REVIEW ARTICLE

Critical care management in burns:

A review of current evidence and guidelines -Part 1
Umesh Jayarajah, Oshan Basnayake, Gayan Ekanayake
Plastic and Reconstructive Surgery, National Hospital of Sri Lanka, Colombo, Sri Lanka

Keywords: Burns; severe burns; critical care; burns narrative review focuses on the contemporary literature, on
resuscitation; fluid resuscitation; review the critical care of severe burns once the patient has been
stabilised after the initial injury. The review consists of two
Abstract parts and the first part focusses on fluid resuscitation, goal-
Recent literature on the management of critically ill patients directed fluid therapy, haemodynamic monitoring and
have altered the beliefs and clinical behaviours, questioning coagulopathy in severe burns. The second part describes
many dogmas that were practiced without much evidence. aspects such as thromboprophylaxis, role of suppressing
The critical care in a severely burn-injured patient requires hypermetabolism, glycaemic control, nutritional support,
special attention in resuscitation, haemodynamic monitoring, sepsis and infection control, management of inhalational
management of complications, organ support and injuries, surgical debridement, pain management and
determinants of outcome. The goal of resuscitation is to palliative care in severe burns.
maintain intravascular volume and tone while correcting the
reversible changes in altered physiology, aided by early Methods
debridement of burned tissue and elimination of the source of We performed a literature search on PubMed and Google
physiological derangement. Practitioners should target Scholar, and looked for published original articles, review
resuscitation based on goal-directed therapy using non- articles and guidelines on critical care management in burns,
invasive markers of cardiac output. The management requires up to November 2019. Our search was limited to articles in
the input of a multi-disciplinary team to achieve critical care English. Correspondence, dissertations and unpublished
and early surgical intervention and management of materials were not considered. The information were
complications and organ support. summarised and presented qualitatively (narratively) under
subheadings.
Introduction
Recent literature on the management of critically ill patients Contents:
have altered the beliefs and clinical behaviours, questioning Fluid resuscitation in severe burns
many dogmas that were practiced without much evidence [1]. Goal-directed fluid therapy and Haemodynamic monitoring
Furthermore, the fundamental understanding of critical care Evidence on choice of fluid for resuscitation
in terms of fluid management, haemodynamic monitoring,
Management of coagulopathy in severe burns
management of acute respiratory distress syndrome (ARDS),
Thromboprophylaxis in burns
organ support and nutrition support are changing [1]. The
goal of resuscitation is to maintain intravascular volume and The role of suppressing hypermetabolism in severe burns
tone while correcting the reversible changes in altered Glycaemic control in severe burns
physiology, aided by early debridement of burned tissue and Nutritional support in severe burns
elimination of the source of physiological derangement. The Sepsis and infection control in burns
definition of severe burns is based on the surface area (20% Management of inhalational injuries and acute respiratory
excluding superficial burns), presence of inhalational or distress syndrome (ARDS)
electrical injury, patients' age and comorbidities [2]. The
Early surgical debridement and soft tissue cover
critical period in severe burns is usually transient, lasting for
few days. However, may include intermittent episodes of Pain management in severe burns
deterioration based on burn related complications. This Palliative care in severe burns

Correspondence: Umesh Jayarajah

E-mail: umeshe.jaya@gmail.com
https://orcid.org/0000-0002-0398-5197
Received: 11-01-2020 Accepted: 29-08-2020
DOI: http://doi.org/10.4038/sljs.v38i2.8664
The Sri Lanka Journal of Surgery 2020; 38(2): 50-56 50
Fluid resuscitation in severe burns replacement may lead to a series of complications [8].
The patients with severe burns receive a large volume of fluid
in the first 24 hours compared with any other trauma patients Goal-directed fluid therapy and Haemodynamic
due to the pathophysiological processes involved. The initial monitoring
burn shock results due to a combination of hypovolaemic Goal-directed fluid therapy has become as essential concept
shock and cell shock. In addition to the local increase in in initial fluid resuscitation in severe burns and for critical
vascular permeability in affected tissue, the inflammatory care in general. Patients with severe burns require a large
mediators such as Nuclear factor κB, tumor necrosis factor volume of fluid in resuscitation. This may not be well
(TNF-α) and other cytokines released by burned tissue causes tolerated and may contribute to complications such as ileus,
sequestration of leucocytes and other inflammatory cells. abdominal and extremity compartment syndromes,
These cells act as a major source of proinflammatory respiratory complications such as pulmonary oedema and
mediators and initiate a major systemic inflammatory adult respiratory distress syndrome (ARDS), and also
response syndrome, increasing the vascular permeability in generalized oedema [1]. Therefore, many studies have been
both the affected and healthy tissue throughout the body [3]. conducted to identify feasible targets to guide fluid
The cascade of events leads to increased fluid shift from the resuscitation. Furthermore, studies have shown that the vital
intravascular compartment to the interstitial space causing signs and the urine output showed minimal variations after
oedema, haemoconcentration and hypovolaemia. In addition, fluid resuscitation, however significant changes were noted in
the cytokine storm produced by the inflammatory response other parameters such as those measured by pulmonary artery
results in decreased vascular resistance due to vasodilation catheterization (PAC). Therefore, vital signs alone was found
and decreased cardiac contractility, contributing to shock. to be inadequate to guide the adequacy of fluid resuscitation
Furthermore, the severity of the inhalation injury also impacts in critically ill patients [10].
the fluid requirements and the prognosis.
Therefore, cardiac output has become an important parameter
The Parkland formula is widely used for initial fluid to guide volume resuscitation, however only less than 10% of
resuscitation in the burns patient. According to the American specialised burns units utilise this parameter as PAC is
Burn Association guidelines the formula was revised to 2–4 required for its measurement [11]. Several studies have
ml of Ringer's lactate (RL) solution per kilogram of weight attempted to find non-invasive alternatives to PAC in fluid
per percentage of burned body surface area in adults [4]. The resuscitation based on goal directed therapy. However in the
primary objectives of fluid resuscitation are preserving and past, the applicability and validity of the novel alternatives in
restoring tissue perfusion and preventing ischaemia. burn resuscitation have been questioned. Therefore, further
However, this is challenging due to the worsening oedema studies were conducted for validation, identification of end
and transvascular displacement of fluids during resuscitation points and the relevance in terms of improving outcomes [12].
[5, 6]. Although the Parkland formula is utilised, the volume Several techniques have been identified as useful or
of fluid has to be adjusted according to the urinary output and potentially useful monitoring parameters for guided fluid
other parameters leading to considerable variations in the therapy in burns. Oesophageal echo-doppler monitoring was
fluid administered. A study by Ete et al has shown significant found to be a useful adjunct to clinical judgement in severe
differences in the fluid administered based on urine output burns [13]. Transpulmonary thermodilution is one such non-
and the fluid calculated by Parkland formula [7]. The invasive method that has been validated in burns [14]. Other
imprecise body surface area calculations and variations in methods include extra-vascular lung water, intrathoracic
fluid shift may contribute to this discrepancy. Suboptimal blood volume, pulse contour cardiac output (PiCCO), arterial
resuscitation leads to increase of burn depth and prolongs the waveform monitoring (LiDCO) devices and bioimpedance
shock period resulting in higher mortality [1, 6]. spectroscopy [1, 12, 15, 16] (Figure 1). However, certain
studies have shown that use of arterial waveform monitoring
Determining the initial amount of fluid therapy devices such as LiDCO systems had lower fluid requirement
As the volume of fluid during resuscitation is proportional to than what was calculated by Parkland formula [12, 17].
the extent of burns, the severe burns are the most challenging Therefore, there is a discrepancy in the amount of volume
to treat [8]. In many units, severe burns is arbitrarily between the Parkland formula and certain monitoring
categorised as involvement of at least 20% of body surface parameters (Figure 1) [12].
area excluding superficial burns because, strict monitoring
and intravenous fluid resuscitation is needed in such patients Although the majority of the studies showed the need of a
[9]. In severe burns, selecting the appropriate choice of fluid more intensive initial fluid resuscitation compared to the
is essential in determining the outcome and incorrect Parkland formula to improve the pre-load factors such as
cardiac index, venous oxygen saturation and oxygen delivery,

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 Figure 1. Goal directed fluid therapy in severe burns

Figure 2. Evidence for choice of fluid in burns resuscitation

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the achievement of normovolaemia was challenging [1, 12]. Ringer's lactate (RL), and therefore has been the fluid of
Therefore, normovolaemia may not be the main goal to choice in burns [21]. The study by Oda et al compared RL with
achieve, and overzealous fluid resuscitation and trying to hypertonic lactated saline in severe burns and found that
normalise the haemodynamic parameters should be avoided. lactated saline group needed significantly lower amount of
fluid and had lower peak abdominal and inspiratory pressures
According to the recent systematic review on fluid [22]. Furthermore, abdominal compartment syndrome was
resuscitation, the non-invasive alternatives to PAC have a seen in 14% of patients in the hypertonic lactated saline group
reasonable role in initial fluid resuscitation in burns [12]. in comparison to 50% in the RL group [22]. Gille et al
However, it is important to note that the studies included small compared RL with Ringer's acetate and found Ringer's acetate
sample sizes and based their conclusion on short-term to be superior in terms of lower organ failure assessment
haemodynamic parameters rather than long term outcome. To scores, requirement of smaller amount of colloids, packed
date, the impact of these monitoring parameters on patients' cells and plasma infusion, shorter duration of hospital stay and
survival has not been determined. It is important to note that, mechanical ventilation. However, there was no difference in
most centres managing critically injured burn patients, the volume of crystalloid infused and the mortality [23].
especially in developing countries do not have these
sophisticated resources to guide goal-directed fluid therapy As balanced solutions have been proven to be superior for
techniques. Therefore, these centres reply on basic critically ill patients, Ringer's acetate seems most suitable for
haemodynamic and biochemical parameters to guide fluid large replacement in burns patients based on the above study.
resuscitation. However, further studies are needed to compare RL and
Ringer's acetate in burns patients due to the methodological
Several metabolic factors have also been analysed in burn weaknesses in the available studies. Although hypertonic
patients. Some variables such as lactate levels, the solutions may be useful in burn resuscitation, the analyses by
lactate/pyruvate ratio, the base deficit, and microalbuminuria the Cochrane systematic reviews, and USA guidelines have
were shown to be useful as prognostic markers and may be shown no clear benefit in terms of efficacy and therefore,
useful to guide initial resuscitation [12, 18]. However, the further studies are required before routine use can be
evidence to support routine use of these parameters is not recommended [24].
available [18]. Therefore, fluid resuscitation in severe burns
should ideally be performed as goal-directed therapy with Colloids are controversial in the management of burns
thermodilution methods as they have been validated in burns especially after the recent warning regarding the use of
and are less invasive than PAC [12]. Hydroxy-ethyl starch (HES) in critical ill patients including
severe burns. Colloids contain macromolecules and possess a
Evidence on choice of fluid for resuscitation greater volume expanding effect than crystalloids [25]. They
Crystalloids are the fluids of choice in initial burn consist of either synthetic (HES and gelatine) or natural
resuscitation although, the volume retained in the intra- (plasma and albumin) components [25].
vascular compartment and the subsequent volume expansion
is lower than colloids [8]. That is because the increased After the HES warning, the gelatins were the only available
capillary permeability during the initial period will cause the synthetic option for burns though the expansion capacity is
colloids to pass through capillaries to the interstitial space and inferior and short lasting (1 hour) [26]. However, there are no
exert a deleterious oncotic effect and paradoxically reduce the studies ensuring safety in burns patients and meta-analyses
intra-vascular fluid volume and worsen the oedema [19]. showed no advantages in using gelatin over crystalloids [26].
Despite the recent studies which claim that the increased Therefore the use of gelatins in burns remains controversial
vascular permeability is relatively short lasting (from 2-7 and routine use is discouraged [26].
hours post-burn), the use of colloid in burns remains
controversial [12]. Several reviews have shown that HES use in critical care
including burns had a higher risk of mortality and kidney
According to the studies published on crystalloid-based fluid injury as opposed to other resuscitation fluids [12]. However,
therapy in various types of critically ill patients, balanced due to the methodological concerns, a randomized trial
solutions were superior to unbalanced crystalloids, due to the comparing mixed resuscitation therapy (HES plus RL) and
multiple adverse effects identified with saline solutions [20]. crystalloids alone (RL) was performed. In that study, no
However, these studies include other critically ill patients and differences were found in the mortality, volume of fluid
the studies on severe burns patients are limited and therefore, administered, or kidney injury between the groups [27].
the question arises whether these can be extrapolated to burns
patients. By definition, the Parkland formula is calculated for Of the natural colloids, fresh frozen plasma has been used as

The Sri Lanka Journal of Surgery 2020; 38(2): 50-56 53

plasma expanders however, the risk of transmission of thromboembolic complications, multi organ failure and
infections hasdiscouraged its use in fluid resuscitation and it increase in morbidity. Moreover, coagulopathy was recently
is mainly used when there is associated coagulopathy [28]. identified as an independent predictor of mortality within 28
Also the activity based cost of fresh frozen plasma per each days in patients with severe burns [32]. Pathophysiology of
unit is around 410 USD in the United States [29] Although the coagulopathy includes dilution of factors by fluid
studies have shown benefits of using plasma in burns in terms resuscitation, hypothermia, endothelial injury, burn wound
of lesser resuscitation volume and lower abdominal excision causing bleeding and activated systemic
compartment pressures, the sample size was very small. inflammatory response [33]. In burns, the evidence and
Therefore, larger studies are needed before considering recommendations for targets in management of coagulopathy
routine use in burns patients [12, 28]. are lacking. An international survey on coagulopathy in burn
patents showed that although this entity is recognized, there is
The use of albumin for fluid resuscitation in burns patients lack of specific treatment among physicians [34].
have been assessed by multiple studies and have shown
conflicting results [12]. However, the recent meta-analysis of The management of coagulopathy includes, general measures
clinical trials in 2014, found that albumin was associated with for minimizing triggers and specific treatment depending on
a lower incidence of compartment syndrome and mortality type of coagulopathy. Minimizing triggers includes,
[30]. Therefore, both albumin and plasma may be a suitable prevention of tissue hypoperfusion by goal directed fluid
option for burn patients, however the lack of large scale management, avoidance of hypothermia, and prevention of
clinical trials restrict their routine use [12] (figure 2). excessive blood loss during surgical treatment. Specific
treatment and interventions may be directed towards
Management of coagulopathy in severe burns anticoagulation or procoagulation depending on the type of
Similar to major trauma, coagulopathy is also associated with coagulopathy. Treatment with antithrombin, activated protein
severe burns. The coagulopathy interferes with proper C, and tissue factor pathway inhibitor have not shown any
surgical debridement and repeated surgical debridement benefit[35]. Newer options like recombinant activated factor
causes more bleeding and worsening coagulopathy. The VIIa have been studied in reduction of perioperative bleeding
coagulopathy is a combination of procoagulation, in burn wound excision but the associated arterial thrombotic
antifibrinolysis and impaired activity of anticoagulation events hinder its use [36] (Figure 3).
systems of the body [31]. This process is associated with

Figure 3. Prevention and treatment of coagulopathy in severe burns

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All authors disclose no conflict of interest. The study was conducted https://doi.org/10.1097/00003246-199103000-00007
in accordance with the ethical standards of the relevant institutional 11.Holm C, Melcer B, Hörbrand F, von Donnersmarck GH,
or national ethics committee and the Helsinki Declaration of 1975, Mühlbauer W: Arterial thermodilution: an alternative to
as revised in 2000. pulmonary artery catheter for cardiac output assessment in burn
patients. Burns 2001, 27(2):161-166.
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