Formula

Fluid
in First 24 Hours

Crystalloid in 2^{nd} 24Hours

Colloid in 2^{nd} 24Hours

Brooke (Yowler, 2000)

RL at 1.5 mL/kg per percentage burn, colloid at 0.5 mL/kg
per percentage burn,
 add 2000 mL D5W

50% of first 24hour volume 
add
2000 mL D5W

50% of first 24hour volume

Modified Brooke

RL at 2 mL/kg per percentage burn



Evans (Yowler, 2000)

NS at 1 mL/kg per percentage
burn, 2000 mL D5W*, and colloid at 1 mL/kg per percentage burn

50% of first 24hour volume and add 2000 mL D5W

50% of first 24hour volume

Monafo hypertonic
Demling 
250 mEq/L saline titrated to urine output at 30 mL/h,
dextran 40 in NS at 2 mL/kg/h for 8 hours, RL titrated to urine output at 30
mL/h, and fresh frozen plasma 0.5 mL/h for 18 hours beginning 8 hours post
burn

Onethird NS titrated to urine output


Metro Health
(Cleveland) 
RL solution with 50 mEq sodium bicarbonate per liter at 4
mL/kg per percentage burn

Half NS titrated to urine output

1 U fresh frozen plasma for each liter of half NS used
and add
D5W as needed for
hypoglycemia

Slater (Yowler, 2000)

RL at 2 L/24 h and
add fresh frozen plasma at 75 mL/kg/24
h



Wednesday, April 16, 2014
Burns treatment, resuscitation in burns, formula, managing burn patients…..
Doc, you described the fluid requirement in the first 24 hrs, what
happens in the next 24 hrs? How do we calculate the fluid requirements for
that?
One more question you gave a few formulas for the burn calculation,
could you outline some more?
Surya, N Delhi, India
The formula for fluid resuscitation
help to calculate the fluid requirements for the first 24 hours. It is during
this period that the critical fluid displacements and loss occur. Loss of body
fluids from the burn surface area as well as the leaking of intravascular
fluids into the extracellular spaces account for the fluid loss that occur in
burn patients. However the body regains its capacity to maintain its intravascular
volume by avoiding the leaking of plasma proteins and in fact by the 2^{nd}
24 hours after the burn, the fluids from the extra vascular spaces start
getting reabsorbed. Therefore at this stage it is not necessary to administer a
lot of fluids as we do in the first 24 hours. During the second 24 hours the
fluids are calculated from the normal daily requirements as any surgical
patient and additional fluids are given to maintain the clinical parameters
like the pulse, blood pressure and urine output (half ml/kg/hr in adults and
one ml/kg/hr in children) as outlined in a previous post.
Some formulas advice cutting down the
fluids to be administered in the 2^{nd} 24 hours to half that of the
first 24 hours. This again is a guideline and one must not forget that the
resuscitation process is a continuous process and no sudden changes must be
attempted in fluid administered which must be very gradually reduced depending
on the clinical parameters and patient response unless the patient is in shock
or with volume overload.
The parkland formula has been
described before in detail. Some of the other resuscitation formulas which were
not mentioned in our previous articles are outlined below:
Resuscitation Formulas in burn patients
*D5W is
dextrose 5% with water
(An original initiative in burn care and education from asktheburnsurgeon++)+
Saturday, April 12, 2014
Burns in children……
Fluid
resuscitation in pediatric population
Doc, are burns in small children more
serious than in adults? Also please tell how does the resuscitation of burn
patients differ in adults and in children?
Milnarnake p,
Sri Lanka.
Management of burns in children differs
significantly from that in adults. This is because the fluid loss in burns
depends on the total body surface area that is burnt and the calculation of the
body surface area is different in adults and children. When compared to adults
it has been found that children have larger head and smaller thighs. Thus while
in adults the head is taken as 9 percent in a newborn or infant it is 20
percent TBSA. Similarly the lower limbs account for 18 percent in adults, however
in an infant it accounts for only 13 percent TBSA, since the infant has a
smaller limb size compared to adults in proportion to the head. Again the upper
limbs account for 9 percent each in adults, but in children this is only eight
percent. In adults the front and back of the body or trunk account for 18 percent
but in infants it is 20 percent.
Thus in an infant
Head – 20
Both upper limbs – 8x2=16
Both lower limbs 13x2=26
Back of trunk 1820
Front of trunk – 1820
This all approximates to about 100
percent
To get the most accurate calculation
in children the Lund and Browder chart should be used.
Urine output/hour which is one of the
most important clinical parameter in monitoring burn patients should be 1 ml/hr
in children as compared to adults (0.5 ml/hr). Children who are over 50 kg
should be managed as adults for calculating the fluid requirement. Minor burns
in children (less than 10% usually do not need any fluid resuscitation as the
body can handle this fluid loss. However children with over 10% burns need
fluid resuscitation as compared to adults over 15%. The requirements in
children are higher and most centers add maintenance fluids to their
resuscitation formula.
It is interesting to note that if the
parkland formula as used in adults
i.e. 4x %TBSA x body weight is used in children,
the fluid calculated will be inadequate and therefore a modified parkland
formula is used in children
3 x %TBSA x body wt + daily maintenance
fluid requirements
How do we calculate the daily fluid requirement in a child? Here’s a
simple method:
First 10 kg 100ml/kg
Second 10 kg 50ml/kg
Rest of kgs 20 ml/hr
This is the total maintenance fluid requirement
for 24 hrs and this is divided by 24 or 25 to get the per hour calculation
Imagine a child with 25 kg what is
the maintenance fluid requirement for 24 hrs?
First 10 kg 100ml/kg i.e. 10x100 =1000ml
Second 10 kg 50ml/kg i.e. 10 x50=
500ml
Rest of kgs 20 ml/hr i.e. 5x 20= 100ml
Total =
1600ml for 24 hours
This maintenance fluid should be
added to the burn fluid requirement – say for example this 25 kg child had 25 percent
TBSA burn
i.e. using parkland formula
3x 25x 25
=1875ml add the maintenance 1600 ml
Total= 3475ml in 24 hrs
Divide by 2= 1738 ml in first 8 hrs
or divide this by 8= 217 ml each hr for the first 8 hrs
For the next sixteen hrs the fluid
will be 1738/16 i.e. 108ml per hour for the next sixteen hours.
This is only a calculation done as a
guideline and should not be rigidly adhered to. We at asktheburnsurgeon are comfortable with the modified parkland
formula and the fluid requirements as done above. We also add a small dose of
albumin or fresh frozen plasma from the second eight hours to help build up the
oncotic pressure that is lowered due to loss of plasma proteins.
Urine output in adult burn patients should
be around 0.5ml/kg/hr 1ml/kg/hr
In children this should be around 1ml/kg/hr
Therefore a 25kg child should produce
at least 25 ml urine per hour
While in an adult of 50 kg a urine
output of 2530ml would be just acceptable
The clinical parameters and the urine
output per hour should be kept in mind and the fluid requirement can be
increased or decreased to maintain all the clinical parameters in the normal
range. The monitoring should be done as in adults.
Children are more susceptible to burn
shock and therefore IV access should be rapidly obtained. Rarely an interosseus
live may be needed when these lines cannot be obtained. Glucose levels should
be frequently checked since hepatic glycogen levels are limited in children, and
addition of D5 Ringer lactate solution can help in preventing troublesome
hypoglycemia.
(An original initiative in burn
care and education from asktheburnsurgeon++)
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