The Accuracy of Prehospital Fluid Resuscitation of Burn Patients: A Systematic Review
Round 1
Reviewer 1 Report
This is an interesting analysis of a well studied phenomenon.
Just a few questions:
I am still confused as to the wording of pre-hospital fluids, as many of the patients in the studies reviewed were transferred from hospital EDs to Burn centers. Please adjust the wording to be more consistent. I believe we are talking about all fluid administered prior to transfer to a a burn center. This would include fluid given at outside hospitals as well as in transit to the burn center. It would also be nice to know if there was a different in those that went straight from the scene to the burn center vs those that stopped at a hospital ED and then were transferred to the burn center.
You state that none of the studies reported a side effect or negative outcome related to the over or under-resuscitation, however just looking at the largest study included (Collis et al.) they did not collect outcome data. How many of the studies included in your analysis actually recorded outcome data, and how can those poor outcomes be attributed to initial fluid management.
It would still also like to know if the studies looked at prehospital TBSA in relation to fluid and if so, can't you make a statement as to the reason for improper fluid administration.
Please correct the following sentence in the Data Synthesis paragraph: "The accuracy of resuscitation was considered only based the local protocol where the study was conducted; that is to say, if the local protocol in one study was using the Parkland formula, for example, it will not be used to compare the accuracy of resuscitation in another study where the protocol is different." (it was not used).
Author Response
Comment: I am still confused as to the wording of pre-hospital fluids, as many of the patients in the studies reviewed were transferred from hospital EDs to Burn centers. Please adjust the wording to be more consistent. I believe we are talking about all fluid administered prior to transfer to a burn center. This would include fluid given at outside hospitals as well as in transit to the burn center. It would also be nice to know if there was a different in those that went straight from the scene to the burn center vs those that stopped at a hospital ED and then were transferred to the burn center.
Author response: We are sorry for this confusion and have made it clear that what is meant by “pre-hospital fluids” is those patients who received fluid resuscitation treatment in the prehospital space prior to transfer from hospital EDs to burn centres. This has been made clearer throughout the text.
Unfortunately, all of the patients in the reported studies went from the prehospital fluid resuscitation to EDs before being transferred to burns centres. None of the studies reported a direct transfer of patients from the scene to the burn centre and hence this data is unavailable.
Comment: You state that none of the studies reported a side effect or negative outcome related to the over or under-resuscitation, however just looking at the largest study included (Collis et al.) they did not collect outcome data. How many of the studies included in your analysis actually recorded outcome data, and how can those poor outcomes be attributed to initial fluid management.
Author response: We have now clarified that although none of the studies presented patient outcome data, five of the seven studies stated in their discussion that significant changes in patient outcomes were not observed. Please refer to Section 3.4 for additions.
Comment: It would still also like to know if the studies looked at prehospital TBSA in relation to fluid and if so, can't you make a statement as to the reason for improper fluid administration.
Author response: Yes, we have mow stated the reason for the incorrect fluid resuscitation volumes as inaccuracies in burn size estimation by prehospital staff as compared to burns unit staff. Please see Section 3.4 for explanation.
Comment: Please correct the following sentence in the Data Synthesis paragraph: "The accuracy of resuscitation was considered only based the local protocol where the study was conducted; that is to say, if the local protocol in one study was using the Parkland formula, for example, it will not be used to compare the accuracy of resuscitation in another study where the protocol is different." (it was not used).
Author response: Thank you. We have amended the section and improved the explanation. Please see section 2.4, Lines 294-299.
Reviewer 2 Report
Thank you for the opportunity to review the manuscript for “The Accuracy of Prehospital Fluid Resuscitation of Burn Patients: A Systematic Review”. This paper is well written and has followed the PRIMSA guidelines. The authors have been transparent throughout the document pertaining to processes followed and how decisions were reached. All critical appraisal tools chosen for this study were appropriate and the results are reflective of this appraisal process. The discussion is supported current published evidence. Some additional details can be included into the recommendation. The conclusion is reflective of the evidence presented in this study.
Abstract
The abstract is clear and demonstrates that the PRIMSA guidelines have been followed and appropriate data bases have been searched. I would suggest not abbreviating key words for maximum exposure in future data base searches.
Introduction
The introduction provides evidence to support the need for this study. The aims and rationale are clearly outlined in this section. PICO has been outlined with adds strength to this study. Line 39 remove the comma between reference 3 and 4. Line 33/34/35 requires a reference to support this statement.
Materials and Methods
It would be beneficial to include the BOOLAN phrases to aid clarity. Please add the ages range cut off for precision as pediatric admission age varies from country to country. Line 105 typo please review. Please reference NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies in your reference list and include date of access. This section is transparent to the processes followed. Definitions pertaining to under and over resuscitation have been made clear. Please reference the protocols of the centers you are referring too. Reference required for GRADE tool line 167.
Results
Under results, please reference figure one. All the critical appraisal tools chosen were appropriate. For ease of the reader, I would suggest placing figure two before table two. There is a good combination of text, tables, and figures in this section. Quality of the studies and bias was considered in depth.
Discussion
The discussion explores the rationale for inconsistencies in the findings and offers possible solutions based on existing research. The impact of treatment at a specialist burns centers after arrival should be explored in more depth to reflect those errors would be corrected. The limitations are realistic and reflective of the findings of this study. The recommendations should include a reference as to how the role of courses such as Emergency Management of Severe Burns BBA: The British Burn Association (emsb.org.uk) could assist in this management.
Conclusion:
The conclusion is an accurate summary of the manuscript presented.
Author Response
Comment: The abstract is clear and demonstrates that the PRIMSA guidelines have been followed and appropriate data bases have been searched. I would suggest not abbreviating key words for maximum exposure in future data base searches.
Author response: We have removed some abbreviations from the abstract.
Comment: The introduction provides evidence to support the need for this study. The aims and rationale are clearly outlined in this section. PICO has been outlined with adds strength to this study. Line 39 remove the comma between reference 3 and 4. Line 33/34/35 requires a reference to support this statement.
Author response: Line 39: comma removed between references 3 and 4. Line 33-35, ref added.
Comment: It would be beneficial to include the BOOLEAN phrases to aid clarity. Please add the ages range cut off for precision as pediatric admission age varies from country to country. Line 105 typo please review. Please reference NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies in your reference list and include date of access. This section is transparent to the processes followed. Definitions pertaining to under and over resuscitation have been made clear. Please reference the protocols of the centers you are referring too. Reference required for GRADE tool line 167.
Author response: Boolean operator now included in Section 2.1, Lines 82-87. Type corrected, now Line 308. NIH Quality tool referenced, Line 341, GRADE tool referenced, Line 457. Pediatric and geriatric ages are now included in Section 2.2. These are general and not specific to any country since we did not age restrict.
Comment: Under results, please reference figure one. All the critical appraisal tools chosen were appropriate. For ease of the reader, I would suggest placing figure two before table two. There is a good combination of text, tables, and figures in this section. Quality of the studies and bias was considered in depth.
Author response: Figure 1 referenced, Line 467. Figure 2 has been placed before Table 2.
Comment: The discussion explores the rationale for inconsistencies in the findings and offers possible solutions based on existing research. The impact of treatment at a specialist burns centers after arrival should be explored in more depth to reflect those errors would be corrected. The limitations are realistic and reflective of the findings of this study. The recommendations should include a reference as to how the role of courses such as Emergency Management of Severe Burns BBA: The British Burn Association (emsb.org.uk) could assist in this management.
Author response: The discussion has been improved throughout to account for reasons for the possible discrepancies in fluid resuscitation volumes. We have mentioned perhaps compensation of inaccurate fluid resuscitation by burn centres since none of the patients went on to have any adverse effects of incorrect fluid resuscitation. We also highlight the BBA course as recommended by the reviewer in our recommendations section.
