Article 1
The use of vasopressors during acute burn resuscitation. Adibfar A, Camacho F, Rogers AD, Cartotto R. Burns. 2021 Feb;47(1):58-66.
This is a retrospective single-institution study examining the use of vasopressors during acute burn resuscitation over a 32-month period. The goal of the study was to identify factors associated with initiation of vasopressor use in the acute burn resuscitation period. Patients were assigned to the PRESSOR group if they received any continuous infusion of vasopressor for at least 30 minutes during the first 48 hours post injury; those who did not receive vasopressor infusion during the same time were placed in the NoPRESSOR group. Fifty-two patients were eligible for the study; with 1 excluded for young age, 10 excluded for vasopressor use prior to arrival, and 17 excluded for comfort measures within the first 24 hours of injury. There were more patients in the NoPRESSOR group, with 30.8% of the study participants in the PRESSOR group. Patients in the PRESSOR group were older (55.3+/- 15.9 yrs vs 42.3 +/- 16 yrs), with significantly larger median total burn size (44% vs 25%) and significantly larger median full thickness burns (33.8% vs 14.5%). The PRESSOR group was also significantly more likely to be diagnosed with an inhalational injury (56.3% vs 22%), placed on mechanical ventilation (100% vs 63.5%), and had a higher mortality rate (56% vs 11%). Vasopressor use was not independently associated with increased mortality. There was a significant difference in prevalence of AKI between the groups (56.3% in PRESSOR, 11.1% NoPRESSOR). There were no significant differences between the groups for percentage of predicted fluid received at any point post-injury, and the PRESSOR group was found to have received 145% of their predicted fluid volume by Parkland formula at the time of vasopressor initiation. The hourly urine output did not differ significantly between the two groups in the first 24 hours post injury. More patients in the PRESSOR group were given high dose vitamin C (HDVC) (68.8% vs 16.7%), but this group was not given more albumin (37.5% vs 47.2%). Patient age and use of HDVC were independently associated with greater use of vasopressors; 5% albumin administration was associated with significantly less vasopressor administration.
This study highlights that there is very little literature on the use of vasopressors during the acute burn resuscitation phase. The patients who received vasopressors had larger and deeper burn injuries, were more frequently receiving ventilatory support, were older in age, and were more likely to have received HDVC. The authors proposed that increased vasopressor use in the setting of HDVC was due to the theoretical osmotic diuretic effect which has been inconsistently reported in the literature. They point to the plasma volume expansion of albumin as a possible explanation for the association between albumin administration and less vasopressor use in this study. They also suggest the known physiologic changes during the aging process and during severe burn injury to explain the association with these factors and increased use of vasopressors. This study is limited due to the small sample size and the retrospective nature; the conclusions would be better supported with large, randomized control studies.
Article 2
Adherence to Burn Resuscitation Guidelines Reduces Resuscitation Fluids and Mortality. Mankowski P, Papp B, Genoway K, Papp A. J Burn Care Res. 2023 Jan 5;44(1):192-196.
This is a single institution retrospective review performed over an eight-year period examining adherence to guidelines distributed by the provincial burn center to surrounding peripheral sites. The guidelines were designed in 2011 by the provincial burn center as an educational tool with guidelines for burn TBSA estimation and an algorithm for fluid resuscitation. This guideline was deemed necessary after an internal audit found areas for improvement in regional burn care, particularly since rural centers around the provincial burn center often are tasked with starting the resuscitation and monitoring of burn patients in the area. The goal of the study was to evaluate guideline adherence in the region and to demonstrate improved outcomes with optimizing burn care through guideline usage. Seventy-two patients were included in the study, with 50% in both the compliant and noncompliant groups. Both groups had similar demographics and injury severity. There was no significant difference between the groups for mean initial or mean final TBSA calculation, although it was noted that 30% of all included patients had an over- or under- estimation of their TBSA by greater than 10% when compared to the burn center TBSA estimation. When looking at total fluid administration between groups, the guideline compliant group had a statistically significant reduction of 27% compared to the guideline non-compliant group. Urine outputs at 12, 24, and 48 hours post-injury were found to be significantly increased in the noncompliant group compared to the compliant group. Mortality rate was the only complication with a significant difference between groups, showing a 83% reduction in the compliant group.
This study ultimately showed improvements in total fluid administration, urine output, and mortality in patients suffering from burn injury when the burn center guidelines were followed at outlying centers prior to transfer. The authors noted that discrepancy in TBSA calculations was still seen across both groups in a minority of patients which highlights an area for improvement in the guidelines. Limitations in this study include its retrospective design and small sample size. Future work in a larger population may be able to delineate differences in other complications seen in burn injury and could examine differences between types of fluids used for resuscitation.
Article 3
Challenging Legacy Burn Resuscitation Paradigms with Fluid Restriction and Early Plasma. Kahn SA, Huff ML, Taylor J, O'Neill K, Hink AB, Mittal R, Bright A, Baliga P. J. Am Coll Surg. 2025 Apr 1;240(4):339-347.
Fluid resuscitation after major burn injury remains a delicate and dynamic balance of maintaining end organ perfusion and preventing deleterious effects from over resuscitation. From a pathophysiological perspective, burns cause large fluid shifts secondary to endothelial damage and capillary leak. In the last several years, the glycocalyx, a structure made up of carbohydrates and proteins that coats the endothelial lining has been identified as potentially playing a key role in capillary leak and subsequent third spacing seen after major burn. Evidence has shown that fresh frozen plasma (FFP) has been shown to help reduce endothelial leak and restore the glycocalyx, but this is not standard of care in burn resuscitation. This article aimed to look not only at the early use of plasma in burn resuscitation but also used an adjusted body weight index and starting crystalloid resuscitation at 2cc/kg/%TBSA. They hypothesized that this approach would result in less fluid administration and superior clinical outcomes compared to traditional resuscitation methods such as Parkland formula (4cc/kg/TBSA). This was a retrospective study comparing patients with >20% TBSA using the adjusted body weight with resuscitation at 2cc/kg/TBSA, early plasma administration and plasma as needed for oliguria and compared this group to “legacy groups” who were resuscitated with Parkland Formula 4cc/kg/TBSA or a less restrictive 3cc/kg/TBSA adjusted body weight group with rescue FFP only.
Demographic and injury data was collected for all patients including age, gender, weight, % TBSA and presence of inhalational injury. The only difference identified among groups was a larger number of inhalational injury in the Parkland group (p<0.05), however the authors stipulated that practice had been previously to diagnose inhalation based on clinical suspicion rather than bronchoscopic grading. Overall, patients in the 2cc/kg and FFP group received significantly less fluid than both of the legacy groups (1.7 vs 3.3, p<0.05) (1.7 vs 4.15, p<0.0001). Urine output was significantly reduced from 1.4 to 1 to 0.7 cc/kg/hr (p<0.0001) with goal urine output titration of 0.5cc/kg/hr. Mortality, mechanical ventilation, tracheostomy, and hemodialysis was significantly less in the 2cc/kg and FFP group as compared to the Parkland 4cc/kg group (p<0.05). Limitations of the study include its retrospective design, data from the 2cc/kg plus FFP group was collected at a different burn center compared to 3cc and 4cc/kg groups and there likely have been other advances in critical care and burn technology since the Parkland cohort was treated. This need for generalizability could be addressed with a randomized multicenter trial and could help validate these findings from this study.
Article 4
Burn Resuscitation Practices in North America: Results of the Acute Burn ResUscitation Multicenter Prospective Trial (ABRUPT). Greenhalgh DG, Cartotto R, Taylor SL, Fine JR, Lewis GM, Smith DJ Jr, Marano MA, Gibson A, Wibbenmeyer LA, Holmes JH, Rizzo JA, Foster KN, Khandelwal A, Fischer S, Hemmila MR, Hill D, Aballay AM, Tredget EE, Goverman J, Phelan H, Jimenez CJ, Baldea A, Sood R. Ann Surg. 2023 Mar 1;277(3):512-519.
Major burn resuscitation has historically been driven using the Parkland Formula 4cc/kg/%TBSA lactated ringers (LR) over the first 24 hours. As time progressed with the use of the Parkland formula there was concern for over resuscitation of patient with resultant “fluid creep” or third spacing so the Modified Brooke Formula was introduced with resuscitation at 2cc/kg/TBSA. It has been hypothesized that the over resuscitation of patients in the modern era could be due to the lack of utilization of colloids. Colloids are thought to limit resuscitation requirements by exerting an osmotic effect. However, in burn injury there is a disruption of the endothelial barrier. There are previous animal and human studies that have shown that compared to crystalloid, colloid can reduce resuscitation volume and limit over resuscitation by maintaining an effective osmotic gradient. In this study, the researchers wanted to examine the use of albumin and crystalloid in burn resuscitation.
The study design was a prospective, noninterventional, observational study of burn patients with TBSA >20% admitted to 21 burn centers in the United States and Canada. Resuscitation was performed per each center’s specific protocol. Detailed information from the resuscitation period was recorded on an hourly basis over the 48 hours of resuscitation including volume of crystalloid and albumin given. Of the 379 patients included in the study, two thirds were resuscitated with albumin plus crystalloid and one third with crystalloid alone. Patients in the albumin group received more fluid overall compared to the crystalloid group (5.2 ± 2.3 vs 3.7 ± 1.7 mL/kg/% TBSA burn/24 hours). The albumin group consisted of older patients, larger and deeper burns, higher Sequential Organ Failure Assessment (SOFA) scores or more inhalational injuries. Albumin did lower the In/Out ratio, was started <12 hours into resuscitation in those with high fluid requirements, started >12 hours into resuscitation in those with intermediate requirements and was not given in those who did respond to just crystalloid. Albumin group did have worse outcomes overall including need for fasciotomies and abdominal compartment syndrome. Overall, the authors thought that this study helped to serve as template for a randomized prospective trial comparing albumin and crystalloid to crystalloid alone in which they will utilize albumin to help with rising requirements and will be given in a 1/3 to 2/3 ratio and since small burns did not require albumin in this study they will increase the inclusion to >25%TBSA and >20% FT burns.
