Five years ago, Arek Wiktor, MD, FACS, FABA, associate professor of GI, trauma, and endocrine surgery and medical director of the UCHealth Burn and Frostbite Center, kicked off a clinical trial at CU Anschutz to study the effects of two colloids, plasma and albumin, in acute burn resuscitation.
“When someone gets a large burn, over 20% of their body, they require a large amount of intravenous fluid to support their organ systems,” Wiktor says. “That’s called a resuscitation. Many different formulas have been developed to try to calculate how much fluid to give. You don't want to give too much fluid because it can flood a patient’s lungs; it can cause a lot of complications. If you give too little fluid, then their organs can also suffer. There’s a fine line.”
Like most hospital patients, burn patients receive what are known as “crystalloid fluids” — the clear IV fluids, such as saline, that typically hang over a hospital bed. But burn patients also receive “colloid” fluids — a type of protein-containing solution that is used to treat patients who need critical replenishment.
“The two most common colloids are plasma, which is a component of blood, and albumin, which is a protein found in plasma,” Wiktor says. “And there’s a debate about which one is better. Our burn center’s standard of care is to use the plasma, but other burn units’ standard of care is the albumin. This study was looking at, ‘OK, if both are being used by different burn centers, is there one that’s better?’”
The trial, which was funded by a $1.5 million grant from the Department of Defense Military Burn Research Program, is now complete, and despite his original hypothesis that fresh-frozen plasma would prove more effective in burn resuscitation, Wiktor found that both colloids performed equally well in the trial.
“We ended up enrolling 59 patients, and we wanted to compare the total amount of fluids that they received in the first 24 and 48 hours, as well as any complications that may have occurred during the resuscitation,” says Wiktor, who presented the research at the annual meeting of the American Burn Association in April.
“At eight hours, both groups were the same in terms of the total amount of fluids, and there were no differences in complications, no differences in respiratory issues, no difference in organ dysfunction, and no difference in endotheliopathy markers.” (Endotheliopathy is a systemic disorder characterized by damage, activation, or dysfunction of the inner cellular lining of blood vessels.)
Unlike plasma, albumin doesn’t have to be thawed or matched by blood type, making it a better solution from a resource-allocation standpoint, Wiktor says, but his research found that if a burn center prefers plasma, it works just as well. Where his research did find room for improvement is in the timing of colloids in burn resuscitation.
In the study, colloid resuscitation didn’t begin until eight hours after a burn injury, due to a theoretical risk of fluid leakage resulting from inflammation.
“The traditional thinking has been, if you give colloid earlier than eight hours, those plasma proteins would leak out and cause more leakage of fluid, because those junctions aren't filled in, but that really hasn't been proven to be true,” Wiktor says.
The results of his clinical trial, as well as additional research on animal models, suggest that earlier intervention may have better results, he says.
“The theory is that when someone gets injured, the endothelial disruption in the blood vessels happens early on, within the first hour or two after injury,” he says. “So maybe we need to focus on giving colloids much earlier, or as soon as possible.”
Wiktor will soon begin research aimed at identifying the earliest possible point of colloid therapy for acute burn injury.
“We're still going to look at both types, albumin and colloid, but plasma is always going to be slower because you have to thaw it,” he says. “There are even some burn centers that are talking about giving plasma or colloid in the ambulance before they reach the hospital.”
Though Wiktor was surprised by the primary findings of his clinical trial — that albumin performs as well as plasma — he is intrigued by the secondary finding around treatment timing.
“We can use the results of this research in our daily practice — we know if a patient comes in six to eight hours after their injury, we can give either colloid, and we know it's equivalent, because we have the data showing that,” he says. “We are now shifting our research focus to that earlier time window.”