С, сепсис, шок, травма, ожоги.

Terms, Definitions, Nomenclature, and Routes of Fluid Administration

Fluid therapy is administered to veterinary patients in order to improve hemodynamics, replace deficits, and maintain hydration. The gradual expansion of medical knowledge and research in this field has led to a proliferation of terms related to fluid products, fluid delivery and body fluid distribution. Consistency in the use of terminology enables precise and effective communication in clinical and research settings. This article provides an alphabetical glossary of important terms and common definitions in the human and veterinary literature. It also summarizes the common routes of fluid administration in small and large animal species.

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.

The Pre-Hospital Initial Fluid Therapy Estimate in Early Nasty Burns (PHIFTEEN B, 15-B) Guideline applied to a retrospective cohort of Intensive Care Unit patients with major burns

BACKGROUND

Appropriate fluid administration in severe burns is a cornerstone of early burns management. The American Burns Association's (ABA) recommendation is to administer 2 mL-4 mL × burnt Body Surface Area (BSA) × weight in the first 24 h with half administered in the first eight hours. Unfortunately, the calculations involved are complex and clinicians do not estimate the BSA or weight well, which can lead to errors in the amount of fluid administered. To simplify cognitive load to calculate the fluid resuscitation of early burns, the investigators derived the PHIFTEEN B (15-B) guideline. The 15-B guideline estimates the initial hourly fluid for adults ≥ 50 kg to be: 15 mL × BSA (to the nearest 10%) AIMS: To model and determine the accuracy of the 15-B calculated based on the characteristics of a retrospective cohort of patients admitted with ≥ 20% BSA to the Royal Brisbane and Women's Hospital (RBWH) Intensive Care Unit (ICU).

METHODS

The 15-B formula was retrospectively calculated on the prehospital BSA estimate on patients admitted to the RBWH ICU. In addition, the 15-B guideline was modelled against a variety of weights and BSAs. The fluid volume was deemed to be clinically significant if it was greater than 250 mL/h outside the ABA's recommendations.

RESULTS

The ICU cohort consisted of 107 patients (63.2% male, median age 37 years), with a median ICU estimated BSA of 40% and a median ICU weight estimation of 80 kg. In 43.9% of the cohort, the magnitude of the proportional difference between prehospital and ICU BSA estimate was greater than 25%. The 15-B formula accurately estimated the hourly fluid for all BSA (20%-100%) and weight combinations (50 kg-140 kg) in a BSA- weight matrix. When prehospital BSA estimate was utilized, 15-B guideline accurately estimated the fluid to be given within clinically significant limits for 97.2% of cases.

CONCLUSIONS

The 15-B formula is a simple, easy to calculate guideline which approximates the early fluid estimates in severely burned patients despite inaccuracy in prehospital BSA estimates.

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.

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.

Prehospital management of burns requiring specialized burn centre evaluation: a single physician-based emergency medical service experience

BACKGROUND

Emergency medical services regularly encounter severe burns. As standards of care are relatively well-established regarding their hospital management, prehospital care is comparatively poorly defined. The aim of this study was to describe burned patients taken care of by our physician-staffed emergency medical service (PEMS).

METHODS

All patients directly transported by our PEMS to our burn centre between January 2008 and December 2017 were retrospectively enrolled. We specifically addressed three "burn-related" variables: prehospital and hospital burn size estimations, type and volume of infusion and pain assessment and management. We divided patients into two groups for comparison: TBSA < 20% and ≥ 20%. We a priori defined clinically acceptable limits of agreement in the small and large burn group to be ±5% and ± 10%, respectively.

RESULTS

We included 86 patients whose median age was 26 years (IQR 12-51). The median prehospital TBSA was 10% (IQR 6-25). The difference between the prehospital and hospital TBSA estimations was outside the limits of agreement at 6.2%. The limits of agreement found in the small and large burn groups were - 5.3, 4.4 and - 10.1, 11, respectively. Crystalloid infusion was reported at a median volume of 0.8 ml/kg/TBSA (IQR 0.3-1.4) during the prehospital phase, which extrapolated over the first 8 h would equal to a median volume of 10.5 ml/kg/TBSA. The median verbal numeric rating scale on scene was 6 (IQR 3-8) and 3 (IQR 2-5) at the hospital (p < 0.001). Systemic analgesia was provided to 61 (71%) patients, predominantly with fentanyl (n = 59; 69%), followed by ketamine (n = 7; 8.1%). The median doses of fentanyl and ketamine were 1.7 mcg/kg (IQR 1-2.6) and 2.1 mg/kg (IQR 0.3-3.2), respectively.

CONCLUSIONS

We found good agreement in burn size estimations. The quantity of crystalloid infused was higher than the recommended amount, suggesting a potential risk for fluid overload. Most patients benefited from a correct systemic analgesia. These results emphasized the need for dedicated guidelines and decision support aids for the prehospital management of burned patients.

Self-inflicted Burn Injury Is Independently Associated With Increased Mortality in a More Economically Developed Country: A Propensity Score Matching Analysis

Self-inflicted burn accounts for considerable morbidity and mortality in more economically developed countries, and there is a substantial debate regarding the pathophysiological relevance between self-inflicted burns and unfavorable outcomes. To validate whether self-inflicted injury is an independent predictor of high mortality regardless of the severity of burn, they conducted a retrospective observational study using the Japan Trauma Data Bank, a nationwide database including over 200 major tertiary care centers. Among 2006 patients with burn who had arrived at collaborating centers between 2004 and 2016, they included patients aged ≥15 years, those who did not present with cardiopulmonary arrest upon arrival, and those who had ≥10 percent total body surface area burns. Patients with missing survival data or unknown mechanism of injury were excluded. In total, 1094 patients were eligible, of whom 222 (20.3 percent) had self-inflicted burns. The patients were divided into the self-inflicted and non-self-inflicted groups, and propensity score was calculated using the demographic information of the patients, injury variables, time from injury to hospital arrival, and other survival predictors. Via a propensity score matching, 98 pairs were selected, and the self-inflicted group had a higher mortality than the non-self-inflicted group (43.9 vs 28.6 percent, hazard ratio = 1.77; 95% confidence interval = 1.10-2.86; P = .02). Inverse probability weighting and multivariate logistic regression were performed as sensitivity analyses, and results validated that self-inflicted burn was independently associated with increased in-hospital mortality. Therefore, patients with self-inflicted burns should receive judicious management, regardless of burn injury severity.

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.

Two known therapies could be useful as adjuvant therapy in critical patients infected by COVID-19

Pneumonia caused by coronavirus, which originated in Wuhan, China, in late 2019, has been spread around the world already becoming a pandemic. Unfortunately, there is not yet a specific vaccine or effective antiviral drug for treating COVID-19. Many of these patients deteriorate rapidly and require intubation and are mechanically ventilated, which is causing the collapse of the health system in many countries due to lack of ventilators and intensive care beds.

In this document we review two simple adjuvant therapies to administer, without side effects, and low cost that could be useful for the treatment of acute severe coronavirus infection associated with acute respiratory syndrome (SARS-CoV-2). Vitamin C, a potent antioxidant, has emerged as a relevant therapy due to its potential benefits when administered intravenous. The potential effect of vitamin C in reducing inflammation in the lungs could play a key role in lung injury caused by coronavirus infection. Another potential effective therapy is ozone: it has been extensively studied and used for many years and its effectiveness has been demonstrated so far in multiples studies. Nevertheless, our goal is not to make an exhaustive review of these therapies but spread the beneficial effects themselves.

Obviously clinical trials are necessaries, but due to the potential benefit of these two therapies we highly recommended to add to the therapeutic arsenal.

Two known therapies could be useful as adjuvant therapy in critical patients infected by COVID-19

Pneumonia caused by coronavirus, which originated in Wuhan, China, in late 2019, has been spread around the world already becoming a pandemic. Unfortunately, there is not yet a specific vaccine or effective antiviral drug for treating COVID-19. Many of these patients deteriorate rapidly and require intubation and are mechanically ventilated, which is causing the collapse of the health system in many countries due to lack of ventilators and intensive care beds. In this document we review two simple adjuvant therapies to administer, without side effects, and low cost that could be useful for the treatment of acute severe coronavirus infection associated with acute respiratory syndrome (SARS-CoV-2). VitaminC, a potent antioxidant, has emerged as a relevant therapy due to its potential benefits when administered intravenous. The potential effect of vitaminC in reducing inflammation in the lungs could play a key role in lung injury caused by coronavirus infection. Another potential effective therapy is ozone: it has been extensively studied and used for many years and its effectiveness has been demonstrated so far in multiples studies. Nevertheless, our goal is not to make an exhaustive review of these therapies but spread the beneficial effects themselves. Obviously clinical trials are necessaries, but due to the potential benefit of these two therapies we highly recommended to add to the therapeutic arsenal.

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.

Effect of high-dose vitamin C therapy on severe burn patients: a nationwide cohort study

BACKGROUND

Vitamin C is a well-documented antioxidant that reduces oxidative stress and fluid infusion in high doses; however, the association between high-dose vitamin C and reduced mortality remains unclear. This study evaluates the effect of high-dose vitamin C in severe burn patients under two varying thresholds.

METHODS

We enrolled adult patients with severe burns (burn index ≥ 15) who were registered in the Japanese Diagnosis Procedure Combination national inpatient database from 2010 to 2016. Propensity score matching was performed between patients who received high-dose vitamin C within 1 day of admission (vitamin C group) and those who did not (control group). High-dose vitamin C was defined as a dosage in excess of 10 g or 24 g within 2 days of admission. The primary outcome was in-hospital mortality.

RESULTS

Eligible patients (n = 2713) were categorized into the vitamin C group (n = 157) or control group (n = 2556). After 1:4 propensity score matching, we compared 157 and 628 patients who were administered high-dose vitamin C (> 10-g threshold) and controls, respectively. Under this particular threshold, high-dose vitamin C therapy was associated with reduced in-hospital mortality (risk ratio, 0.79; 95% confidence interval, 0.66-0.95; p = 0.006). In contrast, in-hospital mortality did not differ between the control and high-dose vitamin C group under the > 24-g threshold (risk ratio, 0.83; 95% confidence interval, 0.68-1.02; p = 0.068).

CONCLUSIONS

High-dose vitamin C therapy was associated with reduced mortality in patients with severe burns when used under a minimum threshold of 10 g within the first 2 days of admission. While "high-dose" vitamin C therapy lacks a universal definition, the present study reveals that different "high-dose" regimens may yield improved outcomes.

A Critical Update of the Assessment and Acute Management of Patients with Severe Burns

Significance: Burns are debilitating, life threatening, and difficult to assess and manage. Recent advances in assessment and management have occurred since a comprehensive review of the care of patients with severe burns was last published, which may influence research and clinical practice. Recent Advances: Recent advances have occurred in the understanding of burn pathophysiology, which has led to the identification of potential biomarkers of burn severity, such as protein C. There is new evidence about the potential superiority of natural colloids over crystalloids during fluid resuscitation, and new evidence about components of initial and perioperative management, including an improved understanding of pain following burns. Critical Issues: The limitations of the clinical examination highlight the need for imaging and biomarkers to assist in estimations of burn severity. Fluid resuscitation reduces mortality, although there is conjecture over the ideal method. The subsequent perioperative period is associated with significant morbidity and the evidence for preventing and treating pain, infection, and fluid overload while maximizing wound healing potential is described. Future Directions: Promising developments are ongoing in imaging technology, histopathology, biomarkers, and wound healing adjuncts such as hyperbaric oxygen therapy, topical negative pressure therapy, stem cell treatments, and skin substitutes. The greatest benefit from further research on management of patients with burns would most likely be derived from the elucidation of optimal fluid resuscitation protocols, pain management protocols, and surgical techniques from randomized controlled trials.

Burn-induced reductions in mitochondrial abundance and efficiency are more pronounced with small volumes of colloids in swine

Severe burn injury results in systemic disruption of metabolic regulations and impaired cardiac function. Restoration of hemodynamic homeostasis utilizing intravenous (IV) fluids is critical for acute care of the burn victim. However, the effects of burns and resuscitation on cardiomyocyte mitochondria are currently unknown. The purpose of this study is to determine cardiac mitochondrial function in a swine burn model with subsequent resuscitation using either crystalloids or colloids. Anesthetized Yorkshire swine (n = 23) sustained 40% total body surface area burns and received IV crystalloids (n = 11) or colloids (n = 12) after recovery from anesthesia. Non-burned swine served as controls (n = 9). After euthanasia at 48 h, heart tissues were harvested, permeabilized, and analyzed by high-resolution respirometry. Citrate synthase (CS) activity was measured, and Western blots were performed to quantify proteins associated with mitochondrial fusion (OPA1), fission (FIS1), and mitophagy (PINK1). There were no differences in state 2 respiration or maximal oxidative phosphorylation. Coupled complex 1 respiration decreased, while uncoupled state 4_O and complex II increased significantly due to burn injury, particularly in animals receiving colloids (P < 0.05). CS activity and electron transfer coupling efficiency were significantly lower in burned animals, particularly with colloid treatment (P < 0.05). Protein analysis revealed increased FIS1 but no differences in mitophagy in cardiac tissue from colloid-treated compared with crystalloid-treated swine. Taken together, severe burns alter mitochondrial respiration in heart tissue, which may be exacerbated by early IV resuscitation with colloids. Early IV burn resuscitation with colloids may require close hemodynamic observation. Mitochondrial stabilizing agents incorporated into resuscitation fluids may help the hemodynamic response to burn injury.

Volume Resuscitation in Patients With High-Voltage Electrical Injuries

Volume resuscitation of patients with high-voltage electrical injuries (>1000 V) is a more complex challenge than standard burn resuscitation. High voltages penetrate deep tissues. These deep injuries are not accounted for in resuscitation formulae dependent on percentage of cutaneous burn. Myonecrosis occurring from direct electrical injury and secondary compartment syndromes can result in rhabdomyolysis, compromising renal function and urine output. Urine output is the primary end point, with a goal of 1 mL/kg/h for adult patients with high-voltage electrical injuries. As such, secondary resuscitation end points of laboratory values, such as lactate, base deficit, hemoglobin, and creatinine, as well as hemodynamic monitoring, such as mean arterial pressure and thermodilution techniques, can become crucial in guiding optimum administration of resuscitation fluids. Mannitol and bicarbonates are available but have limited support in the literature. High-voltage electrical injury patients often develop acute kidney injury requiring dialysis and have increased risks of chronic kidney disease and mortality. Continuous venovenous hemofiltration is a well-supported adjunct to clear the myoglobin load that hemodialysis cannot from circulation.

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.

Vitamin C in the critically ill - indications and controversies

Ascorbic acid (vitamin C) elicits pleiotropic effects in the body. Among its functions, it serves as a potent anti-oxidant, a co-factor in collagen and catecholamine synthesis, and a modulator of immune cell biology. Furthermore, an increasing body of evidence suggests that high-dose vitamin C administration improves hemodynamics, end-organ function, and may improve survival in critically ill patients. This article reviews studies that evaluate vitamin C in pre-clinical models and clinical trials with respect to its therapeutic potential.

Enteral resuscitation with oral rehydration solution to reduce acute kidney injury in burn victims: Evidence from a porcine model

Intravenous (IV) resuscitation of burn patients has greatly improved outcomes and become a cornerstone of modern burn care. However, the heavy fluids and vascular access required may not be feasible in austere environments, mass casualty, or delayed transport scenarios. Enteral resuscitation has been proposed for these situations; we sought to examine the effectiveness of this strategy on improving burn-induced kidney injury. Anesthetized Yorkshire swine sustaining 40% TBSA full-thickness contact burns were randomized to three groups (n = 6/group): fluid deprivation, ad libitum water access, or 70 mL/kg/d Oral Rehydration Salt solution (ORS). Urine and blood were collected at baseline (BL), 6, 12, 24, 32, and 48h post-burn, at which point tissue was harvested and CT angiography performed. Although fluid consumption by ad libitum and ORS groups were matched (132±54mL/kg versus 120±24mL/kg, respectively), ORS intake increased urine output compared with water and no water (47.3±9.0 mL/kg versus 16.1±2.5 mL/kg, and 24.5±1.7 mL/kg respectively). Plasma creatinine peaked 6h following burn (1.67±0.07mg/dL) in all animals, but at 48h was comparable to BL in animals receiving water (1.23±0.06mg/dL) and ORS (1.30±0.09mg/dL), but not fluid deprived animals (1.56±0.05mg/dL) (P<0.05). Circulating levels of blood urea nitrogen steadily increased, but also decreased by 48h in animals receiving enteral fluids (P<0.05). Water deprivation reduced renal artery diameter (-1.4±0.17mm), whereas resuscitation with water (-0.44±0.14 mm) or ORS maintained it (-0.63±0.20 mm;P< 0.02). Circulating cytokines IL-1β, IL-6, IFNγ, and GM-CSF were moderately elevated in the fluid-deprived group. Taken together, the data suggest that enteral resuscitation with ORS rescues kidney function following burn injury. Incorporating enteral fluids may improve outcomes in resource-poor environments and possibly reduce IV fluid requirements to prevent co-morbidities associated with over-resuscitation. Studies into different volumes/types of enteral fluids are warranted. While ORS has saved many lives in cholera-associated dehydration, it should be investigated further for use in burn patients.

Inhalation Injury in the Burned Patient

Inhalation injury causes a heterogeneous cascade of insults that increase morbidity and mortality among the burn population. Despite major advancements in burn care for the past several decades, there remains a significant burden of disease attributable to inhalation injury. For this reason, effort has been devoted to finding new therapeutic approaches to improve outcomes for patients who sustain inhalation injuries.The three major injury classes are the following: supraglottic, subglottic, and systemic. Treatment options for these three subtypes differ based on the pathophysiologic changes that each one elicits.Currently, no consensus exists for diagnosis or grading of the injury, and there are large variations in treatment worldwide, ranging from observation and conservative management to advanced therapies with nebulization of different pharmacologic agents.The main pathophysiologic change after a subglottic inhalation injury is an increase in the bronchial blood flow. An induced mucosal hyperemia leads to edema, increases mucus secretion and plasma transudation into the airways, disables the mucociliary escalator, and inactivates hypoxic vasocontriction. Collectively, these insults potentiate airway obstruction with casts formed from epithelial debris, fibrin clots, and inspissated mucus, resulting in impaired ventilation. Prompt bronchoscopic diagnosis and multimodal treatment improve outcomes. Despite the lack of globally accepted standard treatments, data exist to support the use of bronchoscopy and suctioning to remove debris, nebulized heparin for fibrin casts, nebulized N-acetylcysteine for mucus casts, and bronchodilators.Systemic effects of inhalation injury occur both indirectly from hypoxia or hypercapnia resulting from loss of pulmonary function and systemic effects of proinflammatory cytokines, as well as directly from metabolic poisons such as carbon monoxide and cyanide. Both present with nonspecific clinical symptoms including cardiovascular collapse. Carbon monoxide intoxication should be treated with oxygen and cyanide with hydroxocobalamin.Inhalation injury remains a great challenge for clinicians and an area of opportunity for scientists. Management of this concomitant injury lags behind other aspects of burn care. More clinical research is required to improve the outcome of inhalation injury.The goal of this review is to comprehensively summarize the diagnoses, treatment options, and current research.

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.