Fresh frozen plasma resuscitation in burns

Overview

Fresh frozen plasma is used in burn resuscitation in three distinct roles: as a colloid volume expander, as a plasma-inclusive adjunct intended to treat the endotheliopathy of burns, and historically as the primary colloid in plasma-based shock formulas. The 2024 American Burn Association Clinical Practice Guideline was unable to make a recommendation on the use of FFP as an adjunct during acute burn shock resuscitation ^[1]. This negative guideline conclusion stands alongside renewed clinical and preclinical interest in early plasma, driven by the modern understanding that burn shock disrupts the endothelial glycocalyx and that plasma is a physiologic fluid that stabilizes the endothelium ^[2][3]. The next open question identified by recent reviews is whether plasma or albumin is the better colloid ^[4], but no adequately powered adult randomized trial comparing the two exists. This page covers physiologic rationale, the small and uneven clinical evidence base, protocols that incorporate plasma, outcome signals, risks including TRALI, and the major gaps that structure current disagreement.

Physiologic Rationale

Three mechanisms motivate plasma use during acute burn resuscitation: volume expansion, restoration of plasma colloid osmotic pressure, and stabilization of the endothelial glycocalyx. Plasma is an effective volume expander that reduces overall volume requirements during burn resuscitation ^[2]. Colloids in general improve intravascular colloid osmotic pressure, expand intravascular volume, reduce resuscitation requirements, and limit edema in unburned tissue following major burn ^[5]. In a rat thermal injury model, plasma infusion maintained plasma colloid osmotic pressure and significantly increased the transcapillary oncotic pressure gradient, while lactated Ringer resuscitation reduced both plasma colloid osmotic pressure and the oncotic gradient, favoring edema formation ^[6].

The endothelial mechanism is the central rationale for contemporary interest. Plasma is a physiologic fluid that stabilizes the endothelium ^[3]. The endotheliopathy of trauma has been described and is mitigated by transfusion strategies with a 1:1 ratio of red blood cells to plasma, and thermal injury also results in endothelial dysfunction, described as the endotheliopathy of burns ^[3]. Plasma may have beneficial effects on the endothelium by diminishing the microvascular leak that follows major burn injury ^[2].

Preclinical evidence supports the endothelial mechanism. In a 40% TBSA rat scald model comparing lactated Ringer alone, lactated Ringer plus fresh frozen plasma, and lactated Ringer plus albumin, addition of FFP to lactated Ringer significantly decreased Evans blue dye extraction in large-burn animals, whereas addition of albumin did not ^[7]. The authors concluded that addition of FFP, not albumin, to post-burn resuscitation diminishes vascular leakage associated with large burns ^[7]. In a subsequent rat model examining timing and dose, early FFP boluses at 0, 2, 4, and 8 hours post-injury reduced Evans blue dye extravasation compared with lactated Ringer alone, while late FFP starting at hour 10 did not ^[8]. Early FFP also reduced syndecan-1 shedding at 8, 12, and 24 hours and dampened the cytokine response to injury, and upregulation of glycocalyx components in lung and spleen was decreased by early FFP ^[8]. A companion rat study found that in unburned skin at 24 hours, animals resuscitated with lactated Ringer plus early FFP had significantly lower Evans blue dye extravasation than animals receiving lactated Ringer alone, early albumin had a smaller effect than early FFP, and late FFP at hour 8 did not ameliorate permeability ^[9].

Clinical Evidence

The burn literature supporting or refuting FFP contains few randomized trials in acute resuscitation, a collection of institutional before-after and prospective cohort studies, a randomized trial of plasma exchange in refractory shock, pediatric trials of transfusion ratios during excision, and recent preclinical comparative work. No adequately powered adult randomized trial has directly compared plasma-inclusive resuscitation to crystalloid-only or to albumin-inclusive resuscitation.

Randomized trials

Du and colleagues randomized 30 extensively burned adults (mean BSA 46%) in three groups of 10 to resuscitation with lactated Ringer, hypertonic saline, or fresh frozen plasma, titrated to urine output ^[10]. Mean urine output was comparable among groups, but the volume of infused resuscitation fluid to maintain urine output was 4.8 mL/kg/%BSA in the LR group, 3.16 in the HPT group, and 2.68 in the FFP group, and the difference between FFP and LR was statistically significant (P < 0.01) ^[10]. Median percentage weight gain at the end of the first day was 10.69% in the LR group, 7.88% in the HPT group, and 2.38% in the FFP group ^[10]. The authors concluded that FFP resuscitation was associated with minimal weight gain and minimal edema ^[10]. Zhao and colleagues randomized 20 burn shock patients with greater than 40% TBSA to Gelofusion or plasma resuscitation and reported that, with the exception of lower plasma viscosity in the Gelofusion group within 24 hours, there were no significant differences between groups, and Gelofusion appeared to be a reasonable plasma substitute during early burn shock ^[11].

Plasma exchange

Warden and colleagues reported that plasma exchange in 22 patients failing conventional resuscitation (mean TBSA 47.9%) produced a therapeutic response in 95.4%, with a sharp decrease in fluid requirements from a mean of 260% above predicted hourly volume to within calculated requirements by 2.3 hours following plasma exchange ^[12]. The authors concluded that plasma exchange facilitates resuscitation from burn shock in a select group of patients who do not respond to conventional volume therapy ^[12]. Kravitz and colleagues subsequently randomized 22 subjects to standard Parkland resuscitation with or without plasma exchange ^[13]. Resuscitation was completed earlier in the plasma exchange group (20.2 versus 30.8 hours; P < 0.05), although the total fluid volume did not differ ^[13].

Pediatric transfusion-ratio trials during excision

Palmieri and colleagues conducted a pilot prospective comparison of 4:1 versus 1:1 packed red blood cell-to-FFP transfusion in children with burns greater than 20% TBSA during massive excision ^[14]. The 1:1 strategy increased FFP use and decreased overall PRBC use, and produced higher postoperative protein C and antithrombin III without a difference in INR or PT/PTT ^[14]. Galganski and colleagues subsequently completed a randomized controlled trial (45 children, 22 in the 1:1 group, 23 in the 4:1 group) comparing the same ratios during pediatric burn excision ^[15]. At 1 hour postoperatively, the 1:1 group had lower prothrombin time and PTT, higher protein C and antithrombin III, and less acidosis, while the 4:1 group was more significantly acidotic ^[15]. The 1:1 strategy decreased postoperative markers of coagulopathy and acidosis without changing total blood product volume ^[15]. Tejiram and colleagues reported a larger pediatric randomized cohort (68 children) comparing 1:1 versus 4:1 PRBC:FFP during excision and found no differences in estimated blood loss, ventilator days, length of stay, bloodstream infection, or pneumonia ^[16]. On multivariate analysis, TBSA burn size, inhalation injury, and PRISM scores were the factors associated with infection ^[16].

Institutional cohorts

Fodor and colleagues described a 15-year single-center experience using a formula combining plasma and crystalloids in 356 patients with major burns and reported 27 deaths, 19 of whom had burns greater than 80% TBSA ^[17]. The authors argued for administering colloids during resuscitation starting in the early period after injury ^[17]. Aharoni and colleagues reported a low-volume plasma regimen for severe burns and derived LA50 values by age group that compared favorably to other series, concluding that low-volume resuscitation consisting mainly of colloids could reduce complications of fluid overload and improve LA50 ^[18]. A companion analysis of the same institutional cohort reported that the incidence of ARDS was 2.5% overall and 9.4% in 65 patients with burns greater than 50% TBSA, with pneumonia incidences of 4.4% and 12.5%, and the authors concluded that low-volume colloid-based resuscitation acted as prophylaxis against ARDS and pneumonia ^[19].

Kahn and colleagues reported a retrospective comparative analysis of a restrictive resuscitation protocol (2 mL/kg/%TBSA starting rate with adjusted body-weight indexing, early FFP at admission for burns greater than 30% TBSA, and rescue FFP for oliguria) versus legacy Parkland (4 mL/kg) and an intermediate 3 mL/kg ABWI protocol ^[20]. Patients resuscitated at 2 mL/kg plus FFP received significantly less fluid than the 3 and 4 mL groups (1.7 vs 3.3 vs 4.15 mL/kg/%TBSA; P < 0.05 and P < 0.0001) ^[20]. Mortality, mechanical ventilation, tracheostomy, and hemodialysis were significantly less in the 2 mL/kg plus FFP group (P < 0.05), and acute kidney injury was minimal despite fluid restriction ^[20].

Plasma-inclusive resuscitation safety cohorts

Pinto and colleagues evaluated the association between TRALI and plasma-inclusive resuscitation in 88 severely burn-injured patients using updated Canadian Blood Services Consensus definitions, and no patient developed TRALI type I or type II ^[21]. Earlier PIR was associated with higher %TBSA but was not associated with higher observed 24-hour resuscitation volumes per kg/%TBSA compared with later PIR ^[21]. Mathew and colleagues prospectively enrolled 35 burn patients (median TBSA 34%, inhalation injury 28.6%, mortality 28.6%) treated with PIR and found no transfusion reactions or thrombotic events and no differences in thromboelastography or rotational thromboelastometry parameters overall or by TBSA or inhalation injury, concluding that PIR was not associated with prothrombotic or lytic changes relative to baseline ^[22]. Soo Ping Chow and colleagues prospectively compared coagulation, endothelial, fibrinolytic, and inflammatory biomarkers immediately before and after the first unit of FFP in 33 burn patients (median TBSA 34.0%) ^[23]. Eight biomarkers showed small but statistically significant reductions, all of which either remained within or moved closer to expected reference ranges, and the authors concluded that after the initial FFP transfusion there were no clinically significant changes in the preexisting prothrombotic, fibrinolytic, endothelial, or inflammatory biological profile ^[23].

Blood conservation and displacement of plasma

Sheridan and colleagues reviewed FFP and PRBC use in children with burns of 10% or greater TBSA admitted during two 2-to-3-year intervals separated by a decade, during which the authors' unit systematically replaced FFP with 5% albumin as the routine resuscitative colloid and standardized blood conservation techniques ^[24]. Reductions in FFP use were 100%, 95%, and 97% in the small, medium, and large burn-size groups, and reductions in PRBC use were 89%, 63%, and 80%, without sacrifice of clinical outcomes (survival 97% versus 98%; not significant) ^[24]. This study is a key institutional argument for displacing FFP with albumin as the default colloid.

Animal models

Brazeal and colleagues compared ovine fresh frozen plasma, pentastarch, and pentafraction in 21 sheep with 40% third-degree flame burns ^[25]. Cardiac index in the plasma group decreased significantly for the first 8 hours and did not return to baseline for 48 hours, while cardiac index increased in the pentafraction group ^[25]. The authors concluded that pentafraction was as good or superior to pentastarch and plasma for volume resuscitation ^[25]. Guha and colleagues compared lactated Ringer, hetastarch, and hypertonic saline dextran in ovine 40% burn and found that all three restored and maintained baseline oxygen delivery within 1 hour, but hetastarch and hypertonic saline dextran reduced the net fluid volume over 8 hours by 48% and 74% respectively compared with lactated Ringer ^[26]. In Guangxi Bama miniature swine with 40% TBSA burns, Shi and colleagues compared succinylated gelatin, hydroxyethyl starch 130/0.4, and allogeneic plasma and reported that allogeneic plasma was better than artificial colloid for preserving oxygen metabolism during burn shock ^[27]. Su and colleagues in the same swine model reported that fluid resuscitation with electrolytes plus colloids, including allogeneic plasma, was better than lactated Ringer alone for preserving renal function ^[28]. Chen and colleagues using a related swine model reported that during burn shock, hemorheological parameters with artificial colloids were more stable than those with Parkland lactated-Ringer-only resuscitation ^[29].

Protocols Incorporating FFP

Plasma has a long history in burn resuscitation formulas. In the past century, as therapies for thermal injuries were being developed, plasma was the fluid used for burn resuscitation, and plasma was used in World War II and throughout the 1950s and 1960s ^[3]. Plasma was abandoned because of infectious risks and complications ^[3]. Human plasma was a fundamental component of numerous burn resuscitation formulas historically but largely fell out of favor due to concerns surrounding transmission of infectious viruses ^[2]. The original Parkland formula required a 24-hour volume of 4 mL/kg/%TBSA lactated Ringer followed by an infusion of 0.3 to 0.5 mL/kg/%TBSA plasma, although modern iterations of the formula have omitted the colloid bolus ^[30].

Contemporary plasma-inclusive protocols are institutional. The Kahn protocol uses 2 mL/kg/%TBSA starting crystalloid with adjusted body-weight indexing, 1 to 2 units of FFP at admission for patients with greater than 30% TBSA, titration at 10% to 20% per hour based on urine output, and 1 to 2 units of rescue FFP if oliguric for 2 hours ^[20]. Fodor's formula combines plasma and crystalloid from the start of resuscitation ^[17]. Aharoni's low-volume plasma regimen uses plasma as the predominant fluid with a small crystalloid component ^[18].

Outcomes

The clearest outcome signal associated with FFP-inclusive resuscitation is reduction in total resuscitation volume. In the Du randomized trial, the volume of infused resuscitation fluid required to maintain urine output was 4.8 mL/kg/%BSA in the lactated Ringer group versus 2.68 in the FFP group, and first-day weight gain was 10.69% in the lactated Ringer group versus 2.38% in the FFP group ^[10]. In the Kahn cohort, 2 mL/kg plus FFP received 1.7 mL/kg/%TBSA of fluid compared with 4.15 mL/kg/%TBSA in the 4 mL Parkland group, with concurrent reductions in mechanical ventilation, tracheostomy, dialysis, and mortality ^[20]. Warden's plasma exchange cohort normalized fluid requirements within 2.3 hours ^[12]. Brazeal's ovine model and Guha's ovine model demonstrate volume reductions with colloid-inclusive resuscitation relative to crystalloid alone ^[25][26].

Coagulation and endothelial outcomes have been examined in recent work. In pediatric excision, 1:1 PRBC:FFP decreased postoperative markers of coagulopathy and acidosis without changing total transfusion volume ^[15]. Adult PIR cohorts showed no prothrombotic or lytic changes relative to baseline ^[22] and no clinically significant changes in prothrombotic, fibrinolytic, endothelial, or inflammatory biomarkers after the initial FFP unit ^[23]. Preclinical studies show reduced vascular leak in the setting of early FFP ^[7][8][9].

Mortality and pulmonary outcome signals are harder to interpret because of study design. The low-volume plasma cohorts reported LA50 values comparable to other series ^[18] and pneumonia and ARDS incidences below population expectations ^[19]. The Kahn cohort reported mortality reduction in the 2 mL/kg plus FFP group ^[20]. None of these are randomized comparisons against equivalent crystalloid-only or albumin-inclusive resuscitation.

Special Considerations

Pediatric data on FFP are concentrated in massive intraoperative excision rather than acute shock resuscitation. Randomized comparisons of 1:1 versus 4:1 PRBC:FFP during pediatric excision show improved coagulation markers and less acidosis with 1:1 but no difference in length of stay, ventilator days, bloodstream infection, or pneumonia ^[15][16]. Historical pediatric institutional practice successfully replaced FFP with 5% albumin as the routine resuscitative colloid without affecting survival ^[24]. The Du adult RCT enrolled patients with mean burn size of 46% TBSA ^[10]. Plasma-inclusive resuscitation has been most actively studied in severely burned adults; Pinto's early-PIR cohort had mean TBSA of 36.3% ^[21], and Mathew's cohort had median TBSA of 34% with concomitant inhalation injury of 28.6% ^[22].

Therapeutic plasma exchange has been used selectively in adults who fail conventional resuscitation ^[12][13]. In Kravitz's randomized trial, plasma exchange shortened time to complete resuscitation but did not reduce total fluid volume ^[13]. The indication is restricted to patients who do not respond to conventional therapy.

Risks and Limitations

TRALI is the complication most often cited against FFP in burn resuscitation. Critics of FFP resuscitation cite the development of TRALI as a deterrent to its use ^[31]. In an early single-center analysis of 83 patients receiving FFP resuscitation, 18 met analytic inclusion and one developed TRALI following a total of 6,228 mL of FFP ^[31]. The authors concluded that the possible occurrence of TRALI should be weighed against the reported benefits ^[31]. Under updated Canadian Blood Services Consensus definitions applied to 88 severely burned patients receiving PIR, no patient developed TRALI type I or type II ^[21]. Coagulation profile changes with PIR have not been clinically significant in recent prospective cohorts ^[22][23].

Other limitations are cost, donor exposure, and product availability. Plasma was abandoned historically because of infectious risks and complications, although modern FFP is much safer from a disease-transmission standpoint, and solvent-detergent-treated and lyophilized plasma formulations offer potentially greater safety and efficacy ^[2]. European survey data show that FFP is the colloid of choice in 12% of units ^[32], and North American ISBI/ABA survey data report FFP use in 13.9% of responding programs, with approximately half of programs adding colloid before 24 hours ^[33]. The dominant position remains crystalloid-only or crystalloid-plus-albumin, reflecting cost, availability, and guideline hesitancy rather than negative comparative evidence ^[32][33].

The 2024 ABA Clinical Practice Guideline was unable to make a recommendation on the use of high-dose vitamin C, fresh frozen plasma, early continuous renal replacement therapy, or vasopressors as adjuncts during acute burn shock resuscitation ^[1]. The 2025 ABA Blood Product Transfusion Guideline makes no recommendation on a 1:1:1 RBC:FFP:platelet transfusion strategy during surgical burn wound excision ^[34]. The Cochrane review of albumin for resuscitation and volume expansion in critically ill patients reported a burn-subgroup relative risk of death with albumin of 2.93 (95% CI 1.28 to 6.72), and the reviewers recommended that albumin be used only within the context of well-concealed and adequately powered randomized trials ^[35]; this review addresses albumin rather than plasma, but its conservative stance on colloid mortality data is part of the guideline context FFP operates within.

Controversies and Evidence Gaps

Whether plasma is superior to albumin as a colloid in acute burn resuscitation is an open question. Preclinical data suggest differential effects on endothelial glycocalyx preservation favoring plasma over albumin ^[7][9], and recent reviews identify the plasma-versus-albumin comparison as the next question in the field ^[4]. No adequately powered adult RCT comparing plasma-inclusive resuscitation to albumin-inclusive resuscitation has been published. Available adult randomized data comparing FFP to crystalloid are limited to small single-center trials ^[10][11]. Contemporary research agendas explicitly call for reexamining plasma as a primary or adjunctive resuscitation fluid and applying information about inflammation and endotheliopathy to target the underlying causes of burn shock ^[36]. Future trials are examining the role of plasma and albumin in burn resuscitation ^[37].

Guideline stance is a second active area of disagreement. The 2024 ABA CPG did not make a recommendation on FFP ^[1]. Fluid creep has renewed interest in colloids during acute burn resuscitation, and contemporary reviews argue that FFP is a useful and effective immediate burn resuscitation fluid whose benefits must be weighed against cost and the risks of viral transmission and acute lung injury ^[5]. Current-thoughts reviews argue that plasma may be a better resuscitation fluid for patients with significant burn wounds because of its capability to restore intravascular volume status and treat the endotheliopathy of burns ^[3].

Heterogeneity of protocols is a third gap. Institutional formulas differ on starting crystalloid rate, plasma-administration trigger (admission versus oliguria rescue), plasma dose, and titration rule, and direct comparisons across protocols are not available ^[17][18][20]. A systematic literature search for the 2024 ABA CPG returned 5,978 titles on burn shock resuscitation of which 24 met criteria for review ^[1]; the comparable search for the 2025 Blood Product CPG returned 1,947 titles, of which 10 met criteria ^[34]. Both guideline committees concluded that the available literature was insufficient for a firm FFP recommendation.

References

[1] Cartotto R, Johnson LS, Savetamal A, et al. "American Burn Association Clinical Practice Guidelines on Burn Shock Resuscitation." J Burn Care Res 2024. PMID: 38051821

[2] Cartotto R, Callum J. "A Review on the Use of Plasma During Acute Burn Resuscitation." J Burn Care Res 2020. PMID: 31734693

[3] Gurney JM, Kozar RA, Cancio LC. "Plasma for burn shock resuscitation: is it time to go back to the future?" Transfusion 2019. PMID: 30980739

[4] Greenhalgh DG. "Current Thoughts on Burn Resuscitation." Adv Surg 2024. PMID: 39089770

[5] Cartotto R, Greenhalgh D. "Colloids in Acute Burn Resuscitation." Crit Care Clin 2016. PMID: 27600123

[6] Onarheim H, Reed RK. "Thermal skin injury: effect of fluid therapy on the transcapillary colloid osmotic gradient." J Surg Res 1991. PMID: 1999916

[7] Vigiola Cruz M, Carney BC, Luker JN, et al. "Plasma Ameliorates Endothelial Dysfunction in Burn Injury." J Surg Res 2019. PMID: 30502286

[8] Kelly EJ, Ziedins EE, Carney BC, et al. "Endothelial dysfunction is dampened by early administration of fresh frozen plasma in a rodent burn shock model." J Trauma Acute Care Surg 2024. PMID: 38764137

[9] Lankipalle N, Kelly EJ, Carney BC, et al. "Endothelial dysfunction in areas of unburned skin in a burn injury model." Burns 2025. PMID: 40834481

[10] Du GB, Slater H, Goldfarb IW. "Influences of different resuscitation regimens on acute early weight gain in extensively burned patients." Burns 1991. PMID: 2054073

[11] Zhao XD, Dang W, He ZJ, et al. "Clinical study of plasma substitute (Gelofusion) on fluid resuscitation in patients with burned shock." Zhongguo Wei Zhong Bing Ji Jiu Yi Xue 2003. PMID: 12837183

[12] Warden GD, Stratta RJ, Saffle JR, et al. "Plasma exchange therapy in patients failing to resuscitate from burn shock." J Trauma 1983. PMID: 6632020

[13] Kravitz M, Warden GD, Sullivan JJ, et al. "A randomized trial of plasma exchange in the treatment of burn shock." J Burn Care Rehabil 1989. PMID: 2921255

[14] Palmieri TL, Greenhalgh DG, Sen S. "Prospective comparison of packed red blood cell-to-fresh frozen plasma transfusion ratio of 4:1 versus 1:1 during acute massive burn excision." J Trauma Acute Care Surg 2013. PMID: 23271080

[15] Galganski LA, Greenhalgh DG, Sen S, et al. "Randomized Comparison of Packed Red Blood Cell-to-Fresh Frozen Plasma Transfusion Ratio of 4:1 vs 1:1 During Acute Massive Burn Excision." J Burn Care Res 2017. PMID: 27893574

[16] Tejiram S, Sen S, Romanowski KS, et al. "Examining 1:1 vs. 4:1 Packed Red Blood Cell to Fresh Frozen Plasma Ratio Transfusion During Pediatric Burn Excision." J Burn Care Res 2020. PMID: 31912141

[17] Fodor L, Fodor A, Ramon Y, et al. "Controversies in fluid resuscitation for burn management: literature review and our experience." Injury 2006. PMID: 16118012

[18] Aharoni A, Abramovici D, Weinberger M, et al. "Burn resuscitation with a low-volume plasma regimen - analysis of mortality." Burns 1989. PMID: 2765143

[19] Aharoni A, Moscona R, Kremerman S, et al. "Pulmonary complications in burn patients resuscitated with a low-volume colloid solution." Burns 1989. PMID: 2590399

[20] Kahn SA, Huff ML, Taylor J, et al. "Challenging Legacy Burn Resuscitation Paradigms with Fluid Restriction and Early Plasma." J Am Coll Surg 2025. PMID: 39902941

[21] Pinto DN, Mehta C, Kelly EJ, et al. "Plasma Inclusive Resuscitation Is Not Associated With Transfusion-Related Acute Lung Injury Under Updated Guidelines." J Surg Res 2024. PMID: 39536699

[22] Mathew SK, Le TD, Pusateri AE, et al. "Plasma Inclusive Resuscitation Is Not Associated With Coagulation Profile Changes in Burn Patients." J Surg Res 2024. PMID: 39378792

[23] Soo Ping Chow AM, Pusateri AE, Le TD, et al. "Characterization of the Endothelial, Coagulofibrinolytic, and Inflammatory Profile in Burn Patients after Resuscitation with Fresh Frozen Plasma." J Burn Care Res 2025. PMID: 40402034

[24] Sheridan RL, Szyfelbein SK. "Trends in blood conservation in burn care." Burns 2001. PMID: 11311521

[25] Brazeal BA, Honeycutt D, Traber LD, et al. "Pentafraction for superior resuscitation of the ovine thermal burn." Crit Care Med 1995. PMID: 7532562

[26] Guha SC, Kinsky MP, Button B, et al. "Burn resuscitation: crystalloid versus colloid versus hypertonic saline hyperoncotic colloid in sheep." Crit Care Med 1996. PMID: 8917036

[27] Shi J, Huang W, Shi X, et al. "Effects of resuscitation with different kinds of colloids on oxygen metabolism in swine during shock stage of burn injury." Zhonghua Shao Shang Za Zhi 2015. PMID: 26564569

[28] Su GL, Huang WX, Chen J, et al. "Effects of different fluid resuscitation program on renal function in swine during shock stage of severe burn." Zhonghua Shao Shang Za Zhi 2016. PMID: 27894390

[29] Chen J, Xing N, Zhou JJ, et al. "Effects of different fluid resuscitation methods on hemorheology in pigs during burn shock stage." Zhonghua Yi Xue Za Zhi 2019. PMID: 31137132

[30] Saffle JI. "The phenomenon of 'fluid creep' in acute burn resuscitation." J Burn Care Res 2007. PMID: 17438489

[31] Jones LM, Deluga N, Bhatti P, et al. "TRALI following fresh frozen plasma resuscitation from burn shock." Burns 2017. PMID: 28029475

[32] Boldt J, Papsdorf M. "Fluid management in burn patients: results from a European survey - more questions than answers." Burns 2008. PMID: 18201828

[33] Greenhalgh DG. "Burn resuscitation: the results of the ISBI/ABA survey." Burns 2010. PMID: 20018451

[34] Wallace D, Lavrentieva A, Romanowski KS, et al. "American Burn Association Clinical Practice Guideline on Blood Product Transfusion in Burn Care." J Burn Care Res 2025. PMID: 40720740

[35] Roberts I, Blackhall K, Alderson P, et al. "Human albumin solution for resuscitation and volume expansion in critically ill patients." Cochrane Database Syst Rev 2011. PMID: 22071799

[36] Burmeister DM, Smith SL, Muthumalaiappan K, et al. "An Assessment of Research Priorities to Dampen the Pendulum Swing of Burn Resuscitation." J Burn Care Res 2021. PMID: 33306095

[37] Palmieri TL. "Transfusion and Infections in the Burn Patient." Surg Infect 2021. PMID: 32559401