ORIGINAL ARTICLE

Toward Targeted Early Burn Care: Lessons From a European Survey Anne-Françoise Rousseau, MD,* Paul B. Massion, MD, PhD,* Alexis Laungani, MD,† Jean-Luc Nizet, MD,† Pierre Damas, MD, PhD,* Didier Ledoux, MD, PhD*

During the year 2011, a survey was performed to describe current practices throughout Europe regarding three critical issues of acute burn care, namely fluid resuscitation, nutrition, and burn wound excision strategy. Thirty-eight questionnaires returned by burn centres from 17 different European countries were analyzed. The survey shows that Parkland remains the most commonly used formula to determine fluid needs in adults. All respondent centers use urine output to guide fluid resuscitation. While early excision of deep burns is the rule among centers, burn depth assessment by laser Doppler imaging is used in only a few centers. Indirect calorimetry and Toronto formula to estimate energy requirements do not have unanimous backing from respondents. Current literature encourages clinicians to move forward targeted and individualized therapies using a bundle of basic and advanced hemodynamic parameters, indirect calorimetry, and laser Doppler imaging. The results of this study suggest that such an approach is not common yet, and reinforce the subsequent need for large clinical trials that would evaluate the impact of such guided therapies to provide recommendations with a significant level of evidence. (J Burn Care Res 2014;35:e234–e239)

Critically ill burn patients are not homogenous and their needs are complex: they require both medical and surgical treatments that are highly specific and intricate.1,2 During the first hours after severe burn injury, routine implementation of three hallmarks of modern burn care is fundamental to significantly decrease mortality: fluid resuscitation, early excision of deep burns, and early enteral nutrition. Early fluid resuscitation aims to offset initial hypovolemia (“burn shock”). Prompt excision of deep burn wounds (unconditionally associated to wound coverage) decreases the release of inflammatory mediators and wound bacterial colonization.3 It clearly leads to reduced mortality,4 morbidity,5–7

From the *Intensive Care Department and Burn Centre and †Plastic Surgery Department and Burn Centre, University Hospital, Liège, Belgium. Address correspondence to Anne-Françoise Rousseau, MD, Intensive Care Department and Burn Centre, University Hospital, Sart Tilman B35, B-4000 Liège, Belgium. Copyright © 2014 by the American Burn Association 1559-047X/2014 DOI: 10.1097/BCR.0000000000000027

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and sequelae.8 Finally, rapid initiation of enteral nutrition aims to allow burn patients to deal with the hypermetabolism and hypercatabolism related to burn injury.9–11 Although some experts’ recommendations have been published,12–17 strong evidence-based standard treatments are still lacking. Hence, data about burn management remain limited mostly because large studies with sufficient analytical power are uneasy to generate. Because of this paucity of evidence-based information, one could expect disparity in acute burn care among centers and countries. Therefore, to examine this issue, we performed a survey about current burn management across Europe. We focused on three crucial aspects of early burn care.

MATERIAL AND METHODS Between January 2011 and December 2011, we sent a survey questionnaire by email to contacts of 185 burn centers from 28 different countries in Europe. The email addresses were obtained from national and international burn societies or from corresponding data in peer-reviewed articles published between

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2006 and 2011. The questionnaire consisted of questions related to center organization and major issues about fluid resuscitation, nutrition, and timing of surgical procedures. When relevant, specific questions targeted pediatric patients. All participants (centers’ medical heads) were asked to provide information on the most common practices in their own burn center. For some questions, responders had the opportunity to choose more than one answer, and hence the sum of the option percentages may exceed 100% of respondents. All responses were kept anonymous. Answers were entered and analyzed by using Excel (Excel for Mac 2011, version 14.2.5; Microsoft Corporation 2010, Redmond, WA). Results are expressed as counts and percentages or as medians with interquartile range.

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RESULTS We received 38 questionnaires (20.5%) from 17 European countries (Figure 1). Several questionnaires were found to be partially incomplete. However, these questionnaires contained useful information that could be used. Hence, for each question the number of responses obtained varies.

Centers Characterization Most centers (31 centers, 81%) were university centers. In two third of centers, both adults and children were treated (26/38, 69%). About 30% of centers were either specialized in pediatric burn care (5/38, 13%) or exclusively treated adult patients (7/38, 18%). Demographic data from respondent centers are reported in Table 1.

Figure 1.  European map: numbers of respondent centers in each of the 17 included countries. Countries: Albania, Austria, Belgium, Czech Republic, Finland, France, Germany, Greece, Hungary, Italy, The Netherlands, Norway, Romania, Slovakia, Sweden, Switzerland, and United Kingdom.



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Table 1. Demographic data for the year 2010 Median in Europe Number of admissions in 2010 Age (yr) TBSA (%) Global in-burn center LOS (days) LOS if > 30% TBSA (days) Global hospital mortality rate (%) Mortality if > 30% TBSA (days)

160 [101–318] 37 [30–40] 14 [9.5–18.5] 15 [10–17] 35 [29–45] 3 [1.2–7] 19.5 [4.3–34.5]

LOS, length of stay. Data are expressed as median with interquartile ranges.

Fluid Resuscitation In adults, initial fluid resuscitation is predominantly based on Parkland formula (Table 2), used in 72% of the centers (23/32). Centers that do not use Parkland formula to guide initial fluid resuscitation report use of more restrictive formulas, resulting in fluid loading of 2 to 3 ml/kg/% TBSA in the first 24 hours after injury. Most respondents (21/32, 66%) use dedicated pediatric formula for fluid resuscitation in burn: Galveston and Carvajal formulas are the most frequently reported, respectively, in 43% (9/21) and 33% (7/21) of concerned centers. Albumin is the most commonly used colloid, and hypertonic saline solution is rarely used (Figure 2). Besides basic hemodynamic (heart rate and blood pressure) and biological parameters (such as hematocrit, urea, lactate), urine output is used in all the 38 centers to adjust fluid rates. Urine density or natriuresis are less frequently followed, respectively, in 32% (12/38) and 21% (8/38) of the centers. More than half of the centers do not routinely use advanced hemodynamic monitoring to guide volume replacement therapy. Those that do use such monitoring

mainly use PiCCO-system® (Pulse index Continuous ­Cardiac Output, Pulsion Medical System, Munich, Germany) and transthoracic echocardiography (Figure 2). A few centers also report use of Vigileo® (Edwards Lifesciences, Irvine, CA) or Lidco® (Lidco Group PLC, London, UK) for hemodynamic monitoring (Figure 2).

Timing of Surgical Procedures In the surveyed European centers, laser Doppler imaging (LDI) is not a common practice to assess burn depth: 68% of the centers (25/37) do not use this assessment tool. In most of the centers (74%, 28/38), the first excision of deep burns is performed within the first 5 days. Respondents report that the acceptable length of time to achieve complete excision and wound coverage of deep burns is 7 (5-10) days in 20% BSA burns, 15 (10-20) days in 40% BSA burns, and 20 (14-29) days in 60% BSA burns.14–29 The majority of centers (35/38, 92%) state that surgery for excision and skin grafting is performed at least once a week.

Nutrition Few centers use indirect calorimetry to assess energy requirements in adults (10/33, 30%) or in children (6/28, 21%). Classical Toronto formula is employed in a limited number of adult centers (21%, 7/33) while some centers estimate daily requirements at 35 kcal/kg of usual body weight (42%, 14/33). One center uses the Curreri formula and in another center energy requirements are approximated as being twice the theoretical resting energy expenditure obtained from Harris and Benedict equation. Specific formulas are used more frequently in burned

Table 2. Cited formulas Parkland Carvajal Galveston (fluids) Toronto Milner Hildreth Galveston (nutrition) Schofield

4 ml/kg/TBSA% Ringer Lactate (50% provided during the first 8 hr, remaining fluids during the following 16 hr) 5000 ml/m2 TBSA Ringer Lactate (50% provided during the first 8 hr, remaining fluids during the following 16 hr) + 2000 ml/m2 BA Ringer Lactate 5000 ml/m2 TBSA Ringer Lactate containing 12.5 g albumin/L (50% provided during the first 8 hr, remaining fluids during the following 16 hr) + 2000 ml/m2 BA Ringer Lactate kcal/day = –4343 + (10.5 × %TBSA) + (0.23 × CI) + (0.84 × EBEE) + (114 × temp °C) – (4.5 × PBD) kcal/day = [BMR × (0.274 + 0.0079 × %TBSA – 0.004 × PBD) + BMR] × 24 × m2 BA × AF kcal/day = (1800 × m2 BA) + (2200 × m2 TBSA) 0–1 yr: kcal/day = (2100 × m2 BA) + (1000 × m2 TBSA) 1–11 yr: kcal/day = (1800 × m2 BA) + (1300 × m2 TBSA) 12–18 yr: kcal/day = (1500 × m2 BA) + (1500 × m2 TBSA) Girl 3–10 yr: kcal/day = (16.97 × W) + (1.618 × H) + 371.2 Girl 10–18 yr: kcal/day = (8.365 × W) + (4.65 × H) + 200 Boy 3–10 yr: kcal/day = (19.6 × W) + (1.033 × H) + 414.9 Boy 10–18 yr: kcal/day = (16.25 × W) + (1.372 × H) + 515.5

BA, body area; CI, caloric intake; EBEE, expected basal energy expenditure (calculated by Harris–Benedict formula); PBD , number of postburn days; BMR, basal metabolic rate in healthy population; AF, activity factor (typically 1.2–1.4); W, weight (kg); H, height (cm).

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Figure 2.  Fluid management according to our respondent centers. Number in brackets beside each item is the number of responses obtained. SvO2, central venous oxygen blood saturation; TTE, transthoracic echocardiography.

children (21/32, 66%): Hildreth formula is the most commonly used (16/32) while Galveston and Schofield formulas are rarely mentioned.

DISCUSSION The key issue in critical burn care is to provide a precisely balanced management. Hypovolemia, delayed surgery, and undernutrition have to be avoided, but there are rising concerns about the risks of fluid creep, extensive wound excision, and overnutrition. Fluid or nutrition predictive formulas may either over- or underestimate individual needs. Clinical distinction between superficial or deep partial-thickness burns is challenging but is important to define a surgical strategy. Therefore, acute burn care needs to be targeted to the individual. Closed monitoring and proper evaluation of patient’s needs are crucial. During burn shock resuscitation, restoring normovolemia is illusive and may even be dangerous. Use of more restrictive fluids formula (2–3 ml/kg/% TBSA during the first 24 hours), combined with catecholamines if necessary, could allow to achieve a minimally effective volemia.18 Moreover, in order to determine how to adjust fluid therapy, monitoring of fluid therapy should be based on surrogates bundle rather than on a single parameter such as urine

output or advanced hemodynamic monitoring.19 Data suggest that esophageal doppler or intrathoracic blood volume measurement using PiCCOsystem® may be associated with the administration of even larger fluid amounts.20–22 Ideally, the bundle should include a combination of clinical (minimal mean arterial pressure, minimal urinary output, intraabdominal pressure), laboratory (hematocrit, lactate level, natriuresis, mixed venous oxygen saturation, PaO2), and perhaps advanced hemodynamic parameters. Studies using LDI in order to measure tissular perfusion adequacy could add some new useful knowledge in this field. Such a “bundle based permissive hypovolemia” approach would ideally be part of a goal-directed therapy protocol, as it is now becoming increasingly accepted in the literature for septic23 or surgical cases.24 Surgical strategy should be guided by LDI, the most studied technology developed to assist clinicians in determination of burn depth. Combination of laser technology with Doppler principle provides an estimation of wound perfusion, and healing potential prediction is described as highly accurate.25–27 Indirect calorimetry is currently the most precise way to determine energy expenditure and is recommended to guide nutritional support.28 This technique has limitations: the need of a 30-minute ventilatory steady-state, an inspired oxygen fraction



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Figure 3.  Three main axes of acute burn care: toward targeted and individualized therapy. Other acute strategies include: multimodal sedation and/or analgesia, inhaled therapy and inhalation injury management, pharmaconutrition, thromboprophylaxis, ambient room temperature at 28 to 32°C, positioning.

below 0.6, and the absence of any gas leak. In these cases, energy requirement formulas may substitute for indirect calorimetry28: amounts given by Toronto29 and Milner30,31 formula in adults and Schofield formula in children32 are the closest to indirect calorimetry measurements. In conclusion, acute care of severe burns includes particularly three main axes: fluid resuscitation, wound excision, and enteral nutrition. These treatments must be prompt and aggressive but, first, they need to be targeted to the individual. Closed monitoring and proper evaluation of patient’s needs are crucial. In this context, a bundle of basic and advanced hemodynamic parameters, indirect calorimetry, and LDI are increasingly described as complementary tools to clinical assessment. Even if our results may not be fully representative of practice in all European burn centers, it seems, from our findings, that advanced targeted and individualized approaches are not yet part of the acute routine management of burn patients. Hence, there is a need for large clinical trials that would evaluate the impact of such guided therapies in order to provide recommendations with a meaningful level of evidence.

ACKNOWLEDGMENT We acknowledge all the contacts who took time to participate to their survey.

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Toward targeted early burn care: lessons from a European survey.

During the year 2011, a survey was performed to describe current practices throughout Europe regarding three critical issues of acute burn care, namel...
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