Is a 20 kg, 4-year-old female burn patient (burns) who has produced 100 mL of urine in the last 2 hours adequately resuscitated?

Assessment of Fluid Resuscitation Status in a Pediatric Burn Patient

The 4-year-old female with 40% partial-thickness burns is over-resuscitated based on her urine output of 100 mL over two hours, which exceeds the target range of 0.5-1 mL/kg/hour for pediatric burn patients.

Urine Output Targets in Pediatric Burn Patients

• The recommended urine output target for children with thermal burns is 0.5-1 mL/kg/hour 1
• For this 20 kg child, the appropriate urine output range would be 10-20 mL/hour or 20-40 mL over two hours 1
• The actual urine output of 100 mL over two hours (50 mL/hour) is 2.5 mL/kg/hour, which is significantly above the target range 1

Risks of Over-Resuscitation in Burn Patients

• Excessive fluid administration (known as "fluid creep") is associated with increased morbidity in burn patients 1
• Over-resuscitation can lead to:
  • Increased length of mechanical ventilation time 1
  • Longer hospital stay 1
  • Pulmonary edema 2
  • Abdominal compartment syndrome 1
  • Need for skin grafts in pediatric patients 1

Fluid Management in Pediatric Burn Patients

• Children differ from adults in having a higher body surface area/weight ratio, requiring careful fluid management 1
• Burned children typically require a higher total fluid intake than adults in the first 48 hours (approximately 6 mL/kg/% TBSA) 1
• For children with burns >10% TBSA, many centers calculate daily basal fluid requirements using Holliday and Segar's 4-2-1 rule plus the modified Parkland formula (3-4 mL/kg/%TBSA) 1
• Reducing total fluid intake in children with 10-20% TBSA burns has been associated with shorter hospital stays and reduced need for skin grafts 1

Adjusting Fluid Resuscitation

• Fluid resuscitation rates should be adjusted based on clinical and hemodynamic parameters, with urine output being the easiest and fastest parameter to monitor 1
• When urine output exceeds target ranges, fluid administration should be reduced to prevent complications of over-resuscitation 1
• A retrospective study in children with TBSA >30% showed that hemodynamic monitoring using transpulmonary thermodilution was associated with less fluid administration and lower morbidity 1

Clinical Approach to This Patient

• The current urine output of 2.5 mL/kg/hour indicates excessive fluid administration that should be reduced 1
• Continue to monitor urine output hourly, targeting 0.5-1 mL/kg/hour (10-20 mL/hour) 1
• Consider additional parameters to guide fluid management, such as heart rate, blood pressure, and capillary refill 3
• Be cautious about reducing fluids too rapidly, as this could lead to inadequate resuscitation 1
• Monitor for signs of fluid overload including respiratory distress, pulmonary edema, or increasing abdominal pressure 1

Common Pitfalls in Burn Fluid Resuscitation

• Relying solely on formula calculations without adjusting for individual patient response 1
• Failing to recognize that both under-resuscitation and over-resuscitation can increase morbidity 1
• Not adjusting fluid rates frequently enough based on clinical parameters 1
• Assuming oliguria always represents kidney injury rather than an appropriate response to volume depletion 4
• Using diuretics to "treat" high urine output without addressing the underlying cause (excessive fluid administration) 3