Finally, burned patients have frequent infections with febrile states, which may require additional free water delivery. On the other hand, extensively burned patients frequently experience hypothermia (defined as core temperature below 35°C) on admission, requiring active re-warming. Further surgery under general anesthesia, which inhibits the heatconserving and heat-generating mechanisms, frequently results in hypothermia. Time to recover from hypothermia has been shown to be predictive of outcome in adults, with time to revert to normothermia being longer in non-survivors. Considering that hypothermia favors infections and delays wound healing, the maintenance of peri-operative normothermia is of utmost importance [33]. Tools include warming the ambient room temperature, intravenous fluid warming systems, and warming blankets.

Several centers use fluidized beds for the management of burns to the back, particularly during the 5–7 days following grafting, as it prevents maceration and dries the skin. The temperature of the bed is generally set at 38±0.5°C. However, this is contraindicated in the febrile patient, as it complicates fluid therapy due to largely unpredictable free water losses, and respiratory management due to the supine position. The patient may require additional 1–4 liters of free water per day (as D5W IV or enteral free water) to prevent dehydration. These additional requirements are difficult to assess in absence of bed-integrated weight scales. This further exposes the gut to dehydration with subsequent constipation.

Metabolic modulation

A continued catabolic state results in weight loss, decrease in lean body mass, immunologic compromise, and poor or delayed wound healing with prolonged recovery times. Various efforts have been made to promote anabolism in the thermally injured patient.

Propranolol

The massive catecholamine production associated with thermal injury heavily contributes to the intense catabolic response in major burn patients. The effects are through the intense stimulation of both

alpha and beta receptors with subsequent cardiovascular, thermogenic and metabolic affects. Studies have shown that nonselective -blockers efficiently reduce metabolic rate and protein catabolism, particularly in children and young adults, and to reduce the risk of liver steatosis [43, 68]. The metabolic advantages are observed with a 15–20% reduction of heart rate. The benefits are not as important in adults and elderly patients [4]. The limitations are the usual contraindications to b-blockade: early unstable resuscitation phase, incipient sepsis and asthmatic conditions. Treatment should be initiated as soon as resuscitation is completed (after 3–10 days depending on severity of burns), as it reduces the hypermetabolic response [20]. In adults starting doses are 10 mg 3×/day until achieving a 20% reduction in heart rate.

Oxandrolone

Pharmacologic modulation of anabolism to counteract loss of lean body mass is beneficial in children with major burns [54]. Oxandrolone appears to be a promising anabolic agent although few outcome data are as yet available. A recent multicenter trial of early oxandralone administration in 81 patients seems promising [107]. Its use requires adaptation in case of renal failure and monitoring of liver function. The limited androgenic effects make its use possible in women.

Recombinant human growth hormone

Recombinant human growth hormone (rhGH) therapy has been extensively investigated in GH-deficient children, where rhGH therapy improves nitrogen balance, increases body cell mass, and promotes bone formation [61]. These effects make rhGH a candidate for anabolism stimulation. Supplementation studies in burned pediatric patients have shown a decrease in donor-site healing times and length of hospital stay per %TBSA burns, and attenuation of hyper-metabolism and of inflammation particularly when used in combination with propranolol [55]. While safe in children, the use of rhGH in critically ill adult patients is not warranted, as it doubles mortality, mainly due to multiple organ dysfunction and septic shock [98].