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1、Journal Pre-proofManagement of severe thermal burns in the acute phase in adults andchildrenMatthieu Legrand Damien Barraud Isabelle Constant PaulineDevauchelle Nicolas Donat Mathieu Fontaine Laetitia GoffinetCl ement Hoffmann Mathieu Jeanne Jeanne Jonqueres ThomasLeclerc Hugues Lefort Nicolas Louve
2、t Marie-Reine Losser C eliaLucas Olivier Pantet Antoine Roquilly Anne-Franc oise RousseauSabri Soussi Sandrine Wiramus Etienne Gayat Alice BletPII:S2352-5568(20)30038-2DOI:https:/doi.org/doi:10.1016/j.accpm.2020.03.006Reference:ACCPM 626To appear in:Anaesthesia Critical Care&Pain MedicinePlease cite
3、 this article as:Legrand M,Barraud D,Constant I,Devauchelle P,Donat N,Fontaine M,Goffinet L,Hoffmann C,Jeanne M,Jonqueres J,Leclerc T,Lefort H,Louvet N,Losser M-Reine,Lucas C,Pantet O,Roquilly A,Rousseau A-Franc oise,Soussi S,WiramusS,Gayat E,Blet A,Management of severe thermal burns in the acute ph
4、ase in adults andchildren,Anaesthesia Critical Care and Pain Medicine(2020),doi:https:/doi.org/10.1016/j.accpm.2020.03.006This is a PDF file of an article that has undergone enhancements after acceptance,such asthe addition of a cover page and metadata,and formatting for readability,but it is not ye
5、t thedefinitive version of record.This version will undergo additional copyediting,typesetting andreview before it is published in its final form,but we are providing this version to give earlyvisibility of the article.Please note that,during the production process,errors may bediscovered which coul
6、d affect the content,and all legal disclaimers that apply to the journalpertain.2020 Published by Elsevier.Page 1 of 45Journal Pre-proofRecommendations for Professional PracticeRecommendations for Professional Practice Management of severe thermal burns in the acute phase in adults and Management of
7、 severe thermal burns in the acute phase in adults and children*,*children*,*(Notes de titre)(Notes de titre)*With the collaboration of the following societies:Francophone Society of Burns(Socit francophone de brlologie SFB),French Society of Emergency Medicine (Socit franaise de mdecine durgence SF
8、MU),Association of French-Speaking Paediatric Anaesthesiologists and Intensivists(Association des anesthsistes-ranimateurs pdiatriques dexpression franaise ADARPEF)*Text approved by the SFAR Clinical Reference Committee(15/05/2019)and the SFAR Board of Directors(24/05/2019).Matthieu Legrand1*,Damien
9、 Barraud2,Isabelle Constant3,Pauline Devauchelle4,Nicolas Donat5,Mathieu Fontaine6,Laetitia Goffinet7,Clment Hoffmann5,Mathieu Jeanne8,9,10,Jeanne Jonqueres6,Thomas Leclerc5,Hugues Lefort11,Nicolas Louvet3,Marie-Reine Losser7,2,12,13,Clia Lucas14,Olivier Pantet15,Antoine Roquilly16,17,Anne-Franoise
10、Rousseau18,Sabri Soussi14,19,Sandrine Wiramus20,Etienne Gayat14,21,and Alice Blet14,21,22.1 Department of Anaesthesia and Perioperative Care,University of California San Francisco,United States 2Hopital de Mercy,Intensive care Medicine and burn centre,CHR Metz-Thionville,Ars-Laquenexy,France 3Anaest
11、hesiology Department,Hpital Armand Trousseau,Sorbonne Universit,Assistance Publique Hpitaux de Paris,Paris,France 4CHU Lille,Anaesthesia and Critical Care,Burn Centre,F-59000 Lille,France 5Burn Centre,Percy Military Teaching Hospital,Clamart,France 6Burn Intensive Care Unit,Saint Joseph Saint Luc Ho
12、spital,20 quai Claude Bernard,69007 Lyon,France 7Paediatric Burn Centre,University Hospital of Nancy,Vanduvre-Ls-Nancy,F-54511,France 8Univ.Lille,Inserm,CHU Lille,CIC 1403,F-59000 Lille,France 9Univ.Lille,EA 7365-GRITA,F-59000 Lille,France 10CHU Lille,Anaesthesia and Critical Care,Burn Centre,F-5900
13、0 Lille,France Page 2 of 45Journal Pre-proof11Department of emergency medicine,Legouest Military Teaching Hospital,Metz,France 12Inserm UMR 1116,Team 2 13University of Lorraine,F-54000,Nancy,France 14Department of Anaesthesiology,Critical Care and Burn Centre,Lariboisire-Saint-Louis Hospitals,DMU Pa
14、rabol,APHP Nord,University of Paris,France 15Service of Adult Intensive Care Medicine and Burns,Lausanne University Hospital(CHUV),BH 08-651,Rue du Bugnon 46,1011 Lausanne,Switzerland 16Department of Anaesthesia and Critical Care,Hotel Dieu,University Hospital of Nantes,Nantes,France 17Laboratoire U
15、PRES EA 3826 Thrapeutiques cliniques et exprimentales des infections,University of Nantes,Nantes,France 18Burn Centre and Intensive Care Department,University Hospital of Lige,Lige,Belgium 19Interdepartmental Division of Critical Care,Keenan Research Centre for Biomedical Science and Institute of Me
16、dical Sciences,Faculty of Medicine,University of Toronto,Toronto,ON,Canada 20Department of Anaesthesia and Intensive Care Medicine and burn centre,University Hospital of Marseille,la Timone Hospital,Marseille,France 21Inserm UMR-S 942,Cardiovascular Markers in Stress Conditions(MASCOT),University of
17、 Paris,Paris,France 22Department of Research,University of Ottawa Heart Institute,Ottawa,ON,Canada*Corresponding author at:*Corresponding author at:Department of Anaesthesia and Perioperative Care,University of California San Francisco,United States.Email:(M.Legrand)Experts Coordinators:Experts Coor
18、dinators:Matthieu Legrand(Paris)and Damien Barraud(Metz).Organisers:Organisers:Alice Blet(Paris)and Etienne Gayat(Paris).Group of Experts(ADARPEF):Group of Experts(ADARPEF):Isabelle Constant,Nicolas Louvet Page 3 of 45Journal Pre-proofGroup of Experts(SFAR):Group of Experts(SFAR):Damien Barraud,Isab
19、elle Constant,Pauline Devauchelle,Nicolas Donat,Clment Hoffmann,Mathieu Jeanne,Jeanne Jonqueres,Thomas Leclerc,Matthieu Legrand,Marie-Reine Losser,Clia Lucas,Olivier Pantet,Antoine Roquilly,Anne-Franoise Rousseau,Sabri Soussi Group of Experts(SFB):Group of Experts(SFB):Mathieu Fontaine,Laetitia Goff
20、inet,Sandrine Wiramus Group of Experts(SFMU):Group of Experts(SFMU):Hugues Lefort Working groups:Working groups:-Assessment,admission to specialised centres,and telemedicine:Nicolas Donat(Clamart),Mathieu Fontaine(Lyon),Clment Hoffmann(Clamart),Thomas Leclerc(Clamart),and Hugues Lefort(Metz).-Haemod
21、ynamic management:Pauline Devauchelle(Lille),Nicolas Donat(Clamart),Clment Hoffmann(Clamart),Thomas Leclerc(Clamart),Jeanne Jonqueres(Lyon),Marie-Reine Losser(Nancy),and Sabri Soussi(Paris).-Airways management and smoke inhalation:Damien Barraud(Metz),Pauline Devauchelle(Lille),Hugues Lefort(Metz),M
22、atthieu Legrand(Paris),Marie-Reine Losser(Nancy),Olivier Pantet(Lausanne,Switzerland),and Sandrine Wiramus(Marseille).-Anaesthesia and analgesia:Mathieu Jeanne(Lille)and Antoine Roquilly(Nantes).-Wounds treatment:Damien Barraud(Metz),Mathieu Fontaine(Lyon),Laetitia Goffinet(Nancy),Jeanne Jonqueres(L
23、yon),Matthieu Legrand(Paris),Clia Lucas(Paris),and Anne-Franoise Rousseau(Lige,Belgium).-Other treatments:Marie-Reine Losser(Nancy),Clia Lucas(Paris),Olivier Pantet(Lausanne,Switzerland),and Anne-Franoise Rousseau(Lige,Belgium)-Paediatric recommendations:Nicolas Louvet(Paris)and Isabelle Constant(Pa
24、ris)-Bibliography officer:Boris Glavnik(Metz)Reading groups:Reading groups:-SFAR Clinical Reference Committee:Page 4 of 45Journal Pre-proofLionel Velly(President),Marc Garnier(Secretary),Julien Amour,Alice Blet,Grald Chanques,Hlne Charbonneau,Vincent Compre,Philippe Cuvillon,Etienne Gayat,Catherine
25、Huraux,Herv Quintard,and Emmanuel Weiss.-SFAR Board of Directors:Xavier Capdevila,Herv Bouaziz,Laurent Delaunay,Pierre Albaladejo,Jean-Michel Constantin,Marie-Laure Cittanova Pansard,Marc Lone,Bassam Al Nasser,Hlne Beloeil,Valrie Billard,Francis Bonnet,Marie-Paule Chariot,Isabelle Constant,Alain Del
26、bos,Claude Ecoffey,Jean-Pierre Estebe,Marc Gentili,Olivier Langeron,Pierre Lanot,Luc Mercadal,Frdric Mercier,Karine Nouette-Gaulain,Eric Viel,and Paul Zetlaoui.Conflicts of interest of the SFAR Experts in the 5 years before the date of validation by the SFAR Board of Conflicts of interest of the SFA
27、R Experts in the 5 years before the date of validation by the SFAR Board of Directors:Directors:Matthieu Legrand reports lecture fees from Baxter and Fresenius and consulting fees from Novartis.Mathieu Jeanne reports a conflict of interest with MDMS(LOOS,France).Antoine Roquilly reports working as a
28、 consultant for MSD and bioMerieux.Conflicts of interestConflicts of interest of the SFB Experts in the 5 years before the date of validation by the SFB Board of of the SFB Experts in the 5 years before the date of validation by the SFB Board of Directors:Directors:None.Conflicts of interest of the
29、SFMU Experts in the 5 years before the date of validation by the SMU Board of Conflicts of interest of the SFMU Experts in the 5 years before the date of validation by the SMU Board of Directors:Directors:Hugues Lefort reports working as a consultant for Ethypharm.Conflicts of interest of the ADARPE
30、F Experts in the 5 years before the date of validation by the ADARPEF Conflicts of interest of the ADARPEF Experts in the 5 years before the date of validation by the ADARPEF Board of Directors:Board of Directors:None.ABSTRACT Objectives:To provide recommendations to facilitate the management of sev
31、ere thermal burns during the acute phase in adults and children.Design:A committee of 20 experts was asked to produce recommendations in six fields of burn management,namely,(1)assessment,admission to specialised Burns Centres,and telemedicine;(2)haemodynamic management;(3)airway management and smok
32、e inhalation;(4)anaesthesia and analgesia;(5)burn wound treatments;and(6)other treatments.At the start of the recommendation-formulation process,a formal conflict-of-interest policy was developed and enforced throughout the process.The entire process was conducted independently of any industry fundi
33、ng.The experts drew up a list of questions that were formulated according to the PICO model(Population,Intervention,Comparison,and Outcomes).Two bibliography experts per field analysed the literature published from Page 5 of 45Journal Pre-proofJanuary 2000 onwards using predefined keywords according
34、 to PRISMA recommendations.The quality of data from the selected literature was assessed using GRADE methodology.Due to the current paucity of sufficiently powered studies regarding hard outcomes(i.e.mortality),the recommendations are based on expert opinion.Results:The SFAR guidelines panel generat
35、ed 24 statements regarding the management of acute burn injuries in adults and children.After two scoring rounds and one amendment,strong agreement was reached for all recommendations.Conclusion:Substantial agreement was reached among a large cohort of experts regarding numerous strong recommendatio
36、ns to optimise the management of acute burn injuries in adults and children.Keywords:Keywords:Severe Burns;Intensive Care;Guidelines.IntroductionIntroduction Burn injuries are common and mostly accidental.The majority of cases are not serious and may be treated as outpatients.In France,severe burns
37、are responsible for about 10.000 hospitalisations annually,half of which require stays at specialised Burns Centres(Annex 1).Although these more severe burns are associated with relatively low mortality,they induce considerable morbidity with physical,psychological,and social consequences,long hospi
38、tal stays and a significant use of resources.The incidence of burns is four times higher in children than in adults:burn injuries account for about 25%of all paediatric hospitalisations.The most common cause is hot liquids.The recommendations herewith aim to provide a rational therapeutic approach t
39、o managing severe burn injuries in adults and children.Although an official definition of severe burns is lacking,the experts who produced these recommendations consider both life-threatening and function-threatening burns as severe burns and propose the following criteria to define them:-In adults(
40、Annex 2A):o One of the following criteria:Total body surface area(TBSA)burned 20%,deep burns 5%,presence of smoke inhalation,deep burns in areas that might lead to functional sequelae(face,hands,feet,perineum),burns from high-voltage electricity.o TBSA 75 years,severe comorbidities,known or suspecte
41、d smoke inhalation,deep circular burns,superficial burns in function-sensitive areas(face,hands,feet,perineum,skin folds),TBSA 10%,deep burn 35%,burns from low-voltage electricity,chemical burns(e.g.hydrofluoric acid).-In children(Annex 2B):Page 6 of 45Journal Pre-proofo One of the following criteri
42、a:TBSA 10%,deep burns 5%,infants(30%reported that haemodynamic monitoring using transpulmonary thermodilution was associated with less fluid and lower morbidity 105.Annex 5B proposes a fluid resuscitation algorithm in children.Question 2.4:Should albumin be used for fluid resuscitation in severe bur
43、ns?Question 2.4:Should albumin be used for fluid resuscitation in severe burns?R2.4 R2.4 R2.4 R2.4 The experts suggest administering human The experts suggest administering human albumin to severe burns patients with a total burned body albumin to severe burns patients with a total burned body surfa
44、ce area of over 30%after the first 6 hours of management.surface area of over 30%after the first 6 hours of management.RationaleRationale A recent international survey of intensive care unit physicians showed that more than 30%of responders frequently or systematically used colloids in the early pha
45、se of severe burn management.The most commonly used colloid was human albumin(more than 60%of respondents)72,106.In theory,colloids can increase oncotic pressure,thereby decreasing fluid leakage and reducing the volume of crystalloids administered in the initial phase of severe burn management.As a
46、result,colloid administration could reduce the complications related to fluid overload,which include acute respiratory distress syndrome,congestive acute kidney injury,and abdominal compartment syndrome,thereby potentially improving the prognosis 107,108.Human albumin may also have an anti-inflammat
47、ory and antioxidant activity 106.A recent meta-analysis initially found that,when patients with severe burns were given albumin within the first 24 hours,their survival did not improve.However,when two studies with a high risk of bias were excluded,the meta-analysis showed that albumin administratio
48、n significantly reduced mortality(Odds ratio=0.34;95%confidence interval=0.190.58;p 0.001)109.Another meta-analysis showed that albumin administration within the first 24 hours in severe burns patients also significantly reduced abdominal compartment syndrome from 15.4%in the non-treated control gro
49、up to 2.8%in the albumin-treated group(p 30 g/L)reduced mortality relative to the control group either.However,the patients in the septic shock subgroup who received albumin did have a lower net fluid balance and less mortality than the controls 116.Since the very high volumes of crystalloids admini
50、stered to burns patients is associated with iatrogenic injuries,the experts suggest that severe burns patients should receive enough albumin to maintain albumin levels at 30 g/L.The albumin doses that achieve this are generally around 1-2 g/kg/day.This may help to decrease the infused volumes of cry