Cornelis H. van der Vlies

Burn injury induces profound immune dysregulation that extends beyond the acute phase of wound healing, contributing to complications such as delayed repair, infection, and long-term immune dysfunction. Importantly, these effects are not restricted to severe trauma, as similar immune alterations occur following small- to moderate-sized burns. Despite increasing recognition of post-burn immune dysregulation, targeted immunomodulatory therapies remain limited. In this review, we synthesize current insights into the mechanisms driving immune dysfunction after burn injury and outline therapeutic strategies aimed at restoring immune homeostasis. We examine approaches targeting inflammatory triggers and mediators, including acute clinical interventions, reduction in microbial burden, and inhibition of immune cell activation through systemic and local delivery. We also explore strategies to modulate dysregulated innate immune responses by targeting cell-specific functions, such as neutrophil activity and monocyte/macrophage polarization. Persistent activation and exhaustion of the adaptive immune system may be alleviated through interventions such as β-adrenergic blockade, while metabolic, endocrine, and oxidative stress pathways represent additional therapeutic targets. Finally, we highlight key challenges, including the need for improved diagnostics, early prognostic stratification, and personalized treatment approaches to improve outcomes following burn injury.

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.

Surviving a burn can dramatically alter a child’s life, yet few studies examined long-term health-related quality of life (HRQL). This study assessed HRQL 5–7 years post-burn in children with mild/intermediate and severe burns and identified associated factors. Parents of children (5− < 18 years) who were hospitalized or had burn surgery between 08/2011 and 09/2012 completed the Burn Outcomes Questionnaire (BOQ). Outcomes were compared between two subgroups: children with mild/intermediate burns (20% TBSA burned; or (3) >5% full-thickness burns). A total of 102 children were included (mean age at survey: 8.4 (3.0) years; mean former TBSA: 7.1%). At a mean of 5.7 years post-burn, many parents rated their child’s health as excellent (46.1%) or very good (35.3%), with few reporting issues with ‘pain’ (2.3%), ‘physical function and sports’ (1.6%), and ‘upper extremity function’ (0.9%). Parents of children with severe burns indicated significantly more problems with ‘appearance’ (89.2% versus 71.5%; p = 0.014) and ‘parental concern’ (94.1% versus 84.8%; p = 0.021). Upper limb burns, facial burns, burn size, length of hospital stay, full-thickness burns, and the number of surgeries predicted poorer outcomes. In general, these findings indicate positive long-term HRQL, though especially children with full-thickness burns and/or surgical interventions face a higher risk of reduced HRQL. The results can be used to inform children and their families about the long-term implications. Furthermore, healthcare professionals can use these insights to identify children at higher risk of poorer long-term HRQL.

Burn care quality indicators are used to monitor and improve quality of care and for benchmark purposes. The perspectives of burn survivors, however, are not included in current sets of quality indicators while patient-centred care gains importance. The aim of this study was to explore burn survivors’ perspectives on quality aspects of burn care, which was used to translate their perspectives into patient-centred quality of care indicators. Qualitative descriptive research was conducted in a patient panel group. First, thematic analysis was applied to the focus groups to identify overarching themes. Second, patient-centred quality indicators, informed by burn survivors’ valued aspects of care, were defined. Ten burn survivors with an average age of 54 years (SD = 11; range 38–72 years) and mean TBSA burned of 14% (SD = 11%; range 5–35%) participated in two focus groups. Four overarching themes were identified, pointing to the importance of (1) information tailored to the different phases of recovery, (2) significant others’ wellbeing and involvement, (3) a therapeutic relationship and low-threshold access to healthcare professionals and (4) to participate in decision-making. Eighteen patient-centred process quality of care indicators within nine aspects of care were formulated. The overarching themes are reflected in patient-centred quality indicators, which present a broadened and complementary view of existing clinical quality indicators for burn care. Evaluating these patient-centred quality indicators may increase quality of care and refine patient-centred care.

For deep partial-thickness burns no consensus on the optimal treatment has been reached due to conflicting study outcomes with low quality evidence. Treatment options in high- and middle-income countries include conservative treatment with delayed excision and grafting if needed; and early excision and grafting. The majority of timing of surgery studies focus on survival rather than on quality of life. This study protocol describes a study that aims to compare long-term scar quality, clinical outcomes, and patient-reported outcomes between the treatment options. A multicentre prospective study will be conducted in the three Dutch burn centres (Rotterdam, Beverwijk, and Groningen). All adult patients with acute deep-partial thickness burns, based on healing potential with Laser Doppler Imaging, are eligible for inclusion. During a nine-month baseline period, standard practice will be monitored. This includes conservative treatment with dressings and topical agents, and excision and grafting of residual defects if needed 14–21 days post-burn. The subsequent nine months, early surgery is advocated, involving excision and grafting in the first week to ten days post-burn. The primary outcome compared between the two groups is long-term scar quality assessed by the Patient and Observer Scar Assessment Scale 3.0 twelve months after discharge. Secondary outcomes include clinical outcomes and patient-reported outcomes like quality of life and return to work. The aim of the study is to assess long-term scar quality in deep partial-thickness burns after conservative treatment with delayed excision and grafting if needed, compared to early excision and grafting. Adding to the ongoing debate on the optimal treatment of these burns. The broad range of studied outcomes will be used for the development of a decision aid for deep partial-thickness burns, to fully inform patients at the point of consent to surgery and support optimal person-centred care.

Background: Frailty can have a negative influence on outcomes in elderly patients after burn injuries. The Dutch hospitals have used a four-domain frailty screening instrument from the Dutch Safety Management System (DSMS) since 2012. However, its feasibility and validity have hardly been studied. We aim to assess the feasibility and validity of frailty screening in specialized burn care. Methods: A multicentre retrospective cohort study was conducted in all Dutch burn centres. Patients aged ≥ 70, with a primary admission between 2012–2018, were included. Data were derived from electronic patient files. Results: In total, 515 patients were included. Frailty screening was complete in 39.6% and partially complete in 23.9%. Determinants for a complete screening were admission after 2015 (OR = 2.15, 95% CI 1.42–3.25) and lower percentage TBSA burned (OR = 0.12, 95% CI 0.05–029). In all completely screened patients, 49.9% were at risk of frailty. At risk patients were older, had more comorbidities (known group validity), a longer length of stay, and more frequently a non-home discharge (predictive validity). Conclusion: Frailty screening in specialized burn care is feasible and was conducted in 63.5% of admitted patients. In total, 44% of screened patients were at risk of frailty. Validity of frailty screening was confirmed. Frailty screening can contribute to optimal specialized burn care.

The EQ-5D is increasingly used to assess the health-related quality of life (HRQL) of adult patients with intermediate burns. However, this generic instrument may lack sensitivity, as important problems for burn patients, such as itching and cognition problems are not included in this instrument. This retrospective observational study investigates the value of adding an itching and cognition item to the EQ-5D-3L. Patients completed the EQ-5D-3L, and the Patient and Observer Scar Assessment Scale (POSAS), including an itching item and an extra cognition item three months postburn. The potential added value of an itching and cognition item was studied by distribution, informativity, convergent validity, dimension dependency, and explanatory analyses. In total, 120 patients were included of whom 65% reported itching and 23% reported cognition problems. Adding an itching item to the EQ-5D improved the discriminatory power and informativity of the EQ-5D-3L, but barely increased the explanatory power (0.4%) and decreased the convergent validity (r = −0.529 vs. r = −0.612). In contrast, adding a cognition item slightly improved the informativity and discriminatory power. Moreover, convergent validity (r = −0.617 vs. r = −0.612) and explanatory power increased (4.0%). In conclusion, adding an itching item to the EQ-5D-3L provides some additional information, however, the added value is small, whereas adding a cognition item improved the measurement properties of the EQ-5D-3L in our sample and should be considered when assessing HRQL in adult patients with intermediate burns.

The aim of this study was to provide insight into the admission rate, treatment, and healthcare costs of patients with fireworks-related burns admitted to a Dutch burn center in the past 10 years. We hypothesized that, like the nationwide number of injuries, the number of patients admitted to a burn center with fireworks-related burn injuries would have decreased during the study period. In this retrospective multicenter cohort study, all patients with fireworks-related burns admitted to a Dutch burn center between 2009 and 2019 were eligible. Patients were identified from a national database and data were obtained regarding admission details, patient and injury characteristics, treatment, and healthcare costs. A total of 133 patients were included. On average, 12 patients were admitted per year. No increase or decrease was observed during the study period. The median total body surface area burned was 1% (P₂₅–P₇₅ 0.5–2.5) and 75% of the burns were of partial thickness. Thirteen (10%) patients were admitted to the ICU and 66 (50%) underwent surgical treatment. The mean total healthcare costs across all 133 patients were estimated at €9040 (95% CI €5830 to €12,260) per patient. In contrast to the hypothesis, no increase or decrease was observed in burn center admissions over the past 10 years. Most burns were of small size, but nevertheless, all patients were admitted to a burn center and half of them underwent surgical treatment.

There exists little to no data on the development of donor‐site scars that remain after split skin graft harvesting. The objectives of this study were to 1) examine changes in characteristics of donor‐site scar quality over time and 2) assess the agreement between patient‐reported and observer‐reported donor‐site scar quality in a burn population. A prospective cohort study was conducted including patients that underwent split skin grafting for their burn injury. Patients and observers completed the Patient and Observer Scar Assessment Scale (POSAS) for the first harvested donor‐site at 3 an 12 months post‐surgery. This study included 80 patients with a median age of 34 years. At 3 months post‐surgery the patients scored the POSAS items itch and color as most deviant from normal skin, both improved between 3 and 12 months (3.1 vs 1.5 and 5.0 vs 3.5, respectively [P < 0.001]). Other scar characteristics did not show significant change over time. The patients’ overall opinion score improved from 3.9 to 3.2 (P < 0.001). Observers rated the items vascularization and pigmentation most severe, only vascularization improved significantly between both time points. Their overall opinion score decreased from 2.7 to 2.3 (P < 0.001). The inter‐observer agreement between patients and observers was considered poor (ICC < 0.4) at both time points. Results of current study indicate that observers underestimate the impact of donor‐site scars. This has to be kept in mind whilst guiding therapy and expectations. LEVEL OF EVIDENCE: II, prospective cohort study.