Abstract

Acute burn surgery has long been associated with significant intra-operative bleeding. Several techniques were introduced to limit hemorrhage, including tourniquets, tumescent infiltration, and topical agents. To date, no study has comprehensively investigated the available data regarding topical hemostatic agents in burn surgery. A systematic review was performed by two independent reviewers using electronic databases (PubMed, Scopus, Web of Science) from first available to September 10, 2021. Articles were included if they were published in English and described or evaluated topical hemostatic agents used in burn excision and/or grafting. Data were extracted on the agent(s) used, their dosage, mode of delivery, hemostasis outcomes, and complications. The search identified 1982 non-duplicate citations, of which 134 underwent full-text review, and 49 met inclusion criteria. In total, 32 studies incorporated a vasoconstrictor agent, and 28 studies incorporated a procoagulant agent. Four studies incorporated other agents (hydrogen peroxide, tranexamic acid, collagen sheets, and TT-173). The most common vasoconstrictor used was epinephrine, with doses ranging from 1:1,000-1:1,000,000. The most common procoagulant used was thrombin, with doses ranging from 10-1,000 IU/mL. Among the comparative studies, outcomes of blood loss were not reported in a consistent manner, therefore meta-analysis could not be performed. The majority of studies (94%) were level of evidence III-V. Determining the optimal topical hemostatic agent is limited by low-quality data and challenges with consistent reporting of intra-operative blood loss. Given the routine use of topical hemostatic agents in burn surgery, high-quality research is essential to determine the optimal agent, dosage, and mode of delivery.

Abstract

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.

Abstract

BACKGROUND The management of severe burn-injured Jehovah's Witness patients who decline a blood transfusion poses unique challenges. The literature is scant for guiding perioperative anaemia management in these patients. We present a systematic review of this patient group, along with illustrative, consecutive case reports of our experience. METHODS A systematic review was performed on Embase, MEDLINE and PubMed databases on articles discussing the treatment of burn-injured Jehovah's Witness patients. Articles were excluded if discussing isolated inhalation injury, or if blood transfusions were permitted. RESULTS Nine articles including a total of 11 patients revealed consistent themes. A multimodal medical and surgical approach is suggested. Medical strategies are directed at reducing blood loss and optimising haematopoiesis and include rationalising blood collection, reversing coagulopathy, administering tranexamic acid and regular erythropoietin. Surgical strategies include staged aggressive debridement, tumescent adrenaline infiltration and limb tourniquets. We found that the argon beam coagulator was an effective haemostatic adjunct not previously described in literature. DISCUSSION Management of anaemia in severely burn-injured Jehovah's Witness patients is challenging. This systematic review presents a summary of strategies directed at minimising blood loss, and optimising haematopoiesis. Careful preoperative planning, meticulous surgical technique, and postoperative physiological support are caveats to success.

Abstract

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.

Abstract

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.

Abstract

BACKGROUND Optimal fluid resuscitation in children with major burns is crucial to prevent or minimise burn shock and prevent complications of over-resuscitation. OBJECTIVES To identify studies using endpoints to guide fluid resuscitation in children with burns, review the range of reported endpoint targets and assess whether there is evidence that targeted endpoints impact on outcome. DESIGN Systematic review. METHODS Medline, Embase, Cinahl and the Cochrane Central Register of Controlled Trials databases were searched with no restrictions on study design or date. Search terms combined burns, fluid resuscitation, endpoints, goal-directed therapy and related synonyms. Studies reporting primary data regarding children with burns (<16 years) and targeting fluid resuscitation endpoints were included. Data were extracted using a proforma and the results were narratively reviewed. RESULTS Following screening of 777 unique references, 7 studies fulfilled the inclusion criteria. Four studies were exclusively paediatric. Six studies used urine output (UO) as the primary endpoint. Of these, one set a minimum UO threshold, while the remainder targeted a range from 0.5-1.0 mL/kg/hour to 2-3 mL/kg/hour. No studies compared different UO targets. Heterogeneous study protocols and outcomes precluded comparison between the UO targets. One study targeted invasive haemodynamic variables, but this did not significantly affect patient outcome. CONCLUSIONS Few studies have researched resuscitation endpoints for children with burns. Those that have done so have investigated heterogeneous endpoints and endpoint targets. There is a need for future randomised controlled trials to identify optimal endpoints with which to target fluid resuscitation in children with burns.

Abstract

Major burn surgery is often associated with excessive bleeding and massive transfusion, and the development of a coagulopathy during major burn surgery is associated with increased morbidity and mortality. The aim of this study was to review the literature on intraoperative haemostatic resuscitation of burn patients during necrectomy to reveal strategies applied for haemostatic monitoring and resuscitation. We searched PubMed, EMBASE, and CENTRAL for studies published in the period 2006-2017 concerning bleeding issues related to burn surgery i.e. coagulopathy, transfusion requirements and clinical outcomes. In a broad search, a total of 1375 papers were identified. 124 of these fulfilled the inclusion criteria, and six of these were included for review. The literature confirmed that transfusion requirements increases with burn injury severity and that haemostatic monitoring by TEG((R)) (thrombelastography) or ROTEM((R)) (rotational thromboelastometry) significantly decreased intraoperative transfusions and was useful in predicting and goal-directing haemostatic therapy during excision surgery. Resuscitation of bleeding during major burn surgery in many instances was neither standardized nor haemostatic. We suggest that resuscitation should aim for normal haemostasis during the bleeding phase through close haemostatic monitoring and resuscitation. Randomised controlled trials are highly warranted to confirm the benefit of this concept.

Abstract

BACKGROUND Excessive bleeding is a major concern in scar debridement and grafting procedures. TT-173 is a new topical hemostatic agent based on recombinant human tissue factor that has shown promising results in patients who underwent tooth extraction. EHTIC study sought to evaluate the efficacy and safety of TT-173 to reduce the bleeding in donor sites of skin grafting procedures. METHODS EHTIC study was a phase II, randomized, parallel, double blind, placebo controlled trial. Patients received TT-173 (n=38) or placebo (n=33) sprayed over donor site after graft harvest. Time to hemostasis and incidence of adverse events were recorded. Systemic absorption of the product and its immunogenicity were also measured during the follow up of the subjects. RESULTS Treatment with TT-173 significantly reduced the bleeding time from 7 to 3min (Log-Rank p<0.0001). Moreover, bleeding stopped within the 10min of evaluation period in all the patients that received TT-173. In contrast, 24.24% of patients from placebo group required additional measures to arrest hemorrhage (Fisher p=0.0013). Product related adverse events, systemic absorption into blood stream, interferences with the healing of the donor site or immunogenic reaction against TT-173 were not observed. CONCLUSION The new hemostatic agent TT-173 has proven efficacious and safe to reduce the bleeding from donor site. This study paves the way for further investigation of the product as topical hemostatic treatment in plastic surgery and other surgical indications.

Abstract

OBJECTIVES Fluid resuscitation is the mainstay treatment to reconstitute intravascular volume and maintain end-organ perfusion in patients with severe burns. The use of a hyper-osmotic or iso-osmotic solution in fluid resuscitation to manage myocardial depression and increased capillary permeability during burn shock has been debated. We conducted a systematic review and meta-analysis to compare the efficacies of hyper-osmotic and iso-osmotic solutions in restoring hemodynamic stability after burn injuries. METHODS PubMed, Embase, Cochrane Library, Scopus, and ClinicalTrials. gov registry were searched. Randomized control trials evaluating the efficacy and safety of hyper-osmotic and iso-osmotic fluid resuscitation in patients with burn injuries were selected. Eligible trials were abstracted and assessed for the risk of bias by 2 reviewers and results of hemodynamic indicators in the included trials were analyzed. RESULTS Ten trials including 502 participants were published between 1983 and 2013. Compared with iso-osmotic group, the hyper-osmotic group exhibited a significant decrease in the fluid load (vol/%TBSA/weight) at 24 h postinjury, with a mean difference of -0.54 (95% confidence interval = -0.92 to -0.17). No differences were observed in the urine output, creatinine level, and mortality at 24 h postinjury between groups. CONCLUSIONS Hyper-osmotic fluid resuscitation appears to be an attractive choice for severe burns in terms of total body surface area or burn depth. Further investigation is recommended before conclusive recommendation. This article is protected by copyright. All rights reserved.

Abstract

INTRODUCTION One of the primary intraoperative challenges during burn surgery is to adequately excise the burn while avoiding massive hemorrhage. This has become increasingly important, as we see more burn patients that are older and with more medical comorbidities. While adequate excision down to healthy tissues for deep burns is essential for skin graft to take, it also leads to active bleeding that can be a challenge to control. Good hemostasis is imperative as a hematoma is the most common cause of graft loss. Several new products have become available to help control intraoperative hemorrhage. A new hemostatic dressing, NuStat(R), is available and approved by FDA in United States. METHODS A single institution prospective randomized control trial was completed at Regional Burn Center of the University of South Alabama comparing NuStat(R) with the institutional historic standard of care. Twenty such patients were included in our study. A cost analysis was also completed as part of the study retrospectively. RESULTS For dressings used to treat the burn site, blood loss on the side treated with NuStat(R) was on average less (27g/100cm2) than the side treated with our historic standard of care (31g/100cm2), though it was not statistically significant (p=0.81). Similarly, on the donor site, blood loss on the side treated with NuStat(R) was on average less (14g/100cm2) than the side treated with our historic standard of care (15g/100cm2), but it was also not statistically significant (p=0.92). Average total blood loss from both excision and donor sites was also less with NuStat(R) (10g/100cm2) compared to the historic standard of care (12g/100cm2), but it was also not significant (p=0.77). There was no difference in the number of cycles required to achieve hemostasis for either the burn (1.15 NuStat(R) vs. 1.1 for historic standard of care, p=0.70) or the donor site (1 vs. 1, p=1.0). When comparing the cost of NuStat(R) versus the historic standard of care, the actual costs incurred for the wounds was less for the portion treated with NuStat(R) ($148.43) when compared to the historic standard of care ($186.45) (p<0.001). CONCLUSIONS Based on these findings, NuStat(R) hemostatic action should be comparable to the historic standard of care, and these newer hemostatic agents evaluated further in burn surgery and bleeding during other procedures such as trauma surgery.