Severe burn trauma can significantly impair renal function with increased morbidity and mortality. To preserve renal function after burn trauma, fluid resuscitation should be adequate avoiding hypo- as well as hypervolemia. In 2018, the Dutch Burn Society revised its resuscitation guideline from 4 mL/kg/TBSA hypertonic solution to 3 mL/kg/TBSA isotonic solution. This study analyzes the effects of these changes in the fluid resuscitation protocol on renal function. In this retrospective, single-center, cohort study, we included adult patients with a burn injury of at least 15 % of their total body surface area (≥ 15 % TBSA). The inclusion period lasted from 2.5 years before until 2.5 years after the modification of the fluid resuscitation protocol. We compared the effects of both protocols (4 mL/kg/TBSA hypertonic solution versus 3 mL/kg/TBSA isotonic solution) on renal function, as assessed by glomerular filtration rate, plasma creatinine concentration and urinary output, the incidence of AKI, and the need for renal replacement therapy. We included 108 patients with a median burned TBSA of 22 %, 52 patients receiving 4 mL/kg/TBSA hypertonic solution, and 56 patients receiving 3 mL/kg/TBSA isotonic solution. Baseline characteristics were similar between both groups (mean age 44 years). No significant differences were observed in renal function, need for renal replacement therapy, urinary output, incidence of acute kidney injury, or mortality. Determining the optimal fluid volume and composition for resuscitation of patients with severe burn trauma remains challenging. In our study, reducing the initial resuscitation volume from 4 to 3 mL/kg/TBSA and switching from a hypertonic to an isotonic solution showed no adverse effects on renal function after severe burn trauma. Future studies should investigate whether individualized strategies can help to reach the sweet spot of fluid resuscitation.

Background: Critical care for patients with severe burn injuries is challenging, particularly in the first 24–48 h. Multiple guidelines exist but their recommendations vary in content and in the level of detail. Methods: This narrative review analyzed recent (last 10 years) adult burn guidelines in English, Dutch and German, sourced from PubMed, Medline and official burn society publications. The review focused on airway management, mechanical ventilation, fluid resuscitation, pain management and procedural sedation. Results: All guidelines emphasize early airway assessment and timely intubation in patients at risk for loss of airway patency; however, a strategy for analyzing patients at risk is lacking. Lung-protective ventilation strategy is generally recommended. Fluid resuscitation is the cornerstone during the first phase, though recommendations for thresholds, volume and adjuncts differ. (Chronic) pain management should be multimodal, combining pharmacologic and non-pharmacologic approaches, but specifics on choice of modality are limited, also, there is no uniform strategy for procedural sedation management. Conclusion: Current guidelines offer broadly consistent recommendations for initial burn care but differ in specifics, reflecting evidence gaps. Future guidelines should address advances in airway management, fluid resuscitation endpoints, volume and adjuncts, and give a more detailed (chronic) pain strategy to improve standardization and outcomes.