The aims of fluid resuscitation is to restore circulating volume, preserve vital organs and tissue perfusion. The most widely used formula to estimate fluid resuscitation requirements is the Modified Parkland Formula (38-42). Early management of fluid losses using an accepted fluid resuscitation formula is fundamental to good quality burn care. Mechanisms that control protein and fluid loss from the vascular space are severely compromised following severe burns and the subsequent inflammatory response (4,16,22,32-37).
It is important to assess the adequacy of fluid resuscitation by measuring urine output and other perfusion markers (25). Problems arise when Parkland fluid resuscitation is NOT titrated to urine output and other markers. The weight & %TBSA variables could be inaccurate, subsequently making fluid resuscitation calculations inaccurate, and the patient could be at risk of kidney injury or an increased need for escharotomy or intubation (24).
Acute kidney injury (AKI) is a burn injury complication which can be caused by inadequate fluid resuscitation, and is associated with increased mortality, length of stay, and costs. A recent meta- analysis of AKI in burn injury reported an incidence of AKI in burn patients as 43% (26).
- Establish IV Access, 2 large bore peripheral cannulas
- Commence IV fluids
- Estimate patient’s weight
- Calculate Parklands Formula using %TBSA Assessment & titrate fluids
- Evaluate adequacy of fluid resuscitation & adjust if necessary
- Maintain an accurate Fluid Balance Chart
Establish IV Access, 2 large bore peripheral cannulas
Patients with severe burns require a large amount of IV fluids.
- Insert 2 large bore peripheral cannulas, preferably through non-burnt skin.
- Attempt central or intraosseous access if peripheral access is unavailable or difficult.
- Patients with burns >10 – 19%TBSA should have 1 large-bore IV cannula only.
Commence IV fluids
Begin fluid resuscitation with Normal Saline or Hartmann’s Solution for burns >20%TBSA in adults, and for burns >10%TBSA in children <16 years old. Where appropriate, warm IV fluid administration should be considered to help minimise heat loss.
Estimate patient’s weight
Weight is a variable in all burn fluid resuscitation formulas.
- If the patient is conscious, ask them what is their weight
- Weigh them if able.
- If necessary, estimate the patient’s weight.
Calculate Fluid Resuscitation using %TBSA Assessment & titrate fluids
The Parkland formula for calculating fluid requirements in the first 24 hours for patients following injury:
- Use 4mls/kg if the patient has suspected inhalation injury, electrical injury or other traumatic injuries. Calculate fluid loss from the time of injury. If management has been delayed, titrate fluids
- Also consider fluid already administered by previous clinicians.
Ambulance Victoria (51):
- %TBSA X Weight in kilograms(kg) = mls in the first 2hrs after injury
- Normal Saline is the preferred IV fluid for replacement.
Evaluate adequacy of fluid resuscitation & adjust if necessary
It’s important to assess the accuracy of fluid resuscitation
- Monitor markers of fluid and perfusion status, including urine output, blood pressure, heart rate and adjust fluids accordingly.
- Placement of a Foley catheter and monitor urine output hourly and assess the adequacy of fluid resuscitation.
- Urine output should be maintained at 0.5 – 1.0mL/kg/hr in adult.
Maintain an accurate Fluid Balance Chart
Maintain an accurate Fluid Balance Chart to assist in assessing fluid resuscitation and to inform ongoing management once the patient is transferred.