A primer on burn resuscitation

An integrative literature review of factors contributing to hypothermia in adults during the emergent (ebb) phase of a severe burn injury

BACKGROUND

During the emergent (ebb) phase (first 72 h), the adult person with a severe burn experiences loss of body heat, decreased metabolism, and poor tissue perfusion putting them at risk of hypothermia, increased morbidity, and mortality. Therefore, timely and targeted care is imperative.

AIM

The aim of this integrative literature review was to develop a framework of the factors contributing to hypothermia in adults with a severe burn injury during the emergent (ebb) phase.

METHODS

An integrative review of research literature was undertaken as it provides an orderly process in the sourcing and evaluation of the literature. Only peer reviewed research articles, published in scholarly journals were selected for inclusion (n = 26). Research rigor and quality for each research article was determined using JBI Global appraisal tools relevant to the methodology of the selected study.

FINDINGS

Contributing factors were classified under three key themes: Individual, Pre-hospital, and In-hospital factors.

CONCLUSION

The structured approach enabled the development of an evidence-based framework identifying factors contributing to hypothermia in adults with a severe burn injury during the emergent (ebb) phase and adds knowledge to improve standardized care of the adult person with a severe burn injury.

Diagnosis and Management of Orbital Compartment Syndrome in Burn Patients - a Systematic Review

Orbital compartment syndrome is a poorly understood complication of acute burns. The purpose of this systematic review is to summarize the literature describing orbital compartment syndrome in burn patients to provide greater detail on risk factors and guide management of this morbid condition. A systematic review of the PubMed, Embase, and Cochrane Library databases was performed in June 2023 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study quality was assessed using two validated scoring systems. After removing duplicates, 303 unique articles were reviewed and 8 met inclusion criteria. All publications were retrospective. Most studies considered intraocular pressure >30-40mmHg as diagnostic for orbital compartment syndrome. Sixty unique cases of orbital compartment syndrome were reported. Orbital compartment syndrome occurred most frequently within 24 hours post-burn. The mean total body surface area of burn was 58.7%; the mean 24-hour resuscitation volume was 6.01 cc/kg/%total burn surface area; and 86.5% of cases had periorbital burns. Surgical decompression always started with lateral canthotomy. When pressures were not immediately reduced, cantholysis was performed. Study quality per Median Newcastle Ottawa Scores ranged from 38.9% to 94.4% (median 66.7%). A precise threshold for surgical decompression of OCS remains conflicted; however, IOP>30-40mmHg warrants intervention. Burn surgeons/intensivists should be aware of the risk factors for this vision-threatening complication and act appropriately.

American Burn Association Clinical Practice Guidelines on Burn Shock Resuscitation

This Clinical Practice Guideline (CPG) addresses the topic of acute fluid resuscitation during the first 48 hours following a burn injury for adults with burns ≥20% of the total body surface area (%TBSA). The listed authors formed an investigation panel and developed clinically relevant PICO (Population, Intervention, Comparator, Outcome) questions. A systematic literature search returned 5978 titles related to this topic and after 3 levels of screening, 24 studies met criteria to address the PICO questions and were critically reviewed. We recommend that clinicians consider the use of human albumin solution, especially in patients with larger burns, to lower resuscitation volumes and improve urine output. We recommend initiating resuscitation based on providing 2 mL/kg/% TBSA burn in order to reduce resuscitation fluid volumes. We recommend selective monitoring of intra-abdominal and intraocular pressure during burn shock resuscitation. We make a weak recommendation for clinicians to consider the use of computer decision support software to guide fluid titration and lower resuscitation fluid volumes. We do not recommend the use of transpulmonary thermodilution-derived variables to guide burn shock resuscitation. We are unable to make any recommendations on the use of high-dose vitamin C (ascorbic acid), fresh frozen plasma (FFP), early continuous renal replacement therapy, or vasopressors as adjuncts during acute burn shock resuscitation. Mortality is an important outcome in burn shock resuscitation, but it was not formally included as a PICO outcome because the available scientific literature is missing studies of sufficient population size and quality to allow us to confidently make recommendations related to the outcome of survival at this time.

The Battle of the Titans-Comparing Resuscitation Between Five Major Burn Centers Using the Burn Navigator

The goal of burn resuscitation is to provide the optimal amount of fluid necessary to maintain end-organ perfusion and prevent burn shock. The objective of this analysis was to examine how the Burn Navigator (BN), a clinical decision support tool in burn resuscitation, was utilized across five major burn centers in the United States, using an observational trial of 300 adult patients. Subject demographics, burn characteristics, fluid volumes, urine output, and resuscitation-related complications were examined. Two hundred eighty-five patients were eligible for analysis. There was no difference among the centers on mean age (45.5 ± 16.8 years), body mass index (29.2 ± 6.9), median injury severity score (18 [interquartile range: 9-25]), or total body surface area (TBSA) (34 [25.8-47]). Primary crystalloid infusion volumes at 24 h differed significantly in ml/kg/TBSA (range: 3.1 ± 1.2 to 4.5 ± 1.7). Total fluids, including colloid, drip medications, and enteral fluids, differed among centers in both ml/kg (range: 132.5 ± 61.4 to 201.9 ± 109.9) and ml/kg/TBSA (3.5 ± 1.0 to 5.3 ± 2.0) at 24 h. Post-hoc adjustment using pairwise comparisons resulted in a loss of significance between most of the sites. There was a total of 156 resuscitation-related complications in 92 patients. Experienced burn centers using the BN successfully titrated resuscitation to adhere to 24 h goals. With fluid volumes near the Parkland formula prediction and a low prevalence of complications, the device can be utilized effectively in experienced centers. Further study should examine device utility in other facilities and on the battlefield.

Surgical Management Evolution Between 2 Massive Burn Cases at 17-Year Interval: Contribution of Cell Therapies in Improving the Surgical Care

We report the cases of 2 patients admitted to our hospital at a 17-year interval, both with 90% total body surface area (TBSA) burns. These two young patients were in good health before their accident, but major differences in time of intensive care and hospitalization were observed: 162 versus 76 days in intensive care unit and 18 versus 9.5 months for hospitalization, respectively. We have analyzed the different parameters side-by-side during their medical care and we have identified that the overall improved outcomes are mainly due to a better adapted fluid reanimation in combination with the evolution of the surgical management to encompass allogenic cellular therapy (Biological Bandages). Indeed, autologous cell therapy using keratinocytes has been used for over 30 years in our hospital with the same technical specifications; however, we have integrated the Biological Bandages and routinely used them for burn patients to replace cadaver skin since the past 15 years. Thus, patient 1 versus patient 2 had, respectively, 83% versus 80% TBSA for autologous cells, and 0% versus 189% for allogenic cells. Notably, it was possible that patient 2 was able to recover ∼6% TBSA with the use of Biological Bandages, by stimulating intermediate burn zones toward a spontaneous healing without requiring further skin grafting (on abdomen and thighs). The body zones where Biological Bandages were not applied, such as the buttocks, progressed to deeper-stage burns. Despite inherent differences to patients at their admission and the complexity of severe burn care, the results of these two case reports suggest that integration of innovative allogenic cell therapies in the surgical care of burn patients could have major implications in the final outcome.

Nursing Care for the Initial Resuscitation of Burn Patients

Serious burn injuries may have lifelong impacts for individuals that experience them and require timely medical treatment in order to reduce associated morbidity and mortality. Initial management of a burn is nursing intensive and focuses primarily on stopping the burning process, maintaining homeostasis by keeping the patient warm, and replacing lost fluid and electrolytes. As healing progresses, nurses meet the critical needs of the patient and must skillfully manage pain levels, perform burn care, prevent infection, help the patient meet increased nutrient requirements, and address psychological concerns with the goal to restore health and function to the highest possible level.

The assessment and management of thermal burn injuries in a UK ambulance service: a clinical audit

Background:

Although burn emergencies are infrequently encountered, the ambulance service is often the first point of contact for patients in these situations. It is therefore important that these potentially devastating injuries are managed in accordance with the evidence base. Appropriate assessment and management of these patients in the pre-hospital phase will have a significant impact upon their long-term outcomes, such as scarring cosmesis and functionality.

Aim and objectives:

This audit was conducted to determine if patients presenting to one UK ambulance service with thermal burn injuries were managed safely, effectively and in a timely manner. Areas highlighted for improvement will assist in directing future pre-hospital research and educational requirements. Epidemiological data will also be provided.

Results:

278 thermal burn incidents occurring from June 2017 to May 2018 (inclusive) were included in this audit. A larger proportion of burn patients were paediatrics who fell into the 0–10 age category, most burn patients were injured at a home address and only nine of the overall sample were major burns. Only 35% of patients received adequate cooling of their burns, an essential first aid intervention. The assessment of pain (87%) and provision of analgesia (75%) showed a higher compliance rate. However, only 54% had pain reassessed after analgesia. There was a near 100% compliance rate for patients being managed without hydrogel dressings and topical medicines.

Conclusion:

The results indicate several areas for improvement within the ambulance trust. Of importance is the application of basic first aid, such as cooling. It is important not only to improve education among staff but also to understand non-compliance. It should be acknowledged that assessment of pain and provision of analgesia demonstrated far higher compliance compared to current pre-hospital evidence. Several points for education and research have been identified.

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.

Cardiovascular Responsiveness to Vasopressin and α1-Adrenergic Receptor Agonists After Burn Injury

The effects of burn injury on cardiovascular responsiveness to vasoactive agents are not well understood. The aims of this study were to determine whether burn injury alters cardiovascular reactivity to vasoactive drugs in vivo and intrinsic function of isolated mesenteric resistance arteries. Anesthetized Sprague-Dawley rats were subjected to sham procedure or 30% TBSA dorsal scald burn, followed by crystalloid resuscitation (Parkland Formula). At 24, 72, 96, and 168 hours post burn, rats were reanesthetized, and the mean arterial blood pressure (MAP) responses to various doses of the α1-adrenergic receptor agonist phenylephrine and arginine vasopressin were tested. Mesenteric arteries were harvested from uninjured animals and at 24 and 168 hours post burn. The responsiveness of arteries to phenylephrine and arginine vasopressin was tested by pressure myography. Dose response curves were generated and EC50 concentrations, Hill slopes, and maximal effects were compared. The potency of phenylephrine to increase MAP was reduced 2-fold 24 hours post burn (P < .05 vs sham) and gradually normalized at later time points. The reactivity of isolated arteries to phenylephrine was not significantly altered after burns. The potency of arginine vasopressin to increase MAP and to constrict isolated arteries was increased 2- to 3-fold at 24 hours post burn (P < .05) and normalized at later time points. Our findings suggest that burn injury differentially regulates vasopressor and blood pressure effects of α-adrenergic and vasopressin receptor agonists. Intrinsic vasopressin receptor reactivity of resistance arteries is sensitized early after burns. These findings will help to optimize resuscitation strategies and vasopressor use in difficult to resuscitate burn patients.

In view of standardization Part 2: Management of challenges in the initial treatment of burn patients in Burn Centers in Germany, Austria and Switzerland

INTRODUCTION

Initial therapy of severe burns in specialized burn trauma centers is a challenging task faced by the treating multi-professional and interdisciplinary team. A lack of consistent operating procedures and varying structural conditions was recently demonstrated in preliminary data of our group. These results raised the question on how specific treatment measures in acute burn care are met in the absence of standardized guidelines.

MATERIAL AND METHODS

A specific questionnaire containing 57 multiple-choice questions was sent to all 22 major burn centers in Germany, Austria and Switzerland. The survey included standards of airway management and ventilation, fluid management and circulation, body temperature monitoring and management, topical burn wound treatment and a microbiological surveillance. Additionally, the distribution of standardized course systems was covered.

RESULTS

17 out of 22 questionnaires (77%) were returned completed. Regarding volume resuscitation, results showed a similar approach in estimating initial fluid while discrepancies persisted in the use of colloidal fluid and human albumin. Elective tracheostomy and the need for bronchoscopy with suspected inhalation injury were the most controversial issues revealed by the survey. Topical treatment of burned body surface also followed different principles regarding the use of synthetic epidermal skin substitutes or enzymatic wound debridement. Less discrepancy was found in basic diagnostic measures, body temperature management, estimation of the extent of burns and microbiological surveillance.

CONCLUSION

While many burn-related issues are clearly not questionable and managed in a similar way in most participating facilities, we were able to show that the most contentious issues in burn trauma management involve initial volume resuscitation, management of inhalation trauma and topical burn wound treatment. Further research is required to address these topics and evaluate a potential superiority of a regime in order to increase the level of evidence.

Intravenous Antibiotic and Antifungal Agent Pharmacokinetic-Pharmacodynamic Dosing in Adults with Severe Burn Injury

PURPOSE

Despite advances in the care of patients with severe burn injury, infection-related morbidity and mortality remain high and can potentially be reduced with antimicrobial dosing optimized for the infecting pathogen. However, anti-infective dose selection is difficult because of the highly abnormal physiologic features of burn patients, which can greatly affect the pharmacokinetic (PK) disposition of these agents. We review published PK data from burn patients and offer evidence-based dosing recommendations for antimicrobial agents in burn-injured patients.

METHODS

Because most infections occur at least 48 hours after initial burn injury and anti-infective therapy often lasts ≥10 days, we reviewed published data informing PK-pharmacodynamic (PD) dosing of anti-infectives administered during the second, hypermetabolic stage of burn injury, in those with >20% total body surface area burns, and in those with normal or augmented renal clearance (estimated creatinine clearance ≥130 mL/min). Analyses were performed using 10,000-patient Monte Carlo simulations, which uses PK variability observed in burn patients and MIC data to determine the probability of reaching predefined PK-PD targets. The probability of target attainment, defined as the likelihood that an anti-infective dosing regimen would achieve a specific PK-PD target at the single highest susceptible MIC, and the cumulative fraction of response, defined as the population probability of target attainment given a specific dose and a distribution of MICs, were calculated for each recommended anti-infective dosing regimen.

FINDINGS

Evidence-based doses were derived for burn-injured patients for 15 antibiotics and 2 antifungal agents. Published data were unavailable or insufficient for several agents important to the care of burn patients, including newer antifungal and antipseudomonal agents. Furthermore, available data suggest that antimicrobial PK properties in burned patients is highly variable. We recommend that, where possible, therapeutic drug monitoring be performed to optimize PK-PD parameter achievement in individual patients.

IMPLICATIONS

Given the high variability in PK disposition observed in burn patients, doses recommended in the package insert may not achieve PK-PD parameters associated with optimal infectious outcomes. Our study is limited by the necessity for fixed assumptions in depicting this highly variable patient population. New rapid-turnaround analytical technology is needed to expand the menu of antimicrobial agents for which therapeutic drug monitoring is available to guide dose modification within a clinically actionable time frame.

How to Recognize a Failed Burn Resuscitation

Failed burn resuscitation can occur at various points. Early failed resuscitation will be largely caused by prehospital factors. During resuscitation, failure will present as a patient's nonresponse to adjunctive therapy. Late failure will occur in the setting of multiple organ dysfunction syndrome. Burn care providers must be vigilant during the resuscitation to identify a threatened resuscitation so that adjunctive therapies or rescue maneuvers can be used to convert to a successful resuscitation. However, when a patient's resuscitative course becomes unsalvageable, transition to comfort care should be taken to avoid prolongation of suffering.

Should early amputation impact initial fluid therapy algorithms in burns resuscitation? A retrospective analysis using 3D modelling

AIMS

While the epidemiology of amputations in patients with burns has been investigated previously, the effect of an amputation on burn size and its impact on fluid management have not been considered in the literature. Fluid resuscitation volumes are based on the percentage of the total body surface area (%TBSA) burned calculated during the primary survey. There is currently no consensus as to whether the fluid volumes should be recalculated after an amputation to compensate for the new body surface area. The aim of this study was to model the impact of an amputation on burn size and predicted fluid requirement.

METHODS

A retrospective search was performed of the database at the Queen Elizabeth Hospital Birmingham Regional Burns Centre to identify all patients who had required an early amputation as a result of their burn injury. The search identified 10 patients over a 3-year period. Burn injuries were then mapped using 3D modelling software. BurnCase3D is a computer program that allows accurate plotting of burn injuries on a digital mannequin adjusted for height and weight. Theoretical fluid requirements were then calculated using the Parkland formula for the first 24 h, and Herndon formula for the second 24 h, taking into consideration the effects of the amputation on residual burn size.

RESULTS AND CONCLUSIONS

This study demonstrated that amputation can have an unpredictable effect on burn size that results in a significant deviation from predicted fluid resuscitation volumes. This discrepancy in fluid estimation may cause iatrogenic complications due to over-resuscitation in burn-injured casualties. Combining a more accurate estimation of postamputation burn size with goal-directed fluid therapy during the resuscitation phase should enable burn care teams to optimise patient outcomes.

Point-of-care B-type natriuretic peptide and neutrophil gelatinase-associated lipocalin measurements for acute resuscitation: a pilot study

Adequate resuscitation is paramount to burn patient survival and recovery. Novel biomarkers of intravascular volume and renal perfusion may augment resuscitation strategies. The purpose of this study is to characterize serum B-type natriuretic peptide (BNP) and neutrophil gelatinase-associated lipocalin (NGAL) during burn resuscitation and correlate to clinical assessments of volume status. We hypothesize that BNP and NGAL will help predict inadequate resuscitation during the first 48 hours following burn injury. We conducted a pilot observational study recruiting 15 adult (age ≥18 years) patients with ≥20% TBSA burns. Paired serial BNP, NGAL, and creatinine measurements were performed using point-of-care testing. Samples were tested every 4 hours for the first 48 hours following admission. Acute kidney injury (AKI) was defined by the RIFLE criteria. Over-resuscitation was defined as developing compartment syndrome. Demographics and TBSA were similar between AKI (n = 7) vs non-AKI (n = 8), and over-resuscitated (n = 5) vs adequately resuscitated groups (n = 10). NGAL (184.9 ± 72.2 vs 110.8 ± 35.8 ng/ml, P = .004) and BNP (25.3 ± 17.3 vs 8.8 ± 5.2 pg/ml, P = .033) values were significantly higher in AKI patients. Creatinine values were similar between AKI and non-AKI patients. NGAL levels suggested presence of AKI 12 hours earlier than creatinine levels. BNP values (23.1 ± 21.9 vs 13.9 ± 13.4 pg/ml, P < .001) were significantly higher in over-resuscitated patients. Point-of-care BNP, NGAL, and creatinine measurements aid in the assessment of vascular volume and renal function during acute burn resuscitation. Further studies are warranted to determine BNP and NGAL cut-offs for guiding burn resuscitation.

Modeling Fluid Resuscitation by Formulating Infusion Rate and Urine Output in Severe Thermal Burn Adult Patients: A Retrospective Cohort Study

Acute burn injuries are among the most devastating forms of trauma and lead to significant morbidity and mortality. Appropriate fluid resuscitation after severe burn, specifically during the first 48 hours following injury, is considered as the single most important therapeutic intervention in burn treatment. Although many formulas have been developed to estimate the required fluid amount in severe burn patients, many lines of evidence showed that patients still receive far more fluid than formulas recommend. Overresuscitation, which is known as “fluid creep,” has emerged as one of the most important problems during the initial period of burn care. If fluid titration can be personalized and automated during the resuscitation phase, more efficient burn care and outcome will be anticipated. In the present study, a dynamic urine output based infusion rate prediction model was developed and validated during the initial 48 hours in severe thermal burn adult patients. The experimental results demonstrated that the developed dynamic fluid resuscitation model might significantly reduce the total fluid volume by accurately predicting hourly urine output and has the potential to aid fluid administration in severe burn patients.

Abdominal compartment syndrome (ACS) in a severely burned patient

Abdominal compartment syndrome (ACS) occurs when increasing intra abdominal-pressure (IAP) reduces blood flow to abdominal organs. This results in impairment of pulmonary, cardiovascular, renal, hepatic, central nervous system and gastro-intestinal (gi) function, causing multiple organ dysfunction syndrome and death. The significant prognostic value of elevated intra-abdominal pressure has prompted many intensive care units to adopt measurement of this physiologic parameter as a routine vital sign in patients at risk. ACS generally occurs in patients who are critically ill due to any of a wide variety of medical and surgical conditions. it has been recently described as a rare complication of burn injury. it is fundamental to: 1) recognize IAP and ACS; 2) resuscitate effectively; and 3) prevent the development IAP-induced end-organ dysfunction and failure. We present our recent experience with one patient suffering from ACS secondary to burn injury and the physiologic results of abdominal wall escharotomy.

Early albumin use improves mortality in difficult to resuscitate burn patients

BACKGROUND

The optimal resuscitation algorithm remains elusive for patients with a large burn injury. Recent reports from the military support that larger burns that do not respond well to ongoing lactated Ringer's solution resuscitation may improve with the use of 5% albumin and vasopressors. We hypothesized that the use of 5% albumin and vasopressors, as needed, would decrease complications of fluid resuscitation and burn mortality.

METHODS

Fluid needs during the first 24 hours after burn injury, complications, and demographics were collected from all patients 12 years and older with burn size 20% or more of total body surface area admitted from 2003 to 2010. In March 2007, we changed our resuscitation to include the use of 5% albumin in the first 24 hours if the estimated fluid needs at 12 hours after burn would lead to a fluid volume of 6 mL/kg per percent burn at 24 hours. The patients treated before this change (Preprotocol) were compared with those treated after the guideline change (Postprotocol).

RESULTS

The two groups were well matched for age, burn size, and inhalation injury. Ventilator days and mortality were decreased in the Postprotocol group. There was a trend toward less intravenous fluid use in the Postprotocol group where the use of albumin was higher. There was significantly less vasopressor infusion in the Postprotocol group. There was no statistical difference in the number of escharotomies performed or overall incidence of abdominal compartment syndrome, but no patient required open laparotomy in the Postprotocol group.

CONCLUSION

An algorithm incorporating albumin use in the first 24 hours after burn injury was associated with the use of less vasopressor agents and lower mortality. Early albumin use was also associated with a shorter duration of mechanical ventilation in burn patients sustaining burns 20% or more total body surface area.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Acute burn resuscitation and fluid creep: it is time for colloid rehabilitation

Fluid overloading has become a global phenomenon in acute burn care. The consensus Parkland formula that has excluded colloid use, the impact of goal-directed resuscitation, and the overzealous on the scene crystalloid resuscitation combined with subsequent inefficient titration of fluid administration and lack of timely reduction of infusion rates, have all contributed to this phenomenon of fluid overloading, known as fluid creep and recognized only recently, constituting a landmine in modern burn care. Solid evidence is supportive to the fact that excessive administration of crystalloid and the abandonment of colloid replenishment at some point of resuscitation are the major contributors to fluid creep. With available evidence from the literature, the present is a comprehensive review of literature about fluid creep, trying to determine the etiology behind it as well as to propose strategies to control its magnitude and complications, namely through colloid administration amongst other options.