in the previous issue of critical care , williams and colleagues   provide an overview of the predominant causes of death in burned pediatric patients in order to develop new treatment avenues and future trajectories . over the past decades there has been a significant decrease in mortality and morbidity in severe burns due to improved burn wound management and approaches in critical care [ 2 - 4 ] . many advances have been made , not only concerning the pathophysiology of burns   but also concerning burn management . survival from severe burns is no longer the exception , but unfortunately death still occurs . owing to the fact that the burn injury is multifaceted , the advances cross many injury processes . these issues range from the management of the catabolic state   to modern wound care . one important aspect is that burn treatment has become more proactive , by searching out new technologies to solve old problems . now the treatment approach is altering its focus on manipulating the course of a burn and its final outcome . the survival rate is still of course the most important issue , but not the only issue . the question of whether and to what degree the patient is able to enjoy a normal quality of life becomes more and more essential in how the outcome of the burn treatment is evaluated . restoring function and esthetics are crucial in the difficult process of social reintegration and the return to a normal life . great efforts were made in the past to develop epidermal and dermal replacements to overcome the problem of poor skin quality and scar contraction . in large and deep burns , the approach has changed to rapid excision   and lesion - specific coverage of the burn wound , eliminating the burn as a source of complications . rapid and effective wound coverage and closure are of utmost importance , but infection control and the preservation of active and passive motion are also essential for optimal recovery . nonviable burn tissue is well recognized to be the driving force behind wound infection and burn wound sepsis . williams and colleagues , who determined the predominant causes of death of burned children admitted between 1989 and 2009 , found that the dominant cause of death is sepsis ( 47% of all deaths ) . moreover , they found an increase of deaths due to multidrug - resistant organisms from 42% to 86% over the past 20 years . the aggressive use of antimicrobials has significantly improved survival , but has also led to an increased colonization of pathogens that have resistance to current therapies . in general , early removal and excision of the necrotic tissue with a consecutive rapid and effective closure of the burn wound has become the standard in the management of severe burns . research has proven that application of antimicrobial dressings or early excision and grafting is the key to avoid burn wound infection and its extension to systemic infection [ 8 - 10 ] . the timing and extent of surgery may vary , as well as the method of closing , between different burn centers , but the principal concept is almost the same . based on the findings of williams and colleagues , respiratory failure accounted for 29% of all deaths - 83% of these although the methods used for the management of acute respiratory distress syndrome have changed dramatically over the past 20 years , mortality has remained almost the same . moreover , it seems that there is a need for further studies or for a revisit to the manner in which studies are conducted and their results are implemented in the real world . resuscitation is the major component of initial burn care and must be managed to restore and preserve organ function . prevention of inadequate perfusion , due to burn fluid loss , remains the top priority for initial management . advances in fluid management have led to a marked decrease in fatal burn shock and its related complications . the obvious challenge concerning resuscitation is to provide enough fluid to maintain perfusion without causing overload . without effective and rapid intervention , hypovolemia will develop . a delay in fluid resuscitation beyond 2 hours of the burn injury complicates resuscitation and increases mortality . the consequences of excessive resuscitation and fluid overload are as deleterious as those of under - resuscitation : pulmonary edema , myocardial edema , conversion of superficial into deep burns , the need for fasciotomies and abdominal compartment syndrome . a recent approach has led to conversion of a formula - driven process to a more critical care approach using more physiologic endpoints such as urinary output and other measurements , so the trend in burn resuscitation is shifting the focus from fluid formulas to adequate endpoint monitoring , edema control and adjuvant therapies . on some level , a lot of burn deaths may be preventable with better airway management and more precise and adequate volume management . sepsis due to multidrug - resistant organisms , however , will continue to impede efforts to increase survival . we have to develop strategies to fight these organisms that go beyond the surgical and clinical techniques that are already implemented . moreover there will be a need for further studies that are facing the problems concerning respiratory and multiorgan failure .