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A recent Clinical Practice Guidelines focused on acute fluid resuscitation within the first 48 hours for adults with burns covering 20% or more of TBSA.
A recent Clinical Practice Guideline focused on acute fluid resuscitation within the first 48 hours for adults with burns covering at least 20% of the total body surface area (TBSA). The guideline was developed by an investigation panel that utilized PICO questions and reviewed 24 out of 5978 screened studies.
Key recommendations, which authors published online in the Journal of Burn Care & Research, included using human albumin solution to reduce resuscitation volumes and improve urine output, initiating resuscitation with 2 mL/kg/% TBSA burn, and selectively monitoring intra-abdominal and intraocular pressures. The use of computer decision support software for fluid titration is weakly recommended, while the use of transpulmonary thermodilution-derived variables is not recommended.
Due to insufficient quality studies, the authors offered no recommendations on high-dose vitamin C, fresh frozen plasma, early continuous renal replacement therapy, or vasopressors. The guideline, developed from March 2022 to March 2023 by the American Burn Association (ABA), aims to guide clinicians without being prescriptive, emphasizing the importance of bedside clinical judgment.
Albumin vs Crystalloid
In adults with burns covering at least 20% of their TBSA, the use of albumin during the first 24 hours of fluid resuscitation has shown potential benefits over crystalloid fluid alone. Several studies indicate that albumin can improve urinary output and reduce the total volume of resuscitation fluids, especially in patients with larger burns. In rescue scenarios where resuscitation with crystalloids fails, albumin administration appears particularly beneficial. However, the evidence supporting albumin’s ability to decrease edema-related complications remains limited. The ABA Guidelines advise clinicians to consider albumin use in large burns and deteriorating resuscitation cases, albeit with caution regarding its effects on edema.
Timing of Albumin Administration
The timing of albumin administration in burn patients—whether early (<12 hours post-burn) or late (≥12 hours post-burn)—is a critical consideration. However, current evidence is insufficient to make definitive recommendations. The ABRUPT study, the primary source of data on this topic, suggests that earlier administration of albumin may lead to a faster decline in fluid infusion rates. However, due to potential selection biases and the limited strength of this study, no firm conclusions can be drawn about the optimal timing. Given these uncertainties, initiating albumin within the first 12 hours should ideally be done in the context of ongoing research to better understand its impact on fluid volumes, urine output, and edema.
Fluid Resuscitation Volumes
The shift from a fluid resuscitation protocol starting at 4 mL/kg/%TBSA burn to 2 mL/kg/%TBSA burn has been supported by studies highlighting the risks of over-resuscitation and “fluid creep.” The ABA now recommends initiating resuscitation at 2 to 4 mL/kg/%TBSA, with a tendency towards the lower end to reduce the total volume of resuscitation fluids. This recommendation is based on retrospective observations and emphasizes that initial fluid rates should be adjusted according to the patient’s response. Further research is necessary to confirm the benefits of lower starting rates on edema-related complications and acute kidney injury (AKI).
Fresh Frozen Plasma
The use of fresh frozen plasma (FFP) during acute fluid resuscitation in burn patients remains uncertain. Two studies comparing FFP to crystalloid alone have not provided sufficient evidence to support its routine use for reducing fluid volumes, increasing urine output, or decreasing edema-related complications. Given the current lack of robust data, the administration of FFP in burn resuscitation is recommended only within the framework of research studies to understand its potential benefits and risks better.
High-Dose Ascorbic Acid (Vitamin C)
High-dose vitamin C (66 mg/kg/hour) has been explored as an adjunct to crystalloids in acute fluid resuscitation for burn patients. While some studies suggest it may promote diuresis and reduce resuscitation volumes, the evidence is inconclusive. The potential benefits of high-dose vitamin C are counterbalanced by concerns about its effects on urine output measurement, the risk of dehydration from osmotic diuresis, uncertainties about the optimal dose, and the possibility of oxalate nephropathy. Currently, there is no strong recommendation for its use, and further research is needed to clarify its role in burn care.
CVP, TPTD, SVV, and PPV
In managing acute fluid resuscitation for adults with burns at least 20% TBSA, various monitoring techniques like central venous pressure (CVP), transpulmonary thermodilution (TPTD), and arterial waveform analysis (SVV or PPV) have been considered against the traditional method of using hourly urine output. Evidence from six studies, including high-strength randomized controlled trials and case-control studies, does not support using TPTD-derived variables to reduce total resuscitation fluid volumes or decrease edema-related complications. Due to insufficient evidence, no recommendations can be made regarding SVV or PPV’s efficacy in these outcomes. Consequently, conventional endpoints alongside urine output remain the preferred monitoring strategy.
Computerized Decision Support Software
The use of computerized decision support software (CDSS) in titrating acute resuscitation fluids for burn patients was examined in a high-strength study. CDSS, developed to aid non-specialist providers in initial burn stabilization, uses patient data to recommend hourly fluid rates based on urine output trends. This system, now FDA-approved and widely used, shows promise in reducing total resuscitation fluid volumes. However, concerns about potential neglect of bedside clinical assessment and decision-making limit a strong endorsement. Thus, CDSS is weakly recommended for reducing fluid volumes, but no recommendation is made regarding its impact on edema-related complications.
Norepinephrine vs Vasopressin for Hypotension
In burn patients requiring vasopressors for hypotension, the choice between norepinephrine and vasopressin to reduce 28-day mortality and the incidence of AKI remains unclear. The search for relevant studies yielded no results, leaving the panel unable to provide recommendations on the preferred vasopressor. Therefore, clinical decisions regarding vasopressor selection should be based on individual patient factors and clinician judgment until further evidence becomes available.
Early Continuous Renal Replacement Therapy
The potential benefits of early continuous renal replacement therapy (CRRT) without fluid removal during acute fluid resuscitation in burn patients were explored, but no studies met the inclusion criteria for review. Although CRRT shows promise in reducing inflammation and improving outcomes in other conditions like sepsis and ARDS, its specific effects in the context of burn resuscitation remain unsubstantiated. Consequently, no recommendations can be made regarding using early CRRT to reduce fluid volumes or edema-related complications, highlighting the need for further research.
Monitoring IAP, IOP, Serum Lactate, and Arterial Base Deficit
The utility of monitoring intra-abdominal pressure (IAP), intra-ocular pressure (IOP), serum lactate, and arterial base deficit during the first 48 hours post-burn to manage fluid resuscitation and prevent compartment syndromes was examined. No studies specifically addressed these monitoring strategies’ impact on fluid volumes or the incidence of compartment syndromes. Selective monitoring of IAP and IOP is recommended in cases with extensive burns or high fluid volumes, following clinical indications of compartment syndrome. Routine monitoring of serum lactate and arterial base deficit is not recommended, though selective use may be beneficial based on clinical judgment.
