State of the Art: An Update on Adult Burn Resuscitation

Round 1

Reviewer 1 Report

The authors have done a great job in providing a broad overview of burn resuscitation. The only minor opportunities for improvement are to add comments related pediatric burn resuscitation such as need for glucose containing fluids, different lund browder, etc.  Would also suggest a few comments on other types of resuscitation adjuncts such as vitamin C and/or plasma resuscitation. I know these are not widely adapted however these may be of interest to the audience to understand that it is not widely used.   Would also add a reference for Figure 5 or a statement in the article that this is used or recommend by a particular burn center.  A few comments on the variability of resuscitation across burn centers may also be of interest for the audience to understand there is variability across the world.  Again this is a great overview of resuscitation and thanks for putting this together. 

Author Response

The authors have compiled the reviewers comments and responded to all items.  Please see attached review responses. The authors greatly appreciate the detailed and relevant feedback.

Author Response File: Author Response.pdf

Reviewer 2 Report

Thank you for the opportunity to review this manuscript, which is well-written and highly relevant.

I do have some comments and criticisms.

The paper deals exclusively with resuscitation for adults and this should be reflected in the title.

pathophysiology of burn shock: this paragraph is very summary. There is no mention of the time-dependent evolution of the underlying changes, which is critical to understanding resuscitation. There has not been a shift away from the Starling forces, which still pertain and which the authors themselves allude to earlier in the paragraph. However, understanding of the endothelial glycocalyx is new, and should be explained in more detail.

Initial assessment: I am not sure what the percentages refer to in polytrauma cases. The authors advocate consideration of intubation (and therefore mechanical ventilation?) in cases of more than 40% burn because of the risk of massive laryngeal oedema. Is this true for burns on the lower body? Burns to head and neck are much more critical. The is no mention in the manuscript of the important haemodynamic changes induced by mechanical ventilation, leading to increased fluid requirements. Carbon monoxide poisoning can be easily diagnosed by most laboratories and should always be included in initial tests.

Resuscitation calculations: there is no mention of the importance of sodium.

Figure 6: is entitled “burn navigator”, presumably an example of a burn resuscitation support system. I would appreciate a more detailed account of the workings of these systems (input, output etc)

Pitfalls of resuscitation: “aggressive feeding” is mentioned. Indeed early feeding provides gastric protection and counters villous atrophy.  When should gastric (preferably post-pyloric double-lumen) tube placement be considered? The authors state that acute kidney injury is a common occurrence in severe burn injuries, occurring  in up to 40% of those admitted to the ICU. Is this true? (My personal experience is quite different.) Do all these cases occur during the resuscitation phase? There is no mention of intravascular haemolysis, evidenced by haemoglobinurea, which can occur in deep, extensive burns.

Wound management: the authors are wary of general anaesthesia during resuscitation. In fact general anaesthesia is frequently performed, for escharotomies, wound debridement etc and is safe, provided the reduced volume of distribution is taken into consideration. A sentence or two on pharmacokinetics would be useful (e.g. protein binding etc). The specific wound management mentioned in the paper is highly specific to the US army burn centre. Many European centres, for example, prefer the addition of cerium nitrate, which may (or may not) attenuate the inflammatory response.

In summary, the manuscript deals with an important subject is superficial in places and there are many omissions.

Author Response

The authors have compiled the reviewers comments and responded to all items.  Please see attached review responses. The authors greatly appreciate the detailed and relevant feedback.

Author Response File: Author Response.pdf