Weight-based vs body surface area-based fluid resuscitation predictions in pediatric burn patients.

Treatment for pediatric burns includes fluid resuscitation with formulas estimating fluid requirements based on weight and/or body surface area (BSA) with percent total body surface area burn (%TBSA burn). This study evaluates the risk of complications using weight-based resuscitation in children following burn injuries and compares fluid estimates with those that incorporate BSA. A retrospective review was conducted on 110 children admitted to an ABA-verified urban pediatric burn center over 12 years. Patients had ≥ 15% TBSA burn and were resuscitated with the weight-based Parkland formula. BSA-based Galveston and BSA-incorporated Cincinnati formula predictions were calculated. Complications were collected throughout hospital stay. Patients were classified into weight groups based on percentile. This study included 11 underweight, 60 normal weight, 18 overweight, and 21 obese children. Total fluid administered was higher as percentile increased; however, overweight children received more fluid than the obese (p = 0.023). The Galveston formula underpredicted fluid given over the first 24 h post-injury (p = 0.042); the Parkland and Cincinnati formula predictions did not significantly differ from fluids given. Further research is needed to determine the value of weight-based vs BSA-based or incorporated formulas in reducing risk of complications.

Is the Parkland formula still the best method for determining the fluid resuscitation volume in adults for the first 24 hours after injury? - A retrospective analysis of burn patients in Germany.

BACKGROUND: R Rapid fluid resuscitation is a crucial therapy during the treatment of patients with extensive burns. In 1968, the Parkland Formula was introduced for the calculation of the estimated volume of the resuscitation fluid. Since then, different methods for the calculation of fluid resuscitation volume have been developed. We aimed to evaluate if the Parkland formula is still the most effective method for fluid resuscitation volume calculation in burn patients. METHODS: In the period between January 2015 and January 2019, data from 569 patients over 16 years old with burns of more than 20% total body surface area (TBSA) and at least 15% TBSA full thickness burns were entered in the German burn registry. The patients were divided into 5 groups (0, +1, -1, +2, -2) according to the volume of the resuscitation fluid they received. Group 0 patients received the amount of fluid calculated according to the Parkland formula (n = 83). The 4 other groups received reduced (-1, -2) or increased (+1, +2) fluid volumes in comparison to the value obtained by the Parkland formula. RESULTS: Patients in Group 0 presented a significantly lower mortality in the first week (4.5%) compared to groups -2 (16.7%) and group +2 (19.5%) (p = 0.021). Furthermore, the mean number of operations in group +2 (5.81) was higher than in group -2 (3.81). Surviving patients from group +2 presented a longer hospital stay (68.1 days) compared to the other groups. Additionally, the logistic regression analysis showed a higher survival of patients in groups -2 and -1 (regression coefficients -0.11 and -0.086; Odds Ratio 0.896 and 0.918; 95% Confidence Interval (CI) 0,411-1.951 and 0.42-2.004). CONCLUSION: In this retrospective study, register based analysis a restrictive fluid regime was associated with a higher survival compared to the liberal Parkland guided fluid regime.

Fluid volumes infused during burn resuscitation 1980-2015: A quantitative review.

INTRODUCTION: 'Fluid creep' or excessive fluid delivered to burn patients during early resuscitation has been suggested by several studies from individual burn centers. METHODS: We performed a Medline search from 1980 to 2015 in order to identify studies of burn patients predominantly resuscitated with lactated Ringers with infusion adjusted per urinary output. Data was abstracted for 48 publications (3196 patients) that met entry criteria. RESULTS: Higher resuscitation volumes compared to Parkland estimates were reported, but the trend of increasing resuscitation volumes over the last 30 years is not supported by regression of total fluid infused versus year of study. Mean 24h fluid infused for all studies was 5.2±1.1mL/kg per %TBSA. The mean 24h urinary output reported in 30 studies was 1.2±0.5mL/kg per hr. Burns with inhalation injuries (5 studies) received significantly more fluid than non-inhalation injured burn patients (5.0±1.3 versus 3.9±0.9mL/kg per %TBSA). Fluid infused and urinary outputs were similar for adults and pediatric patients. The most striking finding of our analyses was the great ranges of the means and high standard deviations of volumes infused compared to the original Baxter publication that introduced the Parkland formula CONCLUSIONS: These analyses suggest that burn units currently administer volumes larger than Parkland formula with great patient variability. Individual patient hourly data is needed to better understand the record of burn resuscitation and Fluid Creep.

Effectiveness of Parkland formula in the estimation of resuscitation fluid volume in adult thermal burns.

PURPOSE: Acute burn resuscitation in initial 24 h remains a challenge to plastic surgeons. Though various formulae for fluid infusion are available but consensus is still lacking, resulting in under resuscitation or over resuscitation. Parkland formula is widely used but recently its adequacy is questioned in studies. This study was conducted to see how closely the actual volume of fluid given in our center matches with that of calculated volume by Parkland formula. METHODS: All patients admitted with more than 20% flame burn injury and within 8 h of incident were included in this study. Crystalloid solution for infusion was calculated as per Parkland formula; however, it was titrated according to the urine output. Data on fluid infusion were collected from patient's inpatient records and analyzed. RESULTS: The study included a total of 90 patients, about 86.7% (n = 78) of the patients received fluid less than the calculated Parkland formula. Rate of fluid administered over 24 h in our study was 3.149 mL/kg/h. Mean hourly urine output was found to be 0.993 mL/kg/h. The mean difference between fluid administered and fluid calculated by Parkland formula was 3431.825 mL which was significant (p < 0.001). CONCLUSION: The study showed a significant difference in the fluid infused based on urine output and the fluid calculated by Parkland formula. This probably is because fluid infused based on end point of resuscitation was more physiological than fluid calculated based on formulae.

Effectiveness of Parkland formula in the estimation of resuscitation fluid volume in adult thermal burns / 中华创伤杂志(英文版)

PURPOSE@#Acute burn resuscitation in initial 24 h remains a challenge to plastic surgeons. Though various formulae for fluid infusion are available but consensus is still lacking, resulting in under resuscitation or over resuscitation. Parkland formula is widely used but recently its adequacy is questioned in studies. This study was conducted to see how closely the actual volume of fluid given in our center matches with that of calculated volume by Parkland formula.@*METHODS@#All patients admitted with more than 20% flame burn injury and within 8 h of incident were included in this study. Crystalloid solution for infusion was calculated as per Parkland formula; however, it was titrated according to the urine output. Data on fluid infusion were collected from patient's inpatient records and analyzed.@*RESULTS@#The study included a total of 90 patients, about 86.7% (n = 78) of the patients received fluid less than the calculated Parkland formula. Rate of fluid administered over 24 h in our study was 3.149 mL/kg/h. Mean hourly urine output was found to be 0.993 mL/kg/h. The mean difference between fluid administered and fluid calculated by Parkland formula was 3431.825 mL which was significant (p < 0.001).@*CONCLUSION@#The study showed a significant difference in the fluid infused based on urine output and the fluid calculated by Parkland formula. This probably is because fluid infused based on end point of resuscitation was more physiological than fluid calculated based on formulae.

Effects of obesity on burn resuscitation.

The effects of obesity on resuscitation after severe burn are not well understood. Formulas to calculate 24-h resuscitation volumes incorporate body weight, which in obese patients often leads to excessive fluid administration and potential complications such as pulmonary edema, extremity or abdominal compartment syndrome, and longer mechanical ventilation. We evaluated the impact of obesity on 24-h fluid resuscitation after severe burn using a cohort of 145 adults admitted to the burn ICU from January 2014 to March 2017 with >20% total body surface area burns. Patients were divided into four groups based on body mass index: normal weight (index of <25), overweight (25-29.9), obese (30-39.9), and morbidly obese (>40). Median total body surface area burn was 39.4% (interquartile range: 23.5%-49.5%). Patients were 74.5% male and demographics and injury characteristics were similar across groups. Resuscitation volumes exceeded the predicted Parkland formula volume in the normal and overweight groups but were less than predicted in the obese and morbidly obese categories (p<0.001). No difference was found in 24-h urine output between groups (p=0.08). Increasing body mass index was not associated with increased use of renal replacement therapy. Only total body surface area burned, and age were independent predictors of hospital mortality (p<0.001). We conclude that using body weight to calculate resuscitation in obese patients results in a predicted fluid volume that is higher than the volume actually given, which can lead to over-resuscitation if rates are not titrated regularly to address fluid responsiveness.

Resuscitation using less fluid has no negative impact on hydration status in children with moderate sized scalds: a prospective single-centre UK study.

BACKGROUND: After a burn, optimal fluid resuscitation is critical for positive patient outcome. Although national guidelines advocate using resuscitation fluids of 4mL per kg body weight and percent body surface area (%BSA) for paediatric burns of >10% BSA, evidence in adults suggest that such volumes lead to over-resuscitation and related complications. Our aim was to investigate whether children managed with biosynthetic dressings (Biobrane™) and reduced fluid volumes remain well hydrated, as determined by clinical and laboratory parameters. METHODS: At a single UK Burn Centre, children with scalds of 10-19%BSA managed with Biobrane were given 80% maintenance fluids and no formal burn resuscitation (permissive hypovolaemia [PH] group). Urine output (UO), serum sodium, urea, and creatinine were used as 24h markers of hydration and concentrations compared to those in a patient cohort treated within the same centre when traditional resuscitation was used (TR group). RESULTS: Serum sodium concentrations and UO in the PH group were similar to those in the TR group (median sodium: PH=136, TR=136, P=1.00; median UO: PH=1.5, TR=1.8, P=0.25). Urea concentrations were lower and creatinine concentrations higher in the TR group compared to the PH group (median urea: PH=3.2, TR=2.3, P=0.04; median creatinine: PH=21, TR=30, P<0.001). A higher proportion of TR patients than PH patients fell outside the reference ranges for urea (61% vs. 23%; P=0.04) and creatinine (44% vs. 8%; P=0.03). CONCLUSION: Based on markers of hydration, children with moderate-sized scalds managed with Biobrane can be safely managed with less fluid.

Burn resuscitation on the African continent.

A survey of members of the International Society of Burn Injuries (ISBI) and the American Burn Association (ABA) indicated that although there was difference in burn resuscitation protocols, they all fulfilled their functions. This study presents the findings of the same survey replicated in Africa, the only continent not included in the original survey. One hundred and eight responses were received. The mean annual number of admissions per unit was ninety-eight. Fluid resuscitation was usually initiated with total body surface area burns of either more than ten or more than fifteen percent. Twenty-six respondents made use of enteral resuscitation. The preferred resuscitation formula was the Parkland formula, and Ringer's Lactate was the favoured intravenous fluid. Despite satisfaction with the formula, many respondents believed that patients received volumes that differed from that predicted. Urine output was the principle guide to adequate resuscitation, with only twenty-one using the evolving clinical picture and thirty using invasive monitoring methods. Only fifty-one respondents replied to the question relating to the method of adjusting resuscitation. While colloids are not available in many parts of the African continent on account of cost, one might infer than African burn surgeons make better use of enteral resuscitation.

A comparison of two smartphone applications and the validation of smartphone applications as tools for fluid calculation for burns resuscitation.

We conducted a randomised, blinded study to compare the accuracy and perceived usability of two smartphone apps (uBurn(©) and MerseyBurns(©)) and a general purpose electronic calculator for calculating fluid requirements using the Parkland formula. Bespoke software randomly generated simulated clinical data; randomly allocated the sequence of calculation methods; recorded participants' responses and response times; and calculated error magnitude. Participants calculated fluid requirements for nine scenarios (three for each: calculator, uBurn(©), MerseyBurns(©)); then rated ease of use (VAS) and preference (ranking), and made written comments. Data were analysed using ANOVA and qualitative methods. The sample population consisted of 34 volunteers who performed a total of 306 calculations. The three methods showed no significant difference in incidence or magnitude of errors. Mean (SD) response time in seconds for the calculator was 86.7 (50.7), compared to 71.7 (42.9) for uBurn(©) and 69.0 (35.6) for MerseyBurns(©). Both apps were significantly faster than the calculator (p=0.013 and p=0.017 respectively, ANOVA: Tukey's HSD test). All methods showed a learning effect (p<0.001). The participants rated ease of use on a VAS scale with a higher score indicating greater ease of use. The calculator was easiest to use with a mean score (SD) of 12.3 (2.1), followed by MerseyBurns(©) with 11.8 (2.7) and then uBurn(©) with 11.3 (2.7). The differences were not found to be significant at the p=0.05 level after using paired samples t-test and a multiple correction was applied manually. Preference ranking followed a similar trend with mean rankings (SD) of 1.85 (0.17), 1.94 (0.74) and 2.18 (0.90) for the calculator, MerseyBurns(©) and uBurn(©) respectively. Again, none of these differences were significant at the p=0.05 level.