State of the Art: An Update on Adult Burn Resuscitation

Treatment of patients with severe burn injuries is complex, relying on attentive fluid resuscitation, successful management of concomitant injuries, prompt wound assessment and closure, early rehabilitation, and compassionate psychosocial care. The goal of fluid resuscitation is to maintain organ perfusion at the lowest possible physiologic cost. This requires careful, hourly titration of the infusion rate to meet individual patient needs, and no more; the risks of over-resuscitation, such as compartment syndromes, are numerous and life-threatening. Recognizing runaway resuscitations and understanding how to employ adjuncts to crystalloid resuscitation are paramount to preventing morbidity and mortality. This article provides an update on fluid resuscitation techniques in burn patients, to include choosing the initial fluid infusion rate, using alternate endpoints of resuscitation, and responding to the difficult resuscitation.

Contemporary Aspects of Burn Care

The past one hundred years have seen tremendous improvements in burn care, allowing for decreased morbidity and mortality of this pathology. The more prominent advancements occurred in the period spanning 1930–1980; notably burn resuscitation, early tangential excision, and use of topical antibiotic dressings; and are well documented in burn literature. This article explores the advancements of the past 40 years and the areas of burn management that are presently topics of active discussion and research.

519 The Routine Addition of Maintenance IV Fluid is Not Warranted during all Pediatric Burn Resuscitation: A Retrospective Study

Introduction Pediatric burn resuscitation has improved dramatically over the years with improved survival and outcomes. Recent studies have shown the amount of fluid given (ml/kg/%TBSA) has direct correlation to the outcomes. Over resuscitation (fluid creep) results in multiple systemic and wound complications. We hypothesize the addition of maintenance IV fluid with Parkland resuscitation fluid in younger pediatric burns (< 30kg) may not be needed to achieve adequate end points of resuscitation. Methods We performed a retrospective chart analysis of our pediatric burn patients at our institution by categorizing younger patients (< 30kg) into two groups: The maintenance IV fluid (MF) group and the resuscitation fluid (RF) only group. We identified 18 patients that met the criteria with 9 patients in each group. All of the patients in both groups were under 30kg, age range 2-8yrs, and TBSA: 16–50 %. We included 3 patients under 20% TBSA that were resuscitated due to full thickness burns and smoke inhalation injury. We analyzed their hourly and 24-hour fluid administration including all oral intake and tube feeds as well as their hourly vitals, urine output, and laboratory values during the resuscitation. Results We found that the RF group received 1.311+/- 1.295 cc/kg cc less fluid compared to the MF group without any hypoglycemic events or deleterious hemodynamic effects. The patients who had good oral intake or received tube feeds during resuscitation resulted in significantly less resuscitation volume than the estimated resuscitation volume in both groups. Conclusions We conclude that resuscitation can be safely done in pediatric burn patients under 30 kg without adding routine maintenance IV fluid. Early oral and enteral feeding is very critical in all burn patients. The volume that was administered enterally should also be considered in hourly fluid titration rates to reduce the resuscitation fluids given thereby preventing fluid creep and ensuing deleterious complications.

510 A Case-controlled Retrospective Review of Fluid Resuscitation in Patients with Concomitant Burn and Trauma Injuries

Introduction Aggressive fluid resuscitation with crystalloid has been a mainstay of therapy in burn injuries for over 50 years. However, in trauma populations there has been a shift away from crystalloid based resuscitation and the early administration of blood products has been recommended. The primary objective of this study was to evaluate if large-volume crystalloid resuscitation of patients presenting with both burn and trauma injuries is associated with higher mortality and complications. Methods This was a matched case-controlled retrospective chart review of patients treated over a 5-year period that suffered mixed burn and trauma injuries (MI). Patients that suffered burn only injuries (BO) were used as the control and were matched on TBSA, age, and gender. All patients were resuscitated using the standard burn center resuscitation protocol. Results A total of 4,416 patients were admitted to the burn center during the study period. Of those 18 had concomitant burn and trauma injuries requiring burn fluid resuscitation and were successfully matched to BO patients. There was no difference in age, gender, ethnicity, % TBSA burned, presence of inhalation injury, or Injury Severity Score (ISS). BO patients were more likely to have flame/flash as the etiology of burn injury (p=.0257). With fluid resuscitation, there was no difference in the total volume of fluid administered, or the amount of crystalloid or colloid administered. MI patients were more likely to have received blood products than BO patients (472 ml vs 19 ml, p=.0387). There was no difference in the following outcome measures: mortality, ICU days, ventilator days, number of surgeries, infections, or major complications. The only significant outcome difference was that the BO patients had a greater hospital length of stay (44 days) than the MI patients (24 days, p < 0.001). Conclusions Aggressive fluid resuscitation using existing burn resuscitation protocols did not result in greater complications in burn-trauma patients than in burn only patients. Crystalloid-based burn resuscitation is safe in patients with combined burn and trauma injuries.

A History of Fluid Management—From “One Size Fits All” to an Individualized Fluid Therapy in Burn Resuscitation

Fluid management is a cornerstone in the treatment of burns and, thus, many different formulas were tested for their ability to match the fluid requirements for an adequate resuscitation. Thereof, the Parkland-Baxter formula, first introduced in 1968, is still widely used since then. Though using nearly the same formula to start off, the definition of normovolemia and how to determine the volume status of burn patients has changed dramatically over years. In first instance, the invention of the transpulmonary thermodilution (TTD) enabled an early goal directed fluid therapy with acceptable invasiveness. Furthermore, the introduction of point of care ultrasound (POCUS) has triggered more individualized schemes of fluid therapy. This article explores the historical developments in the field of burn resuscitation, presenting different options to determine the fluid requirements without missing the red flags for hyper- or hypovolemia. Furthermore, the increasing rate of co-morbidities in burn patients calls for a more sophisticated fluid management adjusting the fluid therapy to the actual necessities very closely. Therefore, formulas might be used as a starting point, but further fluid therapy should be adjusted to the actual need of every single patient. Taking the developments in the field of individualized therapies in intensive care in general into account, fluid management in burn resuscitation will also be individualized in the near future.

An Assessment of Research Priorities to Dampen the Pendulum Swing of Burn Resuscitation

On June 17-18, 2019, the American Burn Association, in conjunction with Underwriters Laboratories, convened a group of experts on burn and inhalation injury in Washington, DC. The goal of the meeting was to identify and discuss 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 optimal use of fluids for resuscitation. The resultant practice of judicious and timely infusion of crystalloids has likely 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, re-examining 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.