Vitamin C in severe burns

Date First Published:
April 22, 2012
Last Updated:
April 15, 2013
Report by:
Hisham Ghanayem , Specialty Emergency Trainee (Manchester Royal Infirmary, Manchester, UK)
Search checked by:
Katie Cole, Manchester Royal Infirmary, Manchester, UK
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
Search Details:
(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.
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):
Study Title Patient Group Study type (level of evidence) Outcomes Key results Study Weaknesses
Reduction of resuscitation fluid volumes in severely burned patients using ascorbic acid administration: a randomized, prospective study Tanaka H, Matsuda T, Miyagantani Y, 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)
Supplementation of vitamin E, vitamin C, and zinc attenuates oxidative stress in burned children: a randomized, double blind, placebo-controlled pilot study Barbosa E, Faintuch J, hado Moreira EA, 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
Resuscitation after severe burn injury using high-dose ascorbic acid: a retrospective review Kahn SA, Beers RJ, Lentz CW. 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)
Evaluation of fluid volume requirements in patients with severe burn injury following high dose ascorbic acid infusion Pakraftar S, Reddy N, Faust N, 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
Author Commentary:
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
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
  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
  3. Kahn SA, Beers RJ, Lentz CW. . Resuscitation after severe burn injury using high-dose ascorbic acid: a retrospective review
  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