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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 2nd 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 2nd 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
Formula
Fluid in First 24 Hours
Crystalloid in 2nd  24-Hours
Colloid in 2nd  24-Hours
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 24-hour volume -
add
 2000 mL D5W
50% of first 24-hour 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 24-hour volume and add 2000 mL D5W
50% of first 24-hour 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
One-third 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


*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 -18-20
Front of trunk – 18-20
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 25-30ml 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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