Initial Results of the American Burn Association (ABA) Observational Multi-Center Evaluation on the Effectiveness of the Burn Navigator

The objective of this multi-center observational study was to evaluate resuscitation volumes and outcomes of patients who underwent fluid resuscitation utilizing the Burn Navigator (BN), a resuscitation clinical decision support tool. Two analyses were performed: examination of the first 24 hours of resuscitation, and the first 24 hours post-burn regardless of when the resuscitation began, to account for patients who presented in a delayed fashion. Patients were classified as having followed the BN (FBN) if all hourly fluid rates were within ±20 mL of BN recommendations for that hour at least 83% of the time, otherwise they were classified as not having followed BN (NFBN). Analysis of resuscitation volumes for FBN patients in the first 24 hours resulted in average volumes for primary crystalloid) and total fluids administered of 4.07 ± 1.76 mL/kg/TBSA (151.48 ± 77.46 mL/kg), and 4.68 ± 2.06 mL/kg/TBSA (175.01 ± 92.22 mL/kg), respectively. Patients who presented in a delayed fashion revealed average volumes for primary and total fluids of 5.28 ± 2.54 mL/kg/TBSA (201.11 ± 106.53 mL/kg), 6.35 ± 2.95 mL/kg/TBSA (244.08 ± 133.5 mL/kg), respectively. There was a significant decrease in the incidence of burn shock in the FBN group (p< 0.05). This study shows that the BN provides comparable resuscitation volumes of primary crystalloid fluid to the Parkland Formula, recommends total fluid infusion less than the Ivy Index, and was associated with a decreased incidence of burn shock. Early initiation of the BN device resulted in lower overall fluid volumes.

Approaches of Emergency Department Physicians to Pediatric Burns: A Survey Assessment

Burned children generally arrive at emergency departments before referring to specialized burn centers. Their initial treatments are performed by non-burn doctors who work in emergency departments. The aim of this study was to evaluate emergency department doctors’ knowledge regarding the initial interventions and transfer of pediatric burn patients. There were 196 participants who completed the survey: 59 were emergency medicine specialists, 46 were general practitioners, and 91 were emergency medicine residents. Sixty-five stated that they always calculate the burn surface areas, and 144 stated that the Parkland formula should be used to calculate the fluid requirements for the first 24 hours. Of all participants, only 21 marked the correct choice as the Lund-Browder scheme to calculate the total burned surface area in children. Only 52 participants marked the correct choice as the Lactated Ringer’s of the fluid given in the first 24 hours. Only 108 correctly recognized inhalation injury. To the question “What is the first intervention that doctors should do at the emergency room to burned children?”, 127 participants stated correctly as the assessment of airway maintenance. Among the participants, 124 stated that they use lidocaine pomades when covering burned children’s wounds. Incorrect interventions with burned children increase morbidity and mortality. This survey shows that non-burn doctors working in emergency departments have insufficient knowledge about pediatric burns and require further training. Therefore, they should be trained continuously and regularly on the approach to both adult and childhood burns.

520 Weight-based vs. BSA-based Fluid Resuscitation Predictions in Pediatric Burn Patients

Introduction Current practice for major pediatric burns includes fluid resuscitation using formulas that estimate fluid requirements based on weight and/or body surface area (BSA) along with percent total burn surface area (TBSA). Adult studies have shown that these formulas can cause fluid overload in obese patients and increase risk of complications. These findings have not been validated in pediatric patients. This study aims to evaluate whether a weight-based resuscitation formula increases the risk of complications in obese children following burn injuries and compares fluid estimates to those that incorporate BSA. Methods A retrospective review was conducted on 110 children (≤ 18 years old) admitted to an ABA-verified urban pediatric burn center from October 2008 to May 2020. Patients had ≥15% TBSA, were resuscitated with the weight-based Parkland formula, and had fluids titrated to urine output every two hours (1 ml/kg/hr if ≤ 30kg; 0.5 ml/kg/hr if > 30kg). Demographics, burn type, and TBSA were collected on admission. BSA-based Galveston and BSA-incorporated Cincinnati formula resuscitation predictions were also calculated. Output and input volumes were collected at 8h and 24h post-injury. Complications were collected throughout the hospital stay. Patients were classified into CDC-defined weight groups based on percentile ranges. Statistical analysis was conducted using SPSS Statistics version 10.0. Results This study included 11 underweight, 60 normal weight, 18 overweight, and 21 obese children. Our patients had a mean age-based weight CDC percentile of 62.2%, and mean TBSA of 25.4%. Predicted resuscitation volumes increased as CDC percentile increased for all three formulas (p=0.033, 0.092, 0.038), however there were no significant differences between overweight and obese children. Total fluid administered was higher as CDC percentile increased (p=0.023). However, overweight children received more total fluid than obese children. The difference between total fluids given and Galveston predicted resuscitation volumes were significant across all groups (p=0.042); however, the difference using the Parkland and Cincinnati formulas were not statistically significant. There were more children in the normal weight group who developed complications compared to other groups, but these findings were not significant. Conclusions The Parkland formula tended to underpredict fluid needs in the underweight, normal weight, and overweight children, and it overpredicted fluid needs for the obese. Further research is needed to determine the value of weight-based vs BSA-based or incorporated formulas in terms of their risk of complications.

629 Acute Kidney Injury, Burn Resuscitation, and a Novel, Visualization Approach to Resuscitation Review

Introduction A review of patients who sustained 20% or greater TBSA burns (n = 33) found 58% of the sample to have a stage 1 (n = 5), 2 (n = 4), or 3 (n = 10) acute kidney injury (AKI). Of those who sustained an AKI, 63% did not survive their injuries. An inquiry into the current, resuscitation protocols used at this facility was subsequently conducted. Protocol dictated the Parkland Formula/method as the standard of care for resuscitation needs of the sample. While information for net-totals of inputs and outputs (I&O) and hourly I&O values was easily obtainable, presenting these numbers in table-form was both cumbersome to create and difficult to quickly convey to both clinical and non-clinical staff. Thus, a visual approach was chosen to better understand how each patient was resuscitated in the first 24-hours of burn injury. Methods The software package R (R Core Team, 2020) was used to clean/analyze data, as well as create a graphical illustration of the data via an interactive dashboard using these variables: urine output (UOP); nurse charting of I&Os; fluid orders by provider; pre-hospital fluids; lab values; and vital signs. Using this software an interactive dashboard was created to allow users to interact with the graphs and visualize not only the numerical values associated with resuscitation, but to also see how each of these numbers relate to one another in an hourly timeline (e.g., reducing fluids by half is followed by a decrease in UOP). Results A trend of over-resuscitation in the first 24-hours of burn injury, as compared to the calculated requirements based on the Parkland Formula was observed. Also, irregularities of hourly administration of fluids (e.g., frequent/over blousing) and inadequate hourly charting were observed. Conclusions While this method for assessing resuscitation is a new approach at this facility, the ability to visually recount the resuscitation efforts of each patient has opened the conversation about best practices. Also, more disciplines can participate in the resuscitation efforts due to the ease with which the presented information can be disseminated and explained to both seasoned and novice staff. This has allowed for more stakeholders to participate in the burn program. Finally, further uses and applications of interactive dashboards are being explored for other aspects of burn care management.

Nurses Can Resuscitate

Fluid resuscitation in the first 48 hours postburn is crucial in the management of burn shock. The primary purpose of this study was to evaluate nurses’ adherence to a nurse-driven fluid resuscitation protocol at one adult burn center. Their secondary goal was to establish that the use of a nursing-driven protocol did not result in over resuscitation. Following implementation of a nurse-driven burn resuscitation protocol, a 48-hour data resuscitation data collection tool was developed by the burn physicians and nurses. All resuscitations were reviewed in real-time and in burn leadership meeting to identify opportunities for improvement. Follow-up with nursing staff was done in real time by the clinical nurse specialist following each burn resuscitation. Twenty-two patients requiring formal fluid resuscitation were included in the review. Patients had a median age of 36.5(IQR: 38.74) years and were predominantly male. They found that in the first 24 hours that patients received 3.47 ml/kg/hr and then in the next 24 hours they received an average of 2.68 ml/kg/hr. All 22 patients’ resuscitation was initiated using the Parkland formula in the emergency department, and nurses were successful in consistently adjusting fluid infusions consistent with the protocol. Using a multidisciplinary approach and preparatory and real-time education processes, burn nurses can successfully guide burn resuscitation. Providing education and follow-up in real time can improve the process.

Preserving Vision: Rethinking Burn Patient Monitoring to Prevent Orbital Compartment Syndrome

Burn patients receiving aggressive fluid resuscitation are at risk of developing orbital compartment syndrome (OCS). This condition results in elevated orbital pressures and can lead to rapid permanent vision loss. Risk factors and monitoring frequency for OCS remain largely unknown. A retrospective review was therefore conducted of admitted burn patients evaluated by the ophthalmology service at an American Burn Association verified Burn Treatment Center. Demographic, burn, examination, and fluid resuscitation data were compared using two-sided t-tests, Fisher’s exact tests, and linear regression. Risk factors for elevated intraocular pressures (IOPs; a surrogate for intraorbital pressure) in patients resuscitated via the Parkland formula were found to be total body surface area (% TBSA) burned, resuscitation above the Ivy Index (>250 ml/kg), and Parkland formula calculated volume. Maximum IOP and actual fluid resuscitation volume were linearly related. Analysis of all patients with elevated IOP found multiple patients with significant IOP increases after initial evaluation resulting in OCS within the first 24 hours postinjury. While %TBSA, Ivy Index, and resuscitation calculated volume are OCS risk factors in burn patients, two patients with facial burns developed OCS (25% of all patients with OCS) despite not requiring resuscitation. Orbital congestion can develop within the first 24 hours of admission when resuscitation volumes are the greatest. In addition to earlier and more frequent IOP checks in susceptible burn patients during the first day, the associated risk factors will help identify those most at risk for OCS and vision loss.

787 Burn Resuscitation Critical Reflective Practice

Introduction The Burn Resuscitation Critical Reflective Practice (CRP) was started as collaborative meetings to review 1st 48 hours of admission for burn resuscitations (resus) October 2018- July 2019. All multi- disciplinary teams were invited. The problem identified was on average burn resus patients (>20% TBSA) were being over resuscitated in 1st 24 hours of admission. The goals of the CRP were: 1) Decrease resus fluid in the 1st 24 hours; 2) Increase knowledge of the current fluid resus pathway; 3) Increase communication with interdisciplinary teams during the resus. Methods CRP initiated in October 2018. 6 CRPs were held October 2018- July 2019.The average ml/ KG/ TBSA prior to CRP from January 2017- September 2018 was 5.17ml/kg/TBSA (goal: < 4ml). Chart reviews were done to gather data from each resus (i.e. urine output, fluids, labs, events). Discussions held with staff involved in the 1st 24 hours of resus regarding any communication/process issues.Patient data was presented & staff members present would discuss questions/ issues that came up during the resus. Multi-disciplinary teams surveyed prior to CRP to assess comfort/competence with current resus pathway and communication. 46 surveys received prior to initiating CRP. After initiating CRP October 2018- July 2019, staff members that had attended >1 CRP were post-surveyed. Results January 2017- October 2018 average ml/ KG/ TBSA was 5.17ml/kg/TBSA. October 2018- July 2019 POST CRP implementation, the avg ml/ KG/ TBSA was 3.86 ml LR/ kg/ TBSA in 1st 24 hours of resus. 3 new practices were implemented 1) Decrease fluids by 200ml/hr (instead of 100) when UOP is >100/hr at least 2 hours into resus; 2) Double sign by 2 RNs required when calculating Parkland Formula; 3) Guideline created to guide communication between Burn RNs & trauma bay when burn resus arrives. Post- survey data showed increase in comfort communicating with physicians regarding resus & increase in comfort/confidence in calculating Parkland Formula. 2 additional subjective questions were added onto the post- CRP survey. Conclusions Fluids given in the 1st 24 hours decreased from 5.17 to 3.86 average ml/ kg/ TBSA post- CRP. 3 new practices were implemented as discussed in results. Staff felt more comfortable communicating with team & calculating Parkland formula. Staff had positive responses on the post- survey. Applicability of Research to Practice The monthly CRPs are to be continued to discuss all burn resus patients received during the prior month. Allows team members to continue to modify practice as needed by what’s learned through each CRP to help better our patient outcomes and decrease overall resus fluids.

82 Retrospective Review of Burn Resuscitation Outcomes Between 4 mL and 2 mL as a Starting Guide for Parkland Formula

Introduction The ABA changed their fluid resuscitation guideline in 2011 for adult thermal burn injury patients from 4 mL to 2 mL per kilogram body mass per percent total body surface area (%TBSA) affected as a starting point for the Parkland formula. The primary aim of this change was to reduce the incidence of over resuscitation. We implemented this guideline at our institution in 2013. This retrospective analysis compares burn resuscitation outcomes prior to and post guideline change. Methods After approval from IRB, we collected data for all adult thermal burn injury patients with >20% TBSA from 2010 to 2012 for pre group and 2014–2016 for post group. Demographics, injury mechanisms, 24 and 48 hr resuscitation volume, 24 and 48 hr urine output, 24 hr peak serum creatinine, and mortality data was collected. Pre and post implementation groups were compared for 24 and 48 hr resuscitation volume, 24 and 48 hr urine output, 24 and 48 hr peak serum creatinine with t-test using SAS software. Mortality rates were compared too. Results The data is presented in table below. There was a significant reduction in total volume of resuscitation at 24 and 48 hr after implementation of the new guideline. There was also a significant reduction in the average 24 and 48 hr fluids used in the Parkland formula for the post group. This was achieved without significant reduction in urine output or increase in serum creatinine. Mean TBSA for pre and post groups were 36.2% and 33.1% respectively. There was no significant difference between extent of burn injury between these two groups.There was no significant change in mortality rate between the groups. Conclusions We observed lower volume of resuscitation for major thermal burn injury patients after implementation of the new guideline without adverse effect on renal function or outcomes. Applicability of Research to Practice The current guideline serves as a useful starting point for healthcare providers, allowing them to further resuscitate patients with additional fluids if needed. This change accomplishes optimal urine output and serum creatinine levels, while also providing better control of fluids to avoid over resuscitation.