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Three Part Question

In [patients presenting to the Emergency Department with burns of >15% total body surface area (TBSA)] does [high dose vitamin C]lead to [lower fluid requirement with faster recovery and lower mortality]

Clinical Scenario

A 13-year-old boy presents to the emergency department after sustaining 30% burns. Fluid resuscitation is commenced and he is intubated and ventilated for transfer to the burns unit. The burns team ask you to commence a vitamin C infusion. You wonder whether vitamin C will make any difference to the patient\'s outcome.

Search Strategy

MEDLINE using the Ovid interface, 1946—September week 1 2012
Embase using the Ovid interface, 1980 to 2012 week 37
The Cochrane Database of Systematic Reviews
(exp Burn\\OR exp Burns\\OR burn$.mp. OR scald.mp.) AND exp (Ascorbic Acid\\OR vitamin C.mp. OR ascorbic acid.mp.) limit to humans and English language.

Search Outcome

In total 85 papers were identified in MEDLINE, 360 in Embase and 24 in the Cochrane Database of Systematic Reviews. In total four papers were relevant to the three-part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Tanaka et al, 2000, Japan	37 Patients with >30% (TBSA) burns hospitalised within 2 h of injury. Randomly assigned to receive ascorbic acid IV 66 mg/kg/h or standard treatment alone	Randomised controlled trial	Total fluid infusion in 24 h	Intervention group: 3.0±1.7 ml/kg/%TBSA control group: 5.5±3.1 ml/kg/%TBSA. That is 45.5% reduction (p<0.004)	No placebo control No blinding Small numbers average age of control group higher by 10 years No of fasciotomies was less in intervention group but authors did not specify the severity of injuries between two groups Primary outcome not stated No power calculation
			Length of mechanical ventilation	Intervention group: 12.1±8.8 days control group: 21.3±15.6 days (p=0.03)
Barbosa et al, 2009, Brazil	32 Children with burns >15% TBSA. Randomly assigned to receive antioxidant supplementation (including vitamin C at 1.5 times the upper intake level, vitamin E and zinc) or placebo, starting on day 2 and continuing for 7 days	Randomized controlled trial	Time to wound healing	Lower in intervention group (p<0.001)	Low dose Small numbers, no power calculation Few details reported regarding methodology and results
Kahn et al, 2011, USA	40 Patients with burns >20% TBSA. Some received LR alone, others LR plus 66 mg/kg/h vitamin C	Retrospective chart review	Fluid requirements in 24 h	Vitamin C: 5.3±1 ml/kg/%TBSA LR alone: 7.1±1 ml/kg/TBSA (p<0.05)	Retrospective Vitamin C group is younger in age and had less % TBSA
			Urine output	Vitamin C: 1.5±0.4 mlg/kg/h LR: 1±0.5 ml/kg/h (p<0.05)
			Need for inotropes	Required in 4/17 vitamin C patients vs 9/16 LR patients (p=0.07)
			Mortality	Vitamin C: 3/17 patients LR: 4/16 patients (p=1)
Pakraftar et al, 2011, USA	15 Patients with >25% TBSA burn, resuscitated with 66 mg/kg/h ascorbic acid, in addition to crystalloids	Retrospective chart review	Fluid requirements	13/15 Patients needed an average of 22.83% less fluid than that predicted by the Parkland formula to achieve urine output of 0.5–1.0 ml/kg/h	Small number of patients Retrospective No control group

Comment(s)

Burn injuries are some of the most devastating, with a correlation between burn size and mortality. Recent advances have led to the understanding of burn shock and thus improved outcome for such patients. Fluid resuscitation is indicated for adult patients with burns covering more than 15% of the TBSA and children or elderly patients with burns of more than 10% TBSA. Large amounts of intravenous fluid may be required, which often causes significant tissue oedema and fluid retention and leads to many complications, including impaired wound healing and respiratory impairment. Vitamin C scavenges free radicals, which may reduce vascular permeability and lipid peroxidation. This, in turn, could lead to a theoretical reduction in tissue oedema following a severe burn. Early trials suggest that high dose vitamin C infusions may lead to lower fluid requirements and less respiratory impairment in patients with severe burns

Editor Comment

LR, lactated Ringer\'s; TBSA, total body surface area.

Clinical Bottom Line

High-dose vitamin C can reduce the amount of fluids required for resuscitation of patients with severe burns, and can potentially improve wound healing and reduce ventilation requirements. However, the current evidence is still very preliminary due to the size and quality of available studies and further large trials are needed.

References

1. Tanaka H, Matsuda T, Miyagantani Y, et al. Reduction of resuscitation fluid volumes in severely burned patients using ascorbic acid administration: a randomized, prospective study Arch Surg 2000 Mar;135(3):326-31.
2. Barbosa E, Faintuch J, hado Moreira EA, et al. Supplementation of vitamin E, vitamin C, and zinc attenuates oxidative stress in burned children: a randomized, double blind, placebo-controlled pilot study J Burn Care Res 2009 Sep-Oct;30(5):859-66.
3. Kahn SA, Beers RJ, Lentz CW. Resuscitation after severe burn injury using high-dose ascorbic acid: a retrospective review J Burn Care Res 2011 Jan-Feb;32(1):110-7.
4. Pakraftar S, Reddy N, Faust N, et al. Evaluation of fluid volume requirements in patients with severe burn injury following high dose ascorbic acid infusion J Burn Care Res 2011;Conference(var.pagings):March.