Care for critically ill patients with severe burns has shifted in recent years from a model centered largely on survival to one that also emphasizes functional recovery and quality of life as key measures of care quality. That change has been driven by the creation of highly specialized units, the development of new therapeutic strategies, and the coordinated efforts of multidisciplinary teams.

This was explained to El Médico Interactivo, part of the Medscape Professional Network by Jacinto Baena, Department of Intensive Care, Trauma ICU, Neurotraumatology and Neurosurgery Research Group and Intensive Care Specialist at the Vall d’Hebron University Hospital in Barcelona, Spain.

Fewer Physical Sequelae

“Our goal should not be solely to reduce mortality. We must aim for the patient to survive with the least possible burden of physical, functional, cognitive, and psychological sequelae resulting from both the injury and the critical illness, as well as their stay in the intensive care unit. Functional recovery and quality of life are now fundamental indicators of excellence in care,” Baena noted.

Spain Has Six Centers, Services, and Units of References (CSURs)

Spain currently has six accredited CSUR for the care of critically ill adult burn patients: the A Coruña University Hospital Complex, Galicia, Spain; La Paz University Hospital and Getafe University Hospital, both in Madrid, Spain; Vall d’Hebron University Hospital in Barcelona, Spain; La Fe University and Polytechnic Hospital in Valencia, Span; and Virgen del Rocío University Hospital in Seville, Spain.

This network is supplemented by four regional units: the Miguel Servet University Hospital in Zaragoza, Spain; the Cruces University Hospital in Barakaldo, Spain; the Río Hortega University Hospital in Valladolid, Spain; and the Virgen de la Arrixaca University Hospital in Murcia, Spain; as well as the Dr. Balmis General University Hospital in Alicante, Spain; and the Málaga Regional University Hospital, Málaga, Spain; which serve as referral centers for their respective healthcare regions.

According to Baena, centralizing the most complex cases in specialized units allows for maintaining a sufficient volume of patient care to develop highly trained teams and improve clinical outcomes. It has been widely demonstrated that concentrating patients improves outcomes, as is the case with other complex processes, such as in trauma centers or transplant programs.

The Intensivist

Burn units bring together professionals from multiple specialties. Intensive care physicians, plastic surgeons, anesthesiologists, rehabilitation specialists, physical therapists, occupational therapists, specialized nursing staff, nursing assistants, psychologists, psychiatrists, microbiologists, infectious disease specialists, pharmacists, and public health specialists all participate in a coordinated manner in the care of these patients.

Baena explained, “Burn units are highly specialized and multidisciplinary facilities, in which the intensive care unit and the intensivist play an essential role in the care of critically ill patients.”

In addition to severe burns, these units treat other critical skin conditions that require highly specialized management, such as Lyell syndrome, graft-vs-host disease, or necrotizing fasciitis when they meet criteria for severity.

Well-Established Referral Criteria

Baena explained that there are international criteria that determine when patients should be transferred to a specialized unit. These include burns affecting more than 15% of the body surface area in patients between the ages of 10 and 60. This percentage drops to 10% for children, the older adults, and pregnant women. It also includes deep injuries located in anatomically complex areas, circular burns, third-degree burns affecting more than 5% of the body surface area, and burns caused by high-voltage electricity, chemical agents, ionizing radiation, or frostbite.

Baena emphasized that coordination with emergency services enables the early identification and referral of these patients. “We have excellent out-of-hospital emergency medical and rescue services. Delays in identification or transport are rare,” he stated.

“Unfortunately, events such as those that occurred in Spain this summer force us to remain acutely aware of this risk. Forest fires are becoming increasingly frequent and dangerous, with greater intensity, more human casualties, and incalculable property damage,” he added.

Advances in Treatment

Regarding therapeutic innovations over the past decade, Baena highlighted the use of Bromelain-based enzymatic debridement, which has significantly changed the treatment of certain deep burns. “It has radically changed the way we work, since we can debride the patient early and sequentially at the bedside without needing an operating room,” he explained.

This treatment selectively removes necrotic tissue, preserves viable tissue, and reduces bleeding compared to conventional surgical debridement. Additionally, it improves anatomical and functional outcomes — especially on the hands and face — and facilitates the simultaneous management of multiple patients during incidents involving multiple victims.

Baena also highlighted other advances shared with other ICUs, such as improved hemodynamic and respiratory monitoring, the widespread adoption of ultrasound, more individualized mechanical ventilation, early rehabilitation, optimization of nutritional support, and the use of extracorporeal membrane oxygenation in selected patients with severe respiratory failure secondary to smoke inhalation syndrome.

Postdischarge Follow-Up

Specific follow-up visits allow for the early identification of physical, cognitive, and psychological sequelae, in addition to facilitating their treatment. The intensivist’s role should not end with discharge from the ICU; follow-up in post-ICU clinics allows for the early detection and treatment of many of the sequelae in critically ill patients.

Baena called for strengthening specialized training for intensivists in the management of patients with severe burns. In his view, increasing subspecialization means that many residents have limited contact with this type of patient, which is why he considers it necessary to enhance collaboration between referral centers and hospitals in their catchment areas.

Along with training, Baena has identified research as a priority for the coming years. In this area, he highlighted the need to promote studies on new resuscitation strategies, control of the inflammatory response and infections, regenerative therapies, precision medicine, and long-term functional outcomes.

Regarding the humanization of burn units, Baena has advocated for greater family involvement during hospitalization whenever clinical conditions permit. “Increasing the presence of family members and gradually involving them in care reduces the emotional impact and improves overall outcomes,” he concluded.

Jacinto Baena has disclosed no relevant financial relationships.

This story was translated from Univadis Spanish, part of the Medscape Professional Network.