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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
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 -
 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
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
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 

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