What is the role of Intravenous Immunoglobulin (IVIG) therapy in the treatment of burn patients, particularly those with severe burns covering more than 20% of the total body surface area?

IVIG Therapy in Burn Patients: Not Recommended

IVIG therapy is not indicated for burn wound healing or routine management of severe thermal burns, regardless of total body surface area involvement. 1

Evidence-Based Recommendation

The most authoritative guideline on severe thermal burn management explicitly states that IVIG is not indicated for burn wound healing after comprehensive expert consensus review. 1 This recommendation supersedes older theoretical considerations about immunoglobulin supplementation in burn patients.

Why IVIG Is Not Recommended

Lack of Supporting Evidence:

• The European Committee for Hyperbaric Medicine (ECHM) and three major international burn societies (American Burn Association, European Burn Association, and International Society for Burn Injuries) provide no recommendations supporting IVIG use for burn wound healing. 1
• The scientific evidence that exists is described as "old, limited, and of very low-level evidence." 1

Distinction from Other Conditions:

• IVIG has documented efficacy in Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN), which involves epidermal detachment but is not a thermal burn injury. 1
• The pathophysiology of thermal burns differs fundamentally from immunologically-mediated skin conditions, making extrapolation inappropriate.

What Actually Works for Severe Burns >20% TBSA

Immediate Priorities (First 24 Hours):

1. Aggressive Fluid Resuscitation - This is the cornerstone intervention that reduces mortality:

   • Use balanced crystalloid solution (Ringer's Lactate preferred) at 2-4 mL/kg/%TBSA over 24 hours (Parkland formula). 2
   • Give half the calculated volume in first 8 hours post-burn. 2
   • Target urine output of 0.5-1 mL/kg/hour. 2
   • Avoid normal saline as it increases hyperchloremic acidosis and acute kidney injury risk. 3

2. Pain Management with Multimodal Analgesia:

   • Titrate intravenous opioids and ketamine based on validated pain scales. 1
   • Ketamine is particularly effective for burn-induced pain and reduces morphine requirements. 1, 4

3. Early Wound Care:

   • Clean wounds with tap water, isotonic saline, or antiseptic solution. 1
   • Apply appropriate dressings, avoiding prolonged silver sulfadiazine on superficial burns as it delays healing. 1, 4
   • Early excision and grafting when appropriate. 5

Specialized Interventions with Evidence:

• Albumin administration after first 6 hours for TBSA >30% to maintain serum albumin >30 g/L. 2
• Nutritional support with early enteral feeding to decrease hypermetabolic response. 5
• Infection prevention with topical antimicrobials and appropriate systemic antibiotics only when infection is documented. 6, 5

The One Study Supporting IVIG: Context Matters

A single retrospective study from 2006 showed reduced septic episodes and shorter hospital stays with prophylactic IVIG combined with polymyxin B in severely burned children. 7 However:

• This was retrospective, non-randomized data comparing two different hospitals with different protocols.
• The IVIG was combined with polymyxin B, making it impossible to attribute benefit to IVIG alone.
• No major burn guideline has incorporated this finding into recommendations despite nearly 20 years passing since publication. 1
• The 2020 expert consensus specifically reviewed available evidence and concluded IVIG is not indicated. 1

Critical Pitfalls to Avoid

• Do not delay evidence-based interventions (fluid resuscitation, pain control, wound care) while considering unproven therapies like IVIG. 3, 2
• Do not confuse thermal burns with SJS/TEN, where IVIG has a different (though still controversial) evidence base. 1
• Transfer to specialized burn center is mandatory for burns >10% TBSA in adults or >5% in children—this improves outcomes far more than any adjunctive therapy. 2, 4
• Avoid "fluid creep" (excessive resuscitation) which causes compartment syndrome and respiratory complications. 2

Bottom Line for Clinical Practice

Focus resources and attention on proven interventions: aggressive fluid resuscitation with balanced crystalloids, adequate pain control with ketamine and opioids, early wound excision and closure, nutritional support, and infection prevention. 1, 2, 5 IVIG adds cost and potential complications (volume overload, allergic reactions, renal dysfunction) without demonstrated benefit in thermal burn injuries. 1