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

Pediatric Burns-Time to Collaborate Together

How to cite this article: Baalaaji M. Pediatric Burns-Time to Collaborate Together. Indian J Crit Care Med 2023;27(12):873-875.

Pediatric burn care: new techniques and outcomes

PURPOSE OF REVIEW

Thermal injury is a leading cause of morbidity and mortality in children. This review highlights the current management of thermal injury and its complications.

RECENT FINDINGS

Many recent advances in burn care have improved the outcomes of patients with thermal injury; however, variability does exist, and there are many opportunities for improvement. This review will highlight the complexity of issues encountered along the continuum of care for thermal injury patients. Accurate estimation of total burn surface area (TBSA) of a burn continues to be a challenge in pediatric patients. Variability continues to exist surrounding the management of burn resuscitation and complex wounds. Children with extensive burns have profound immune and metabolic changes that can lead to multiple complications, including infections, growth arrest, and loss of lean body mass. Standardization in measurements related to quality of life and psychological stress following pediatric thermal injury is much needed.

SUMMARY

The care of pediatric patients with thermal injury is complex and multifaceted. This review highlights the most recent advances in pediatric burn care.

Variation in acute fluid resuscitation among pediatric burn centers

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVES

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

DESIGN

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

RESULTS

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

CONCLUSION

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