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Greenhalgh DG. Current Thoughts on Burn Resuscitation. Adv Surg 2024; 58:1-17. [PMID: 39089770 DOI: 10.1016/j.yasu.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
The optimal treatment of burn shock is still unresolved. The problem of "fluid creep" continues despite modern devices that fail to improve outcomes over hourly urine output. Colloids, especially albumin, reduce fluid requirements. Albumin can be used either immediately at the start of resuscitation, or as a "rescue" when crystalloid use is excessive. Several studies confirm that when crystalloid resuscitation is "out of control" the majority of caregivers will add albumin to reduce fluid rates. A multi-center trial is underway comparing crystalloids with albumin to confirm the benefit of colloids. The next question is whether albumin or plasma is as the better colloid choice.
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Affiliation(s)
- David G Greenhalgh
- Burn Department, Shriners Children's Northern California, 2425 Stockton Boulevard, Sacramento, CA 95817, USA; Emeritus, Department of Surgery, University of California, Davis, CA, USA.
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2
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Cartotto R, Johnson LS, Savetamal A, Greenhalgh D, Kubasiak JC, Pham TN, Rizzo JA, Sen S, Main E. American Burn Association Clinical Practice Guidelines on Burn Shock Resuscitation. J Burn Care Res 2024; 45:565-589. [PMID: 38051821 DOI: 10.1093/jbcr/irad125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
This Clinical Practice Guideline (CPG) addresses the topic of acute fluid resuscitation during the first 48 hours following a burn injury for adults with burns ≥20% of the total body surface area (%TBSA). The listed authors formed an investigation panel and developed clinically relevant PICO (Population, Intervention, Comparator, Outcome) questions. A systematic literature search returned 5978 titles related to this topic and after 3 levels of screening, 24 studies met criteria to address the PICO questions and were critically reviewed. We recommend that clinicians consider the use of human albumin solution, especially in patients with larger burns, to lower resuscitation volumes and improve urine output. We recommend initiating resuscitation based on providing 2 mL/kg/% TBSA burn in order to reduce resuscitation fluid volumes. We recommend selective monitoring of intra-abdominal and intraocular pressure during burn shock resuscitation. We make a weak recommendation for clinicians to consider the use of computer decision support software to guide fluid titration and lower resuscitation fluid volumes. We do not recommend the use of transpulmonary thermodilution-derived variables to guide burn shock resuscitation. We are unable to make any recommendations on the use of high-dose vitamin C (ascorbic acid), fresh frozen plasma (FFP), early continuous renal replacement therapy, or vasopressors as adjuncts during acute burn shock resuscitation. Mortality is an important outcome in burn shock resuscitation, but it was not formally included as a PICO outcome because the available scientific literature is missing studies of sufficient population size and quality to allow us to confidently make recommendations related to the outcome of survival at this time.
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Affiliation(s)
- Robert Cartotto
- Department of Surgery, Ross Tilley Burn Centre, Sunnybrook Heath Sciences Centre, University of Toronto, Canada
| | - Laura S Johnson
- Department of Surgery, Walter L. Ingram Burn Center, Grady Memorial Hospital, Emory University, Atlanta, GAUSA
| | - Alisa Savetamal
- Department of Surgery, Connecticut Burn Center, Bridgeport Hospital, Bridgeport, CT, USA
| | - David Greenhalgh
- Shriners Hospital for Children, Northern California, Sacramento, CA, USA
| | - John C Kubasiak
- Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Tam N Pham
- Department of Surgery, University of Washington Regional Burn Center, Harborview Medical Center, Seattle, WA, USA
| | - Julie A Rizzo
- Department of Trauma, Brooke Army Medical Center, Fort Sam Houston, San Antonio, TX, USA
- Uniformed Services University of Health Sciences, Bethesda, MD, USA
| | - Soman Sen
- Department of Surgery, Division of Burn Surgery, University of California, Davis, CA, USA
| | - Emilia Main
- Sunnybrook Health Sciences Centre, Toronto, Canada
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Caffarelli C, Santamaria F, Piro E, Basilicata S, D'Antonio L, Tchana B, Bernasconi S, Corsello G. Advances for pediatricians in 2022: allergy, anesthesiology, cardiology, dermatology, endocrinology, gastroenterology, genetics, global health, infectious diseases, metabolism, neonatology, neurology, oncology, pulmonology. Ital J Pediatr 2023; 49:115. [PMID: 37679850 PMCID: PMC10485969 DOI: 10.1186/s13052-023-01522-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 08/30/2023] [Indexed: 09/09/2023] Open
Abstract
The last year saw intensive efforts to advance knowledge in pediatric medicine. This review highlights important publications that have been issued in the Italian Journal of Pediatrics in 2022. We have chosen papers in the fields of allergy, anesthesiology, cardiology, dermatology, endocrinology, gastroenterology, genetics, global health, infectious diseases, metabolism, neonatology, neurology, oncology, pulmonology. Novel valuable developments in epidemiology, pathophysiology, prevention, diagnosis and treatment that can rapidly change the approach to diseases in childhood have been included and discussed.
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Affiliation(s)
- Carlo Caffarelli
- Clinica Pediatrica, Department of Medicine and Surgery, Azienda Ospedaliera- Universitaria, University of Parma, Parma, Italy.
| | - Francesca Santamaria
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Ettore Piro
- Department of Sciences for Health Promotion and Mother and Child Care "G. D'Alessandro", University of Palermo, Palermo, Italy
| | - Simona Basilicata
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Lorenzo D'Antonio
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Bertrand Tchana
- Cardiologia Pediatrica, Azienda-Ospedaliero Universitaria, Parma, Italy
| | | | - Giovanni Corsello
- Department of Sciences for Health Promotion and Mother and Child Care "G. D'Alessandro", University of Palermo, Palermo, Italy
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Barrios EL, Polcz VE, Moldawer LL, Rincon JC, Efron PA, Larson SD. VARIABLES INFLUENCING THE DIFFERENTIAL HOST RESPONSE TO BURNS IN PEDIATRIC AND ADULT PATIENTS. Shock 2023; 59:145-154. [PMID: 36730790 PMCID: PMC9957807 DOI: 10.1097/shk.0000000000002042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
ABSTRACT Burn injury is a significant source of morbidity and mortality in the pediatric population. Although 40,000 pediatric patients in the United States are admitted to the hospital with burn wounds annually, significant differences exist in the management and treatment of these patients, even among highly specialized burn centers. Some aspects of pediatric burn research, such as metabolic changes and nutritional support after burn injury, have been studied extensively; however, in many aspects of burn care, pediatric research lags behind the study of adult populations. This review compares and contrasts a wide array of physiologic and immune responses between children and adults after burn injury. Such a review elucidates where robust research has been conducted, where adult research is applicable to pediatric patients, and where additional pediatric burn research needs to be conducted.
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Affiliation(s)
- Evan L Barrios
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
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Cao A, Bellfi LT, Schoen J, Greiffenstein P, Marr AB, Stuke L, Hunt JP, Pino R, Smith A. Perioperative Fluid Management in Surgical Patients: A Review. Am Surg 2022:31348221121565. [PMID: 35977846 DOI: 10.1177/00031348221121565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Intravenous (IV) fluids are one of the most widely prescribed medications. Despite their frequent usage, IV fluids are often not used appropriately. High-quality evidence to guide the surgeon in the perioperative period is sparse. A plethora of choices for IV fluids exists with limited evidence to help guide the surgeon in specific patient populations and situations. To address this, the authors have set out to provide a critical review of commonly used IV fluids to treat surgical patients. Gaps in the existing literature for the surgical population will also be discussed as potential target areas for future research.
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Affiliation(s)
- Alex Cao
- 12258Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA, USA
| | | | - Jonathan Schoen
- 12258Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA, USA
| | - Patrick Greiffenstein
- 12258Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA, USA
| | - Alan B Marr
- 12258Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA, USA
| | - Lance Stuke
- 12258Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA, USA
| | - John P Hunt
- 12258Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA, USA
| | - Richard Pino
- 12258Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA, USA
| | - Alison Smith
- 12258Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA, USA
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Taylor A, Foster NW, Ricca RL, Choi PM. Pediatric Surgical Care During Humanitarian and Disaster Relief Missions. CURRENT TRAUMA REPORTS 2022. [DOI: 10.1007/s40719-022-00237-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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7
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Cartotto R, Burmeister DM, Kubasiak JC. Burn Shock and Resuscitation: Review and State of the Science. J Burn Care Res 2022; 43:irac025. [PMID: 35218662 DOI: 10.1093/jbcr/irac025] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- Robert Cartotto
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and University of Toronto, Canada
| | - David M Burmeister
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland and United States Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas USA
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Sasaki J, Matsushima A, Ikeda H, Inoue Y, Katahira J, Kishibe M, Kimura C, Sato Y, Takuma K, Tanaka K, Hayashi M, Matsumura H, Yasuda H, Yoshimura Y, Aoki H, Ishizaki Y, Isono N, Ueda T, Umezawa K, Osuka A, Ogura T, Kaita Y, Kawai K, Kawamoto K, Kimura M, Kubo T, Kurihara T, Kurokawa M, Kobayashi S, Saitoh D, Shichinohe R, Shibusawa T, Suzuki Y, Soejima K, Hashimoto I, Fujiwara O, Matsuura H, Miida K, Miyazaki M, Murao N, Morikawa W, Yamada S. Japanese Society for Burn Injuries (JSBI) Clinical Practice Guidelines for Management of Burn Care (3rd Edition). Acute Med Surg 2022; 9:e739. [PMID: 35493773 PMCID: PMC9045063 DOI: 10.1002/ams2.739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/29/2022] [Accepted: 02/03/2022] [Indexed: 01/28/2023] Open
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10
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Overview of Albumin Physiology and its Role in Pediatric Diseases. Curr Gastroenterol Rep 2021; 23:11. [PMID: 34213692 DOI: 10.1007/s11894-021-00813-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2021] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW Albumin plays a critical role in a wide range of disease processes; however, the role of albumin in pediatric patients has not been well described. This article aims to review albumin physiology and kinetics in children, albumin's impact on pediatric diseases, and the utility of albumin as a predictor of clinical outcome. RECENT FINDINGS Hypoalbuminemia is seen in a wide range of conditions, including protein-losing enteropathy, hepatic synthetic failure, malnutrition, inflammatory states, and renal disease. While the impact of hypoalbuminemia has been more extensively studied in adult patients, there is a relative paucity of literature in the pediatric population. Hypoalbuminemia is a marker of poor outcome in critically ill children and those undergoing a wide range of medical interventions. Albumin infusions may be an effective therapy for fluid resuscitation and for patients with severe hypoalbuminemia.
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11
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Burmeister DM, Smith SL, Muthumalaiappan K, Hill DM, Moffatt LT, Carlson DL, Kubasiak JC, Chung KK, Wade CE, Cancio LC, Shupp JW. An Assessment of Research Priorities to Dampen the Pendulum Swing of Burn Resuscitation. J Burn Care Res 2020; 42:113-125. [PMID: 33306095 DOI: 10.1093/jbcr/iraa214] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
- David M Burmeister
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,United States Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - Susan L Smith
- The Warden Burn Center, Orlando Regional Medical Center, Orlando, Florida
| | | | - David M Hill
- Firefighters' Burn Center, Regional One Health, Memphis, Tennessee
| | - Lauren T Moffatt
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, District of Columbia.,The Burn Center, MedStar Washington Hospital Center; Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Deborah L Carlson
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - John C Kubasiak
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kevin K Chung
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Charles E Wade
- Center for Translational Injury Research, and Department of Surgery, McGovern School of Medicine and The John S. Dunn Burn Center, Memorial Herman Hospital, Houston, Texas
| | - Leopoldo C Cancio
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - Jeffrey W Shupp
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, District of Columbia.,The Burn Center, MedStar Washington Hospital Center; Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia
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12
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Dittrich MHM, Hosni ND, de Carvalho WB. Association between fluid creep and infection in burned children: A cohort study. Burns 2020; 46:1036-1042. [DOI: 10.1016/j.burns.2020.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 01/21/2020] [Accepted: 02/06/2020] [Indexed: 02/01/2023]
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Abstract
Management of the pediatric burn patient presents a variety of clinical challenges for the pediatric anesthesiologist. Despite the high incidence of burn injuries, standard management strategies are far from universal. The complex physiologic changes presented by burn injuries present airway management and resuscitation challenges and mandate careful consideration of adequate nutritional support. Long hospital stays with frequent operations and dressing changes necessitate creative approaches to anxiolysis and pain control. Underutilized modalities warranting further research include regional anesthesia and nonpharmacologic approaches, such as virtual reality. Further research and collaboration between burn centers are needed to standardize care for this population.
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Pediatric burn resuscitation, management, and recovery for the pediatric anesthesiologist. Curr Opin Anaesthesiol 2020; 33:360-367. [PMID: 32371635 DOI: 10.1097/aco.0000000000000859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The purpose of this article is to summarize literature in pediatric burn resuscitation and management that is relevant to the pediatric anesthesiologist. The scope of the literature is expanding as long-term survival in even the most critically ill, burn-injured children has increased. RECENT FINDINGS Longstanding variations in the care of burn-injured children exist despite decades of experience in burn care management. There seems to be a discomfort outside major burn centers in the triage, evaluation, and assessment of burned children. This is evidenced by the prevalence of 'unnecessary intubations', continued overestimation of total body surface area injured, and subsequent fluid administration disproportionate to injury leading to over-resuscitation. Techniques, such as virtual reality and regional anesthesia are increasingly available and serve adjuncts to pharmacologic therapies for anxiolysis and analgesia. Such techniques reduce opioid utilization while maintaining patient comfort and satisfaction particularly during wound dressing changes. Questions about transfusion threshold and ratio of blood products remain topics of ongoing research. SUMMARY Literature review continues to reveal underpowered or retrospective analyses of these very important questions. Public health burden caused by burns warrants rigorous, prospective studies to take the best care of these patients and portend the best long-term outcomes. Collaboration amongst pediatric anesthesiologists who care for these children is necessary to develop and execute powered studies to answer important questions.
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Legrand M, Barraud D, Constant I, Devauchelle P, Donat N, Fontaine M, Goffinet L, Hoffmann C, Jeanne M, Jonqueres J, Leclerc T, Lefort H, Louvet N, Losser MR, Lucas C, Pantet O, Roquilly A, Rousseau AF, Soussi S, Wiramus S, Gayat E, Blet A. Management of severe thermal burns in the acute phase in adults and children. Anaesth Crit Care Pain Med 2020; 39:253-267. [PMID: 32147581 DOI: 10.1016/j.accpm.2020.03.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
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.
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Affiliation(s)
- Matthieu Legrand
- Department of Anaesthesia and Perioperative Care, University of California, San Francisco, United States.
| | - Damien Barraud
- Hôpital de Mercy, Intensive Care Medicine and Burn Centre, CHR Metz-Thionville, Ars-Laquenexy, France
| | - Isabelle Constant
- Anaesthesiology Department, Hôpital Armand-Trousseau, Sorbonne Université, Assistance publique-Hôpitaux de Paris, Paris, France
| | | | - Nicolas Donat
- Burn Centre, Percy Military Teaching Hospital, Clamart, France
| | - Mathieu Fontaine
- Burn Intensive Care Unit, Saint-Joseph Saint-Luc Hospital, 20, quai Claude-Bernard, 69007 Lyon, France
| | - Laetitia Goffinet
- Paediatric Burn Centre, University Hospital of Nancy, 54511 Vandœuvre-Lès-Nancy, France
| | | | - Mathieu Jeanne
- CHU Lille, Anaesthesia and Critical Care, Burn Centre, 59000 Lille, France; University of Lille, Inserm, CHU Lille, CIC 1403, 59000 Lille, France; University of Lille, EA 7365 - GRITA, 59000 Lille, France
| | - Jeanne Jonqueres
- Burn Intensive Care Unit, Saint-Joseph Saint-Luc Hospital, 20, quai Claude-Bernard, 69007 Lyon, France
| | - Thomas Leclerc
- Burn Centre, Percy Military Teaching Hospital, Clamart, France
| | - Hugues Lefort
- Department of emergency medicine, Legouest Military Teaching Hospital, Metz, France
| | - Nicolas Louvet
- Anaesthesiology Department, Hôpital Armand-Trousseau, Sorbonne Université, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Marie-Reine Losser
- Hôpital de Mercy, Intensive Care Medicine and Burn Centre, CHR Metz-Thionville, Ars-Laquenexy, France; Paediatric Burn Centre, University Hospital of Nancy, 54511 Vandœuvre-Lès-Nancy, France; Inserm UMR 1116, Team 2, 54000 Nancy, France; University of Lorraine, 54000 Nancy, France
| | - Célia Lucas
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France
| | - Olivier Pantet
- Service of Adult Intensive Care Medicine and Burns, Lausanne University Hospital (CHUV), BH 08-651, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Antoine Roquilly
- Department of Anaesthesia and Critical Care, Hôtel-Dieu, University Hospital of Nantes, Nantes, France; Laboratoire UPRES EA 3826 "Thérapeutiques cliniques et expérimentales des infections", University of Nantes, Nantes, France
| | | | - Sabri Soussi
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France; Interdepartmental Division of Critical Care, Keenan Research Centre for Biomedical Science and Institute of Medical Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sandrine Wiramus
- Department of Anaesthesia and Intensive Care Medicine and Burn Centre, University Hospital of Marseille, La Timone Hospital, Marseille, France
| | - Etienne Gayat
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France; Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), University of Paris, Paris, France
| | - Alice Blet
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France; Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), University of Paris, Paris, France; Department of Research, University of Ottawa Heart Institute, Ottawa, ON, Canada
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Dittrich MHM, Hosni ND, de Carvalho WB. Resuscitation in Extensive Burn in Pediatrics and Fluid Creep: an Update. ACTA ACUST UNITED AC 2019. [DOI: 10.1007/s40746-019-00182-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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17
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de Tymowski C, Pallado S, Anstey J, Depret F, Moreno N, Benyamina M, Cupaciu A, Jully M, Oueslati H, Fratani A, Coutrot M, Chaussard M, Guillemet L, Dudoignon E, Mimoun M, Chaouat M, Mebazaa A, Legrand M, Soussi S. Early hypoalbuminemia is associated with 28-day mortality in severely burned patients: A retrospective cohort study. Burns 2019; 46:630-638. [PMID: 31629616 DOI: 10.1016/j.burns.2019.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 09/06/2019] [Accepted: 09/20/2019] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Christian de Tymowski
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France; University Paris Diderot, Paris, France; INSERM U1149, Centre de Recherche sur l'Inflammation CRI, Paris, France; Laboratoire d'Excellence (Labex) Inflammex, ComUE Sorbonne Paris Cité, Paris, France.
| | - Simon Pallado
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France.
| | - James Anstey
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Melbourne, Australia.
| | - François Depret
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France; University Paris Diderot, Paris, France; Institut National de la Santé et de la Recherche Médicale (INSERM), UMR INSERM 942, Lariboisière Hospital, Paris, France.
| | - Nabilla Moreno
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Biochemistry laboratory, Paris, France.
| | - Mourad Benyamina
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France.
| | - Alexandru Cupaciu
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France
| | - Marion Jully
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France
| | - Haikel Oueslati
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France
| | - Alexandre Fratani
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France
| | - Maxime Coutrot
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France
| | - Maité Chaussard
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France
| | - Lucie Guillemet
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France
| | - Emmanuel Dudoignon
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France
| | - Maurice Mimoun
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France; University Paris Diderot, Paris, France; Hôpitaux de Paris (AP-HP), Groupe Hospitalier St Louis-Lariboisière, Plastic Surgery and Burn Unit, Paris, France
| | - Marc Chaouat
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France; University Paris Diderot, Paris, France; Hôpitaux de Paris (AP-HP), Groupe Hospitalier St Louis-Lariboisière, Plastic Surgery and Burn Unit, Paris, France
| | - Alexandre Mebazaa
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France; University Paris Diderot, Paris, France; Institut National de la Santé et de la Recherche Médicale (INSERM), UMR INSERM 942, Lariboisière Hospital, Paris, France.
| | - Matthieu Legrand
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France; University Paris Diderot, Paris, France; Institut National de la Santé et de la Recherche Médicale (INSERM), UMR INSERM 942, Lariboisière Hospital, Paris, France.
| | - Sabri Soussi
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France; University Paris Diderot, Paris, France; Institut National de la Santé et de la Recherche Médicale (INSERM), UMR INSERM 942, Lariboisière Hospital, Paris, France.
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Development of clinical process measures for pediatric burn care: Understanding variation in practice patterns. J Trauma Acute Care Surg 2019; 84:620-627. [PMID: 29140950 DOI: 10.1097/ta.0000000000001737] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND There has been little systematic examination of variation in pediatric burn care clinical practices and its effect on outcomes. As a first step, current clinical care processes need to be operationally defined. The highly specialized burn care units of the Shriners Hospitals for Children system present an opportunity to describe the processes of care. The aim of this study was to develop a set of process-based measures for pediatric burn care and examine adherence to them by providers in a cohort of pediatric burn patients. METHODS We conducted a systematic literature review to compile a set of process-based indicators. These measures were refined by an expert panel of burn care providers, yielding 36 process-based indicators in four clinical areas: initial evaluation and resuscitation, acute excisional surgery and critical care, psychosocial and pain control, and reconstruction and aftercare. We assessed variability in adherence to the indicators in a cohort of 1,076 children with burns at four regional pediatric burn programs in the Shriners Hospital system. The percentages of the cohort at each of the four sites were as follows: Boston, 20.8%; Cincinnati, 21.1%; Galveston, 36.0%; and Sacramento, 22.1%. The cohort included children who received care between 2006 and 2010. RESULTS Adherence to the process indicators varied both across sites and by clinical area. Adherence was lowest for the clinical areas of acute excisional surgery and critical care, with a range of 35% to 48% across sites, followed by initial evaluation and resuscitation (range, 34%-60%). In contrast, the clinical areas of psychosocial and pain control and reconstruction and aftercare had relatively high adherence across sites, with ranges of 62% to 93% and 71% to 87%, respectively. Of the 36 process indicators, 89% differed significantly in adherence between clinical sites (p < 0.05). Acute excisional surgery and critical care exhibited the most variability. CONCLUSION The development of this set of process-based measures represents an important step in the assessment of clinical practice in pediatric burn care. Substantial variation was observed in practices of pediatric burn care. However, further research is needed to link these process-based measures to clinical outcomes. LEVEL OF EVIDENCE Therapeutic/care management, level IV.
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Stutchfield C, Davies A, Young A. Fluid resuscitation in paediatric burns: how do we get it right? A systematic review of the evidence. Arch Dis Child 2019; 104:280-285. [PMID: 30262511 DOI: 10.1136/archdischild-2017-314504] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 08/06/2018] [Accepted: 08/24/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND Optimal fluid resuscitation in children with major burns is crucial to prevent or minimise burn shock and prevent complications of over-resuscitation. OBJECTIVES To identify studies using endpoints to guide fluid resuscitation in children with burns, review the range of reported endpoint targets and assess whether there is evidence that targeted endpoints impact on outcome. DESIGN Systematic review. METHODS Medline, Embase, Cinahl and the Cochrane Central Register of Controlled Trials databases were searched with no restrictions on study design or date. Search terms combined burns, fluid resuscitation, endpoints, goal-directed therapy and related synonyms. Studies reporting primary data regarding children with burns (<16 years) and targeting fluid resuscitation endpoints were included. Data were extracted using a proforma and the results were narratively reviewed. RESULTS Following screening of 777 unique references, 7 studies fulfilled the inclusion criteria. Four studies were exclusively paediatric. Six studies used urine output (UO) as the primary endpoint. Of these, one set a minimum UO threshold, while the remainder targeted a range from 0.5-1.0 mL/kg/hour to 2-3 mL/kg/hour. No studies compared different UO targets. Heterogeneous study protocols and outcomes precluded comparison between the UO targets. One study targeted invasive haemodynamic variables, but this did not significantly affect patient outcome. CONCLUSIONS Few studies have researched resuscitation endpoints for children with burns. Those that have done so have investigated heterogeneous endpoints and endpoint targets. There is a need for future randomised controlled trials to identify optimal endpoints with which to target fluid resuscitation in children with burns.
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Affiliation(s)
| | - Anna Davies
- Centre for Academic Child Health, University of Bristol, Bristol, UK
| | - Amber Young
- School of Social and Community Medicine, University of Bristol, Bristol, UK.,University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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Young AE, Davies A, Bland S, Brookes S, Blazeby JM. Systematic review of clinical outcome reporting in randomised controlled trials of burn care. BMJ Open 2019; 9:e025135. [PMID: 30772859 PMCID: PMC6398699 DOI: 10.1136/bmjopen-2018-025135] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Systematic reviews collate trial data to provide evidence to support clinical decision-making. For effective synthesis, there must be consistency in outcome reporting. There is no agreed set of outcomes for reporting the effect of burn care interventions. Issues with outcome reporting have been identified, although not systematically investigated. This study gathers empirical evidence on any variation in outcome reporting and assesses the need for a core outcome set for burn care research. METHODS Electronic searches of four search engines were undertaken from January 2012 to December 2016 for randomised controlled trials (RCTs), using medical subject headings and free text terms including 'burn', 'scald' 'thermal injury' and 'RCT'. Two authors independently screened papers, extracted outcomes verbatim and recorded the timing of outcome measurement. Duplicate outcomes (exact wording ± different spelling), similar outcomes (albumin in blood, serum albumin) and identical outcomes measured at different times were removed. Variation in outcome reporting was determined by assessing the number of unique outcomes reported across all included trials. Outcomes were classified into domains. Bias was reduced using five researchers and a patient working independently and together. RESULTS 147 trials were included, of which 127 (86.4%) were RCTs, 13 (8.8%) pilot studies and 7 (4.8%) RCT protocols. 1494 verbatim clinical outcomes were reported; 955 were unique. 76.8% of outcomes were measured within 6 months of injury. Commonly reported outcomes were defined differently. Numbers of unique outcomes per trial varied from one to 37 (median 9; IQR 5,13). No single outcome was reported across all studies demonstrating inconsistency of reporting. Outcomes were classified into 54 domains. Numbers of outcomes per domain ranged from 1 to 166 (median 11; IQR 3,24). CONCLUSIONS This review has demonstrated heterogeneity in outcome reporting in burn care research which will hinder amalgamation of study data. We recommend the development of a Core Outcome Set. PROSPERO REGISTRATION NUMBER CRD42017060908.
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Affiliation(s)
- Amber E Young
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Anna Davies
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Sara Brookes
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Jane M Blazeby
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Abstract
Pediatric burns are a leading cause of injury and mortality in children in the United States. Prompt resuscitation and management is vital to survival in severe pediatric burns. Although management principles are similar to their adult counterparts, children have unique pathophysiologic responses to burn injury thus an understanding of the differences in fluid resuscitation requirements, airway management, burn and wound care is essential to optimize their outcomes.
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Affiliation(s)
- Mary K Arbuthnot
- Naval Medical Center Camp Lejeune, Department of General Surgery, 100 Brewster Blvd., Camp Lejeune, NC 28547, USA.
| | - Alejandro V Garcia
- Johns Hopkins Hospital, Department of Pediatric Surgery, 1800 Orleans St. Bloomberg Bldg 7313, Baltimore, MD 21287, USA.
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Affiliation(s)
- Robert L Sheridan
- Burn Service, Boston Shriners Hospital for Children; Division of Burns, Massachusetts General Hospital; and Department of Surgery, Harvard Medical School, Boston, MA
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Burns in Children. J Burn Care Res 2018; 38:e618-e624. [PMID: 28328667 DOI: 10.1097/bcr.0000000000000536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Children have a great deal to gain from recent and future advances in burn care. A very broad range of realized and potential developments are involved. These will be very briefly reviewed within the context of four areas: 1) early evaluation and care issues, 2) acute surgical and critical care issues, 3) rehabilitation and reconstruction issues, and 4) organizational and outcomes issues.
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Romanowski KS, Palmieri TL. Pediatric burn resuscitation: past, present, and future. BURNS & TRAUMA 2017; 5:26. [PMID: 28879205 PMCID: PMC5582395 DOI: 10.1186/s41038-017-0091-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 07/07/2017] [Indexed: 01/20/2023]
Abstract
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.
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Affiliation(s)
- Kathleen S Romanowski
- Department of Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, JCP 1500, Iowa City, IA 52242 USA
| | - Tina L Palmieri
- Shriners Hospitals for Children Northern California, Sacramento, California USA.,University of California Davis, Davis, California USA
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Evaluation of the "Early" Use of Albumin in Children With Extensive Burns: Were the Differences Significant? Pediatr Crit Care Med 2017; 18:399. [PMID: 28376013 DOI: 10.1097/pcc.0000000000001082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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The authors reply. Pediatr Crit Care Med 2017; 18:399-400. [PMID: 28376014 DOI: 10.1097/pcc.0000000000001108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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The authors reply. Pediatr Crit Care Med 2016; 17:1019-1020. [PMID: 27705999 DOI: 10.1097/pcc.0000000000000933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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