Plasma for burn shock resuscitation: is it time to go back to the future?

Abstract

Patients with burn shock can be challenging to resuscitate. Burn shock produces a variety of physiologic derangements: Patients are hypovolemic from volume loss, have a increased systemic vascular resistance, and may have a depressed cardiac output depending on the extent of the thermal injury. Additionally, the burn wound produces a significant inflammatory cascade of events that contributes to the shock state. Fluid resuscitation is foundational for the initial treatment of burn shock. Typical resuscitation is with intravenous lactated Ringer's in accordance with well‐established formulas based on burn wound size. In the past century, as therapies to treat thermal injuries were being developed, plasma was the fluid used for burn resuscitation; in fact, plasma was used in World War II and throughout the 1950s and 1960s. Plasma was abandoned because of infectious risks and complications. Despite huge strides in transfusion medicine and the increased safety of blood products, plasma has never been readopted for burn resuscitation. Over the past 15 years, there has been a paradigm shift in trauma resuscitation: Less crystalloid and more blood products are used; this strategy has demonstrated improved outcomes. Plasma is a physiologic fluid that stabilizes the endothelium. The endotheliopathy of trauma has been described and is mitigated by transfusion strategies with a 1:1 ratio of RBCs to plasma. Thermal injury also results in endothelial dysfunction: the endotheliopathy of burns. Plasma is likely a better resuscitation fluid for patients with significant burn wounds because of its capability to restore intravascular volume status and treat the endotheliopathy of burns.

Association of Prehospital Plasma With Survival in Patients With Traumatic Brain Injury

“…The postulated benefits of plasma in patients with burn injuries include a restoration of intravascular volume and reduction of burn injury-associated endotheliopathy. 43 The association between prehospital plasma and survival may depend on the severity of TBI and the presence of concomitant polytrauma. Preliminary data from an exploratory subgroup analysis suggest that patients with impaired neurological function (GCS score <8) who received prehospital plasma had an associated 44% reduction in the risk of mortality (HR, 0.56; 95% CI, 0.35-0.91).…”

A narrative review of changes in microvascular permeability after burn

“…The essence of burn shock is the rapid and extensive fluid transfer in burn and non-burn tissues (6). After severe burns, the local and systemic vascular permeability increase, causing intravascular fluid extravasation, leading to a progressive decrease in effective circulation volume, an increase in systemic vascular resistance, a decrease in cardiac output, peripheral tissue edema, multiple organ failure, and even death (7,8). The increase in vascular permeability is characterized as a significant change in the permeability of capillaries and post-capillary venules.…”

Impact of a goal-directed factor-based coagulation management on thromboembolic events following major trauma

“…Haemostatic resuscitation was traditionally performed by transfusion of RBC, FFP and PC at a fixed ratio [4,10]. Allogeneic blood transfusions are associated with several adverse events (e.g.…”