Burn Resuscitation Practices in North America: Results of... : Annals of Surgery (original) (raw)

Original Articles

Results of the Acute Burn ResUscitation Multicenter Prospective Trial (ABRUPT)

Greenhalgh, David G. MD*; Cartotto, Robert MD†; Taylor, Sandra L. PhD‡; Fine, Jeffrey R. MPH‡; Lewis, Giavonni M. MD§; Smith, David J. Jr MD¶; Marano, Michael A. MD||; Gibson, Angela MD**; Wibbenmeyer, Lucy A. MD††; Holmes, James H. TV, MD‡‡; Rizzo, Julie A. MD||||; Foster, Kevin N. MD¶¶; Khandelwal, Anjay MD||||; Fischer, Sarah MSN, RN***; Hemmila, Mark R. MD†††; Hill, David PharmD‡‡‡; Aballay, Ariel M. MD§§§; Tredget, Edward E. MD¶¶¶; Goverman, Jeremy MD||||||; Phelan, Herbert MD****; Jimenez, Carlos J. MD††††; Baldea, Anthony MD‡‡‡‡; Sood, Rajiv MD§§§§,§§

*Department of Surgery, University of California, Davis School of Medicine and Shriners Hospitals for Children Northern California, Sacramento, CA;

†Department of Surgery, Sunnybrook Medical Center, Toronto, Ontario, Canada;

‡Department of Public Health Sciences, School of Medicine, University of California, Davis, Sacramento, CA;

§Department of Surgery, University of Utah, Salt Lake City, UT;

¶Department of Surgery, University of South Florida, Tampa, FL;

||Department of Surgery, Saint Barnabas, Livingston, NJ;

**Department of Surgery, University of Wisconsin, Madison, WI;

††Department of Surgery, University of Iowa, Iowa City, IA;

‡‡Department of Surgery, Wake Forrest University, Winston-Salem, NC;

§§Department of Surgery, Institute of Surgical Research, San Antonio, TX;

¶¶Department of Surgery, Arizona Burn Center, Maricopa, AZ;

||||Department of Surgery, Metro Health Center, Cleveland, OH;

***Department of Surgery, Ascension Via Christi St. Francis, Wichita, KS;

†††Department of Surgery, University of Michigan, Ann Arbor, MI;

‡‡‡Department of Pharmacy, University of Tennessee Health Science Center, Memphis, TN;

§§§Department of Surgery, West Penn Medical Center, Pittsburgh, PA;

¶¶¶Department of Plastic Surgery, University of Alberta, Edmonton, Alberta, Canada;

||||||Department of Surgery, Massachusetts General Hospital, Boston, MA;

****Department of Surgery, University of Texas, Southwestern Medical Center, Dallas, TX;

††††Department of Surgery, University of Texas Medical Branch, Galveston, TX;

‡‡‡‡Department of Surgery, University of Loyola, Maywood, IL; and

§§§§Department of Plastic Surgery, University of Indiana, Indianapolis, IN.

[email protected].

ABRUPT Financial Disclosures: Conflict of Interest: A.G.: Consultant for Mallinckrodt, Inc.; L.A.W.: Research support from Avita, Inc., MEDIWound, Inc., Mallincrodt, Inc.; J.H.H.: Equity in Abbott Labs, AbbVie, Change Healthcare, Imbed Biosciences, and consultant for Avita, Inc. and Mallinckrodt, Inc.; K.N.F.: Consultant for Baxter, Integra, Inc., Skingenix; A.K.: Consultant for Avita, Inc.

The authors report no conflicts of interest.

Grant Support: Supported by the American Burn Association and funded by the Department of Defense USAMRMC Award W81XWH-16-2-0048, and National Center for Advancing Translational Sciences, National Institutes of Health, ULI TR001860

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website, www.annalsofsurgery.com.

Abstract

Objectives:

ABRUPT was a prospective, noninterventional, observational study of resuscitation practices at 21 burn centers. The primary goal was to examine burn resuscitation with albumin or crystalloids alone, to design a future prospective randomized trial.

Summary Background Data:

No modern prospective study has determined whether to use colloids or crystalloids for acute burn resuscitation.

Methods:

Patients ≥18 years with burns ≥ 20% total body surface area (TBSA) had hourly documentation of resuscitation parameters for 48 hours. Patients received either crystalloids alone or had albumin supplemented to crystalloid based on center protocols.

Results:

Of 379 enrollees, two-thirds (253) were resuscitated with albumin and one-third (126) were resuscitated with crystalloid alone. Albumin patients received more total fluid than Crystalloid patients (5.2 ± 2.3 vs 3.7 ± 1.7 mL/kg/% TBSA burn/24 hours), but patients in the Albumin Group were older, had larger burns, higher admission Sequential Organ Failure Assessment (SOFA) scores, and more inhalation injury. Albumin lowered the in-to-out (I/O) ratio and was started ≤12 hours in patients with the highest initial fluid requirements, given >12 hours with intermediate requirements, and avoided in patients who responded to crystalloid alone.

Conclusions:

Albumin use is associated with older age, larger and deeper burns, and more severe organ dysfunction at presentation. Albumin supplementation is started when initial crystalloid rates are above expected targets and improves the I/O ratio. The fluid received in the first 24 hours was at or above the Parkland Formula estimate.