E. J. Kelly1, C. Mehta2, B. C. Carney1,4, M. M. Mclawhorn1, L. T. Moffatt1,4, T. E. Travis1,3, S. Tejiram1,3, J. W. Shupp1,3,4 1Firefighter’s Burn and Surgical Research Laboratory, Medstar Health Research Institute, Washington, DC, USA 2Georgetown University School of Medicine, Washington, DC, USA 3Medstar Washington Hospital Center, Burn Surgery, Washington, DC, USA 4Georgetown University School of Medicine, Surgery And Biochemistry, Washington, DC, USA
Introduction: Burn shock following major thermal burn injury (MThBI) is hallmarked by hypotension and decreased end organ perfusion stemming from hypovolemia, endothelial dysfunction and distributive shock. Patients are typically resuscitated with large volumes of crystalloid fluid that are titrated based on physiologic response. However, excessive fluid administration (fluid creep) may lead to poor outcomes resulting from complications such as edema, respiratory distress, and compartment syndrome. Colloid-based resuscitation has been utilized as a means of mitigating excessive resuscitation. Previous work has demonstrated that fresh frozen plasma (FFP) has the ability to mitigate endothelial dysfunction. However, there is a paucity of literature regarding the appropriate timing of FFP administration in burn patients. The objective of this study was to investigate the timing of FFP administration and its effect on crystalloid volume requirements in MThBI patients.
Methods: A retrospective review of MThBI patients was performed. Patient demographics, mortality, clinical data, and timing of FFP administration were collected over a 3-year period. Included patients had a minimum 15% total body surface area (TBSA) burned and underwent formal post-injury resuscitation. Patients were grouped by TBSA into cohorts of under 40% TBSA or over 40% TBSA. After adjusting for weight and percent TBSA, timing of FFP administration and total crystalloid volume required in the first 24 hours of admission were compared between cohorts.
Results: Sixty-four patients were included in the analysis. Forty-eight patients were in the under 40% TBSA cohort and 16 patients were in the over 40% TBSA cohort. Seventy percent of patients were male with a mean TBSA of 30.7% ± 17.7% and a mean age of 52.7yrs ± 22.4yrs. The mean hospital length of stay was 36.6 days ± 31.1 days. The time to initial FFP administration following injury was significantly longer in the under 40% TBSA cohort compared to the over 40% TBSA cohort (12.3hrs, vs. 6.4hrs, p<0.001) (Fig.1A). The under 40% TBSA cohort also received significantly more crystalloid than the over 40% TBSA cohort (5.7 cc/kg/%TBSA ± 2.5 cc/kg/%TBSA vs. 4.0 cc/kg/%TBSA ± 1.0 cc/kg/%TBSA, p<0.001) (Fig.1B).
Conclusion: Identifying higher fluid requirements or failure to resuscitate in patients with large burns is essential to improving outcomes and decreasing morbidity. This study shows patients with larger burns received FFP earlier and required less crystalloid fluid in the 24-hour period following injury compared to those with later FFP administration. Optimizing FFP administration and timing for burn injured patients may help mitigate the adverse effects of fluid creep.
