Vasoactive and/or inotropic drugs in initial resuscitation of burn injuries: A systematic review
Acta anaesthesiologica Scandinavica. 2022
BACKGROUND According to current guidelines initial burn resuscitation should be performed with fluids alone. The aims of the study were to review the frequency of use of vasoactive and/or inotropic drugs in initial burn resuscitation, and assess benefits and harms of adding such drugs to fluids. METHODS A systematic literature search was conducted in PubMed, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, UpToDate, and SveMed+ through 3 December 2021. The search included studies on critically ill burn patients receiving vasoactive and/or inotropic drugs in addition to fluids within 48 hours after burn injury. RESULTS The literature search identified 1058 unique publications that were screened for inclusion. After assessing 115 publications in full text, only two retrospective cohort studies were included. One study found that 16 out of 52 (31%) patients received vasopressor(s). Factors associated with vasopressor use were increasing age, burn depth and % total body surface area (TBSA) burnt. Another study observed that 20 out of 111 (18%) patients received vasopressor(s). Vasopressor use was associated with increasing age, Baux score and %TBSA burnt in addition to more frequent dialysis treatment and increased mortality. Study quality assessed by the Newcastle-Ottawa quality assessment scale was considered good in one study, but uncertain due to limited description of methods in the other. CONCLUSION This systematic review revealed that there is lack of evidence regarding benefits and harms of using vasoactive and/or inotropic drugs in addition to fluids during early resuscitation of patients with major burns.
Efficacy and safety of blood purification in the treatment of deep burns: A systematic review and meta-analysis
INTRODUCTION This meta-analysis aimed to systematically review and evaluate randomized controlled trials (RCTs) and cohort studies examining the efficacy and safety of blood purification in the treatment of patients with deep burns. METHODS The PubMed, Cochrane Library, and Embase databases and relevant references were systematically searched for RCTs and cohort studies published until the end of September 2020 to investigate the potential of blood purification in improving the prognosis of severely burned patients. The primary outcome of this systematic review was overall patient mortality; secondary outcomes included the incidence of sepsis and infection prevention (vital signs and routine blood tests). RESULTS A total of 6 RCTs and 1 cohort study were included, with a total of 538 burn patients (274 patients who received blood purification and 264 control patients). Compared with patients who received conventional treatment, those treated with blood purification displayed significant 2-day reduction in mortality and sepsis with relative risks of 0.62 and 0.41, respectively (95% confidence intervals [CIs], 0.74-0.82 and 0.25-0.67, respectively; P < .05). In terms of vital signs and blood biochemistry, the respiratory rates and blood urea nitrogen levels of patients in the blood purification group 3 days post-treatment were significantly higher than those in the control group (randomized standard deviations (SMDs), 0.78 and 0.77, respectively; 95% CIs, 0.33-1.23 and 1.22-0.31, respectively; P < .05). However, there were no significant differences between groups on day 3 with regard to temperature (P = .32), heart rate (P = .26), white blood cell count (P = .54), or neutrophil count (P = .74), potentially owing to the small sample size or the relatively short intervention time. Heterogeneous differences existed between the groups with respect to blood urea nitrogen (SMD = -1.22; 95% CI, -2.16 to -0.40; P < .00001) and Cr (SMD = -3.13; 95% CI, -4.92 to -1.33; P < .00001) on day 7. No systematic adverse events occurred. CONCLUSIONS Blood purification treatment for deep burn patients can significantly reduce the mortality rate and the incidence of complications.
Effectiveness of platelet rich plasma in burn wound healing: A systematic review and meta-analysis
The Journal of dermatological treatment. 2020;:1-25
Background: To evaluate the efficacy of platelet-rich plasma (PRP) in the treatment of burn wounds.Methods: A comprehensive literature survey was conducted in electronic medical journal databases to identify studies that examined the effect of PRP treatment to burn wounds and meta-analyses of mean differences (MD) standardized MD, or odds ratios (OR) were performed.Results: The percentage of graft take was not significantly different between PRP-treated and control wound areas. Healing rate was significantly better in PRP-treated wounds. Healing time was also significantly less in PRP-treated wounds. There was no significant difference between PRP-treated and control wound areas in epithelialization, or in the incidence of adverse events. Incidence of infection was also not different between PRP-treated and control wound areas. Scar assessment score was significantly better in PRP-treated than in control wound areas.Conclusion: PRP treatment to burn wounds is found to improve healing. Variations in study design and sample size, types of wounds, PRP preparation protocols, and high risk of bias in some of the included studies may have impact on these outcomes.
Evaluation of the Effect of Platelet-Rich Fibrin on Wound Healing at Split-Thickness Skin Graft Donor Sites: A Randomized, Placebo-Controlled, Triple-Blind Study
The international journal of lower extremity wounds. 2020;:1534734619900432
Split-thickness skin grafting (STSG) is widely used to heal wounds resulting from trauma, burns, and chronic wounds. This study aimed to determine the true effect of platelet-rich fibrin (PRF) on patients with burn wounds requiring STSG during treatment of donor wounds. This randomized, triple-blind clinical trial was conducted on patients who referred to the burn ward of Vasei Hospital of Sabzevar, Iran, from May 2017 to May 2018. The donor site was randomly divided into 2 groups: PRF and control (Vaseline petrolatum gauze) using Vaseline gauze. In the intervention group, the PRF gel was applied to the wound and covered with Vaseline gauze and wet dressing. Conversely, only Vaseline gauze and wet dressing were applied to the control group. Outcome evaluation was conducted using paired t test and Wilcoxon signed rank-sum test, as appropriate, on days 8 and 15. The mean age of the patients was 33.10 +/- 2.60 years, and 51.50% were male. The mean wound healing time in the PRF and control groups was 11.80 +/- 3.51 and 16.30 +/- 4.32 days, respectively (P < .001). The PRF group showed significantly higher wound healing rates than the control group at 8 and 15 days dressing (P < .001 and P < .001, respectively). Moreover, the mean wound healing for all wound healing indices diagnosed by 2 specialists in PRF was higher than control group on days 8 and 15 (P < .001). We found a statistically significant difference on days 8 and 15 regarding the mean pain levels between the 2 groups (P < .001). The findings showed that PRF can significantly increase the time and rate of donor wound healing compared with conventional treatment and also reduce the severity of pain.
The best strategy for red blood cell transfusion in severe burn patients, restrictive or liberal: A randomized controlled trial
Burns : journal of the International Society for Burn Injuries. 2020
INTRODUCTION Although blood transfusion is common in burns, data are lacking in appropriate transfusion thresholds. It has been reported that a restrictive blood transfusion policy decreases blood utilization and improves outcomes in critically ill adults, but the impact of a restrictive blood transfusion policy in burn patients is unclear. We decided to investigate the outcome of decreasing the blood transfusion threshold. MATERIAL AND METHODS Eighty patients with TBSA > 20% who met our inclusion criteria were included. They were randomly divided into control and intervention groups. The intervention group received packed cells only when Hemoglobin declined to less than 8 g/dL at routine laboratory evaluations. While the control group received packed-cell when hemoglobin was declined to less than 10 g/dl. The total number of the received packed cell before, during and after any surgical procedure was recorded. The outcome was measured by the evaluation of the infection rate and other complications. RESULT The mean hemoglobin level before transfusion was 7.7 ± 0.4 g/dL in the restrictive group and 8.8 ± 0.7 g/dL in the liberal group. The mean number of RBC unit transfusion per patient in the restrictive group was significantly lower than the traditional group (3.28 ± 2.2 units vs. 5.9 ± 3.7 units) (p-value = 0.006). The total number of RBC transfused units varied significantly between the two groups (p-value = 0.014). The number of transfused RBC units outside the operation room showed a significant difference between groups (restrictive: 2.8 ± 1.4 units vs. liberal: 4.4 ± 2.6 units) (p = 0.004). We did not find any significant difference in mortality rate or other outcome measures between groups. CONCLUSION Applying the restrictive transfusion strategy in thermal burn patients who are highly prone to all kinds of infection, does not adversely impact the patient outcome, and results in significant cost savings to the institution and lower rate of infection. We conclude that the restrictive transfusion practice during burn excision and grafting is well tolerated and effective in reducing the number of transfusions without increasing complications. CLINICAL TRIAL REGISTRATION REFERENCE IRCT20190209042660N1.
Adult thermal burn patients (n= 80).
Restrictive transfusion threshold: haemoglobin less than 8 g/dL (n= 40).
Liberal transfusion threshold: haemoglobin less than 10 g/dL (n= 40).
The mean haemoglobin level before transfusion was 7.7 ± 0.4 g/dL in the restrictive group and 8.8 ± 0.7 g/dL in the liberal group. The mean number of RBC unit transfusion per patient in the restrictive group was significantly lower than the traditional group (3.28 ± 2.2 units vs. 5.9 ± 3.7 units). The total number of RBC transfused units varied significantly between the two groups. The number of transfused RBC units outside the operation room showed a significant difference between groups (restrictive: 2.8 ± 1.4 units vs. liberal: 4.4 ± 2.6 units). No significant difference in mortality rate or other outcome measures between groups was found.
Physiological response to fluid resuscitation with Ringer Lactate versus Plasmalyte in critically ill burn patients
Journal of applied physiology (Bethesda, Md. : 1985). 2020
The metabolic consequences in vivo of various balanced solutions are poorly known in critically ill patients. The main objective of this study was to describe the metabolic consequences of Plasmalyte(R) versus Ringer lactate (RL) in critically ill burn patients, with a special focus on the plasma clearance of buffer anions (i.e. gluconate, acetate and lactate). We conducted a randomized trial between August 2017 and October 2018 in a tertiary teaching hospital in Paris, France. Patients with burn total body surface area >30% were randomized to receive Plasmalyte(R) or RL. The primary endpoint was the base excess (BE) 24 hours after inclusion. The secondary endpoints were acetate, gluconate and lactate plasma concentration, the strong ion difference (SID). Twenty-eight patients were randomized. Twenty-four hours after inclusion, plasma BE was not significantly different in the Plasmalyte(R) and RL groups (-0.9 [CI95% -1.8-0.9] vs -2.1 [CI95% -4.6-0.6] mmol/L respectively, p=0.26). Plasma gluconate concentration was higher in the Plasmalyte(R) group (p<0.001) with a maximum level of 1.86 (CI95% 0.98-4.0) mmol/L vs 0 (IC95% 0-0.15) mmol/L. Plasma acetate and lactate were not significantly different. Ionized calcium level was lower in the Plasmalyte(R) group (p=0.002). Hemodynamics did not differ between groups. To conclude, alkalinizing effect of Plasmalyte(R) was less important than expected with no difference in base excess compared to RL, in part due to gluconate accumulation. Acetate and lactate did not significantly accumulate. Plasmalyte(R) led to significantly lower ionized calcium levels.
Examining 1:1 Versus 4:1 Packed Red Blood Cell to Fresh Frozen Plasma Ratio Transfusion During Pediatric Burn Excision
Journal of burn care & research : official publication of the American Burn Association. 2020
Blood transfusions following major burn injury are common due to operative losses, blood sampling, and burn physiology. While massive transfusion improves outcomes in adult trauma patients, literature examining its effect in critically ill children is limited. The study purpose was to prospectively compare outcomes of major pediatric burns receiving a 1:1 vs 4:1 packed red blood cell (PRBC) to fresh frozen plasma (FFP) transfusion strategy during massive burn excision. Children with >20% total body surface area (TBSA) burns were randomized to a 1:1 or 4:1 PRBC/FFP transfusion ratio during burn excision. Parameters examined include patient demographics, burn size, Pediatric Risk of Mortality (PRISM) scores, Pediatric Logistic Organ Dysfunction (PELOD) scores, laboratory values, total blood products transfused, and the presence of blood stream infections or pneumonia. A total of 68 children who met inclusion criteria were randomized into two groups (n=34). Mean age, PRISM scores, estimated blood loss (600 mL (400 - 1175 mL) v 600 mL (300 - 1150 mL), p = 0.68), ventilator days (5 v 9, p = 0.47), and length of stay (57 v 60 days, p = 0.24) had no difference. No differences in frequency of blood stream infection (20 v 18, p = 0.46) or pneumonia events (68 v 116, p = 0.08) were noted. On multivariate analysis, only TBSA burn size, inhalation injury, and PRISM scores (p < 0.05) were significantly associated with infections.
Autologous Platelet Rich Plasma As A Preparative for Resurfacing Burn Wounds with Split Thickness Skin Grafts
World J Plast Surg. 2020;9(1):29-32
BACKGROUND Split thickness skin graft is a widely accepted technique to cover large defects. Shearing, hematoma and infection have often been attributed as major causes for graft loss. Autologous platelet rich plasma (PRP) has been used in various treatment modalities in the field of plastic surgery for its healing, adhesive and hemostatic properties owing to the growth factors that are released. This Study primarily throws light on the usage of PRP over difficult Burn wound beds to augment graft uptake and attenuate complications. METHODS The patients were divided into two groups of those who were subjected to use of autologous PRP as a preparative burn surfacing and the control group who underwent standard method of treatment. RESULTS Patients in PRP group significantly showed a higher graft adherence rate as compared to those with other method. It also reduced pain, and hematoma formation. CONCLUSION Application of PRP is a safe, cost effective, easy method to increase graft adherence rate in patients with burns where graft loss is noticed and there is shortage of donor sites.
[Effect of fluid resuscitation guided by pulse contour cardiac output monitoring technology on organ function in extremely severe burn patients]
Zhonghua shao shang za zhi = Zhonghua shaoshang zazhi = Chinese journal of burns. 2020;36(10):939-946
Objective: To investigate the effect of fluid resuscitation guided by pulse contour cardiac output (PiCCO) monitoring technology on the organ function in extremely severe burn patients. Methods: From May 2015 to March 2019, 52 patients with extremely severe burn hospitalized in Tongren Hospital of Wuhan University & Wuhan Third Hospital, meeting the inclusion criteria, were recruited to conduct a prospectively randomized control study. The patients were divided into PiCCO monitoring rehydration group (25 cases, 17 males and 8 females) and traditional rehydration group (27 cases, 20 males and 7 females) according to the random number table, with the ages of (47±9) and (49±8) years respectively. After admission, all the patients were rehydrated according to the rehydration formula of the Third Military Medical University during shock stage. In traditional rehydration group, fluid resuscitation of the patients was performed by monitoring the traditional shock indicators such as urine volume and central venous pressure, while PiCCO monitoring was performed in patients in PiCCO monitoring rehydration group, and the global end-diastolic volume index combined with the other relevant indicators of PiCCO monitoring were used to guide rehydration on the basis of the monitoring indicators of traditional rehydration group. The rehydration coefficients and urine volumes per kilogram of body weight per hour during the first and second 24 h post injury were compared between the two groups, which were compared with the corresponding rehydration scheme value of the Third Military Medical University (hereinafter referred to as the scheme value) at the same time. The total rehydration volumes within post injury hour (PIH) 8 and during the first and second 24 h post injury, the urine volumes per hour during the first and second 24 h post injury, and the levels of creatinine, urea nitrogen, lactate clearance rate, procalcitonin, creatine kinase isoenzyme (CK-MB) in blood and mean arterial pressure (MAP) on post injury day (PID) 1, 2, and 3 were measured. The incidence of complications, the application case number of mechanical ventilation, and the mechanical ventilation time within PID 28 were analyzed. Data were statistically analyzed with analysis of variance for repeated measurement, t test, Bonferroni correction, Mann-Whitney U test, chi-square test, and Fisher's exact probability method test. Results: During the second 24 h post injury, the rehydration coefficient of patients in traditional rehydration group was significantly higher than the scheme value (t=5.120, P<0.01). During the first and second 24 h post injury, the rehydration coefficients of patients in PiCCO monitoring rehydration group were significantly higher than the scheme values (t=3.655, 10.894, P<0.01) and those in traditional rehydration group (t=3.172, 2.363, P<0.05 or P<0.01). Within PIH 8, the total rehydration volumes of patients between the two groups were similar. During the first and second 24 h post injury, the total rehydration volumes of patients in PiCCO monitoring rehydration group were significantly higher than those in traditional rehydration group (t=4.428, 3.665, P<0.01). During the first and second 24 h post injury, the urine volumes per kilogram of body weight per hour of patients in traditional rehydration group were significantly higher than the schema values (t=4.293, 6.362, P<0.01), and the urine volumes per kilogram body weight per hour of patients in PiCCO monitoring rehydration group were significantly higher than the schema values (t=6.461, 8.234, P<0.01). The urine volumes per kilogram of body weight per hour and urine volumes per hour of patients in PiCCO monitoring rehydration group during the second 24 h post injury were significantly higher than those in traditional rehydration group (t=2.849, 3.644, P<0.05 or P<0.01). The creatinine levels of patients between the two groups on PID 1, 2, and 3 were similar. The urea nitrogen levels of patients in PiCCO monitoring rehydration group on PID 1, 2, and 3 were (6.8±1.5), (5.6±1.4), (4.4±1.4) mmol/L respectively, which were significantly lower than (8.6±1.8), (6.6±1.5), (5.5±1.4) mmol/L in traditional rehydration group (t=3.817, 2.511, 2.903, P<0.05 or P<0.01). The lactate clearance rates of patients in PiCCO monitoring rehydration group on PID 1, 2, and 3 were significantly higher than those in traditional rehydration group (t=2.516, 4.540, 3.130, P<0.05 or P<0.01). The procalcitonin levels of patients in PiCCO monitoring rehydration group on PID 2 and 3 were significantly lower than those in traditional rehydration group (Z=-2.491, -2.903, P<0.05). The CK-MB level of patients in PiCCO monitoring rehydration group on PID 3 was (35±10) U/L, which was significantly lower than (51±16) U/L in traditional rehydration group (t=4.556, P<0.01). The MAP levels of patients between the two groups on PID 1, 2, and 3 were similar. Within PID 28, the incidence of complications of patients in traditional rehydration group was significantly higher than that in PiCCO monitoring rehydration group (χ(2)=4.995, P<0.05), and the application case number of mechanical ventilation and the mechanical ventilation time of patients between the two groups were similar. Conclusions: The use of PiCCO monitoring technology to guide the early fluid resuscitation of extremely severe burn patients is beneficial for accurate determination of the fluid volume required by the patients and reduction of organ injury caused by improper rehydration.
Pediatric Toxic Shock Syndrome After a 7% Burn: A Case Study and Systematic Literature Review
Annals of plastic surgery. 2019
INTRODUCTION Toxic shock syndrome (TSS) is a life-threatening condition, which occurs in children after sustaining a burn. Often diagnosed retrospectively, many patients may not receive optimal treatment.The primary objective of this study was to evaluate a severe and complex case of TSS at our unit and subsequently conduct a Preferred Reporting for Systematic Reviews and Meta-Analyses-compliant systematic literature review, to identify cases of postthermal injury TSS and evaluate their presentation and management. CASE REPORT A 9-year-old boy with Down syndrome presented with a 7% total body surface area scald to his back and posterior head. Four days after discharge, he developed a fever. The following day, he deteriorated, becoming stridulous and unresponsive. A working diagnosis of TSS was made. The patient's intensive care stay was arduous with multiple complications, including 2 cardiac arrests. METHODS A Preferred Reporting for Systematic Reviews and Meta-Analyses-compliant systematic literature review was conducted. MEDLINE, PubMed, and Web of Science were searched using key terms "burns, thermal injury, scalds, paediatric, child, infant, neonate, toxic shock syndrome" to identify cases. Two authors independently checked each study against inclusion criteria. RESULTS The systematic literature search yielded 9 articles, identifying 40 cases. Ages ranged between 9 months and 8 years. The mean number of days' postburn patients presented with symptoms of TSS was 2.5 days (1-7 days). The most common presenting symptoms were fever (75%), rash (70%), and diarrhea, and/or vomiting (52.5%). Intravenous immunoglobulins were administered in 11 (27.5%) cases. DISCUSSION We have highlighted a case where a possible delayed diagnosis along with the immunodeficiency seen in Down syndrome may have impacted the severity of TSS. The literature review highlighted that a significant proportion of patients do not meet diagnostic criteria. CONCLUSIONS It is fundamental that appropriate diagnostic and management guidelines are developed. Furthermore, this case highlights the importance of educating patient's carers and health professionals of key symptoms to be wary of postburn.