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FLUID AND ELECTROLYTE THERAPY, CALCULATION OF FLUIDS AND ITS

ADMINISTRATION
1. Introduction:
The most urgent need is preventing irreversible shock by replacing lost fluids and
electrolytes. Survival of burn victims depends on adequate fluid resuscitation.
Intravenous lines and an indwelling catheter must be in place before implementing fluid
resuscitation. Baseline weight and laboratory test results are obtained as well. These
parameters must be monitored closely in the immediate post-burn (resuscitation) period.
Controversy continues regarding the definition of adequate resuscitation and the optimal
fluid type for resuscitation. Refinement of resuscitation techniques remains an active area
of burn research.
2. Fluid Replacement Therapy:
The total volume and rate of intravenous fluid replacement are gauged by the patients
response.
The adequacy of fluid resuscitation is determined by following urine output totals,
an index of renal perfusion.
Output totals of 30 to 50 mL/hour have been used as goals. Other indicators of
adequate fluid replacement are a systolic blood pressure exceeding
100 mm Hg and/or a pulse rate less than 110/minute.
Additional gauges of fluid requirements and response to fluid resuscitation
include hematocrit and hemoglobin and serum sodium levels.
If the hematocrit and the hemoglobin levels decrease or if the urinary output
exceeds 50 mL/hour, the rate of intravenous fluid administration may be
decreased.
The goal is to maintain serum sodium levels in the normal range during fluid
replacement.

Appropriate resuscitation endpoints for burn patients remain controversial.


Research in this area has led to the study of hemodynamic and oxygen transport
resuscitation endpoints.
When these endpoints were used, massive fluid resuscitation volumes were
administered that could have deleterious effects.
Successful resuscitation is associated with increased delivery of oxygen and
consumption of oxygen with declining serum lactate levels.
Attention has been directed recently toward other indicators of adequate
resuscitation: base deficit and serum lactate levels.
Measurement of serum lactate levels does not appear useful in the treatment of
burn patients because of the large amounts of lactate released from burned tissue;
however, metabolism of lactate is unaltered. Elevated levels occur despite
adequate fluid resuscitation.
Factors that are associated with the increased fluid requirements include delayed
resuscitation, scald burn injuries, inhalation injuries, high-voltage electrical
injuries, hyperglycemia, alcohol intoxication, and chronic diuretic therapy.
Second 24-hour post-burn fluid infusion rates incorporate both the maintenance
amount of fluid and any additional fluid needs secondary to evaporative water
loss through the burn wound.
3. Fluid Requirements:
The projected fluid requirements for the first 24 hours are calculated by the
clinician based on the extent of the burn injury.
Some combination of fluid categories may be used: colloids (whole blood, plasma,
and plasma expanders) and crystalloids/electrolytes (physiologic sodium
chloride or lactated Ringers solution).
Adequate fluid resuscitation results in slightly decreased blood volume levels
during the first 24 post-burn hours and restores plasma levels to normal by the end
of 48 hours. Oral resuscitation can be successful in adults with less than 20% TBSA
and children with less than 10% to 15% TBSA.
Formulas have been developed for estimating fluid loss based on the estimated
percentage of burned TBSA and the weight of the patient. Length of time since burn

injury occurred is also very important in calculating estimated fluid needs. Formulas must
be adjusted so that initiation of fluid replacement reflects the time of injury. Resuscitation
formulas are approximations only and are individualized to meet the requirements of each
patient.

As early as 1978, the NIH Consensus Development Conference on Supportive


Therapy in Burn Care established that salt and water are required in burn patients,
but that colloid may or may not be useful during the first 24 to 48 post-burn
hours.
The consensus formula provides for the volume of balanced salt solution to be
administered in the first 24 hours in a range of 2 to 4 mL/kg per percent burn. In
general, 2 mL/kg per percent burn of lactated
Ringers solution may be used initially for adults. This is the most common fluid
replacement formula in use today. As with the other formulas, half of the calculated total
should be given over the first 8 post-burn hours, and the other half should be given over
the next 16 hours. The rate and volume of the infusion must be regulated according to the
patients response by changing thehourly infusion rates. Fluid boluses are recommended

only in the presence of marked hypotension, not low urine output. Typical fluid rate
changes should involve an increase or decrease in flow rate by no more than 25% to 33%.
The following example illustrates use of the formula in a 70-kg (168-lb) patient with a
50% TBSA burn:
1. Consensus formula: 2 to 4 mL/kg/% TBSA
2. 2 70 50 7,000 mL/24 hours
3. Plan to administer: First 8 hours 3,500 mL, or 437 mL/ hour; next 16 hours 3,500
mL, or 219 mL/hour
The rationale for this replacement method is that by increasing serum osmolality,
fluid will be pulled back into the vascular space from the interstitial space. Reduced

systemic and pulmonary edema has been reported after administering hypertonic

solutions.
Circulation
Obtain IV access anywhere possible

Unburned areas preferred

Burned areas acceptable

Central access more reliable if proficient

Cut-downs are last resort

Resuscitation in burn shock (first 24 hours)

Massive capillary leak occurs after major burns

Fluids shift from intravascular space to interstitial space

Fluid requirements increase with greater severity of burn (larger % TBSA, increase
depth, inhalation injury, associate injuries - see above)

Fluid requirements decrease with less severe burn (may be less than calculated rate)

IV fluid rate dependent on physiologic response

Place Foley catheter to monitor urine output

Goal for adults: urine output of 0.5 ml/kg/hour


Goal for children: urine output of 1 ml/kg/hour

If urine output below these levels, increase fluid rate

Preferred fluid: Lactated Ringer's Solution

Isotonic

Cheap

Easily stored

Resuscitation formulas are just a guide for initiating resuscitation

Resuscitation formulas:

Parkland formula most commonly used

IV fluid - Lactated Ringer's Solution

Fluid calculation

4 x weight in kg x %TBSA burn

Give 1/2 of that volume in the first 8 hours

Give other 1/2 in next 16 hours

Example of fluid calculation

100-kg man with 80% TBSA burn

Parkland formula:
4 x 100 x 80 = 32,000 ml
Give 1/2 in first 8 hours = 16,000 ml in first 8 hours
Starting rate = 2,000 ml/hour

Adjust fluid rate to maintain urine output of 50 ml/hr

Albumin may be added toward end of 24 hours if not adequate response

Resuscitation endpoint: maintenance rate

When maintenance rate is reached (approximately 24 hours), change fluids to D50.5NS


with 20 mEq KCl at maintenance level

Maintenance fluid rate = basal requirements + evaporative losses

Basal fluid rate

Adult basal fluid rate = 1500 x body surface area (BSA) (for 24 hrs)

Pediatric basal fluid rate (<20kg) = 2000 x BSA (for 24 hrs)

May use

100 ml/kg for 1st 10 kg

0 ml/kg for 2nd 10 kg

20 ml/kg for remaining kg for 24 hrs

Evaporative fluid loss

Adult: (25 + % TBSA burn) x (BSA) = ml/hr

Pediatric (<20kg): (35 + % TBSA burn) x (BSA) = ml/hr


GUIDELINES AND FORMULAS FOR FLUID REPLACEMENT IN BURN
PATIENTS:
Consensus Formula

Lactated Ringers solution (or other balanced saline solution): 24 mL kg


body weight
%
total body surface area (TBSA) burned. Half to be given in first 8 hours; remaining
half to be given over next 16 hours.
Evans Formula
1. Colloids: 1 mL /kg body weight %
TBSA burned
2. Electrolytes (saline): 1 mL body

weight %
TBSA burned
3. Glucose (5% in water): 2,000 mL for insensible loss
Day 1: Half to be given in first 8 hours; remaining half over next 16 hours
Day 2: Half of previous days colloids and electrolytes; all of insensible fluid replacement
Maximum of 10,000 mL over 24 hours. Second- and third-degree (partial- and fullthickness) burns exceeding 50% TBSA are calculated on the basis of 50% TBSA.
Brooke Army Formula
1. Colloids: 0.5 mL kg
body weight %
TBSA burned
2. Electrolytes (lactated Ringers solution): 1.5 mL kg
body weight %
TBSA burned
3. Glucose (5% in water): 2,000 mL for insensible loss
Day 1: Half to be given in first 8 hours; remaining half over next 16 hours
Day 2: Half of colloids; half of electrolytes; all of insensible fluid replacement.
Second- and third-degree (partial- and full-thickness) burns exceeding 50% TBSA are
calculated on the basis of 50% TBSA.
Parkland/Baxter Formula
Lactated Ringers solution: 4 mL kg
body weight %
TBSA burned
Day 1: Half to be given in first 8 hours; half to be given over next 16 hours
Day 2: Varies. Colloid is added.
Hypertonic Saline Solution
Concentrated solutions of sodium chloride (NaCl) and lactate with concentration of 250
300 mEq of sodium per liter, administered at a rate sufficient to maintain a desired
volume of urinary output. Do not increase the infusion rate during the first 8 postburn
hours. Serum sodium levels must be monitored closely. Goal: Increase serum sodium
level and osmolality to reduce edema and prevent pulmonary complications.
FLUID ADMINISTRATION:

Need for salt and water


First principle: To achieve survival, patients with extensive burns need to be given large
quantities of fluid which must contain sodium salts.
Quantity of fluid required
The central role of hypovolaemia in the pathogenesis of burn shock.
The fluid should consist of equal quantities of colloid and non-colloid electrolyte
solutions; and that two thirds of the total requirement should be given in the first 24
hours. The total volume predicted was 3 ml/kg body weight/percent burn.
The guidelines of regime are: during the first 24 hours no colloid, 4 ml/kg/% burn of
Ringer's lactate - one-half of which is given in the first 8 hours (cf. Evans' formula: 2
ml/kg/% burn for the whole of the first 24 hours). In practice, the infusion rate is slowed
down once a urine flow of more than 50 ml/hour has been achieved.
Second principle: The total volume of salt containing fluid required to satisfy obligatory
burni oedema and make good urine losses is between 2 and 4 ml/kg/% burn, but the
actual volume is to some extent dependent upon the type of salt solution used. Crystalloid
versus colloid
Although the treatment of burn shock is quite possible with 0.9% saline, there is
convincing evidence (Fox 1970) that a balanced salt solution is preferable.
Third principle: Compared with the use of an isotonic salt solution, the use of a similar
fluid containing a suitable colloid is associated with less generalized oedema, a reduced
total fluid volume requirement and a reduced period of plasma volume deficit.
Fourth principle: The quantity of sodium ions required for effective resuscitation has an
order of magnitude of 0.5 mmol/kg/% burn.
Fifth principle: The total water requirement (and hence the average sodium
concentration of the fluid therapy) varies depending upon the treatment of the burn
wound. The quantity of sodium-free water administered should not exceed that required
to prevent marked hypernatraemia.
Sixth principle: Methods of monitoring the effectiveness of resuscitation should be
chosen taking account of the behaviour in the body of the fluid regime in use. The
Resuscitation of a patient with an extensive burn requires the administration, during the
first 48 hours, of fluid containing salt and water. The optimum sodium load is of the order

of 0.5 mmol/kg/% burn and the total volume of fluid required (excluding the replacement
of excessive evaporative losses) has a magnitude of between 2 and 4 ml/kg/% burn. The
actual volume required can be minimized by the inclusion of colloid or by using a
hypertonic salt solution.
Conclusion:
Controversy continues regarding the definition of adequate resuscitation and the
optimal fluid type for resuscitation. Refinement of resuscitation techniques remains an
active area of burn research.
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