What are the guidelines for fluid administration in burn patients and during NPO (Nil Per Os) for adult and pediatric age groups?

Fluid Administration in Burn Patients and During NPO

Initial Fluid Resuscitation in Burns

All burn patients—both adults (≥10% TBSA) and children (≥10% TBSA)—should receive 20 mL/kg of balanced crystalloid solution intravenously within the first hour of management, regardless of precise burn size assessment. 1, 2

First-Line Fluid Choice

• Use Ringer's Lactate or Hartmann's solution as the primary resuscitation fluid for both adults and children 1, 2, 3
• Avoid 0.9% normal saline due to increased risk of hyperchloremic metabolic acidosis and acute kidney injury compared to balanced solutions 1, 2, 4
• Balanced crystalloid solutions have electrolyte concentrations closer to plasma, particularly regarding sodium and chloride 1

Vascular Access Strategy

• Establish IV access immediately, preferably in unburned areas 1, 2
• If IV access cannot be rapidly obtained, use intraosseous route 1
• Consider central femoral venous access only as a last resort 1

Formal Fluid Resuscitation Protocols

Adults

For adults with burns ≥10% TBSA, calculate 24-hour fluid requirements using the Parkland Formula: 2-4 mL/kg/% TBSA 1, 4

• Administer half of the calculated 24-hour volume in the first 8 hours post-burn (calculated from time of injury, not time of presentation) 2, 3, 4
• Give the remaining half over the next 16 hours 2, 3, 4
• Target urine output of 0.5-1 mL/kg/hour to guide ongoing fluid administration 2, 4

Pediatric Patients

Children with burns ≥10% TBSA require the Modified Parkland Formula: 3-4 mL/kg/% TBSA for 24 hours 2, 3

• Use the higher end of the range (4 mL/kg/% TBSA) for deep partial-thickness or full-thickness burns 2, 3
• Children require higher total fluid intake than adults due to their higher body surface area-to-weight ratio 3
• Retrospective studies show children typically need approximately 6 mL/kg/% TBSA over the first 48 hours 3
• Target urine output of 0.5-1 mL/kg/hour in children 3, 4
• Administer half in first 8 hours, half over next 16 hours, same as adults 2, 3

Critical Monitoring Parameters

Hemodynamic Endpoints

• Urine output is the easiest and fastest parameter to monitor and should be the primary endpoint 3, 4
• Mean arterial pressure (MAP) serves as a secondary endpoint 5
• Adjust fluid rates based on these clinical parameters rather than rigidly adhering to formulas 1, 5

Avoiding "Fluid Creep"

Over-resuscitation ("fluid creep") causes significant morbidity and must be actively prevented 2, 3, 4

• Studies show 76% of resuscitations exceed the upper Parkland limit, averaging 6.3 mL/kg/% TBSA 2
• Complications of over-resuscitation include compartment syndrome, pulmonary edema, intestinal edema, and acute kidney injury 2, 4
• Monitor for signs of fluid overload and titrate down when urine output targets are consistently met 3, 4

Colloid Supplementation

Albumin Use

Consider albumin 5% supplementation starting at 8-12 hours post-burn in patients with large burns who require fluid rates above expected targets 4, 6

• Albumin reduces total crystalloid volumes administered and improves the input-to-output ratio 4, 6
• Target serum albumin levels >30 g/L with doses of approximately 1-2 g/kg/day 4
• Albumin is typically used in older patients with larger/deeper burns and higher initial Sequential Organ Failure Assessment (SOFA) scores 6
• Hydroxyethyl starches (HES) are contraindicated in burn patients 4

NPO Management in Burn Patients

Maintenance Fluids During NPO

While the provided evidence focuses primarily on acute burn resuscitation rather than routine NPO maintenance:

• Continue IV fluid administration during NPO periods using the calculated resuscitation formula for the first 24-48 hours 1, 3
• After the acute resuscitation phase, transition to standard maintenance fluid calculations while accounting for ongoing evaporative losses from burn wounds 1
• Early enteral nutrition should be initiated as soon as feasible rather than prolonged NPO status 1

Common Pitfalls to Avoid

Assessment Errors

• Do not use the Rule of Nines for TBSA calculation—it overestimates TBSA in 70-94% of cases, leading to fluid over-administration 4
• Use the Lund-Browder chart (with pediatric version for children) as the gold standard for TBSA assessment 2, 4
• Reassess TBSA during initial management to prevent both overtriage and undertriage 4

Resuscitation Errors

• Do not delay initial 20 mL/kg bolus while calculating precise TBSA—early fluid administration within the first hour is critical 1, 2
• Avoid rigid adherence to formulas; they provide starting points only and must be adjusted based on urine output and hemodynamic response 1, 5
• Do not continue excessive fluid rates once adequate urine output is achieved 2, 3
• Full-thickness burns increase risk of wound conversion and may require volumes at the higher end of the Parkland range 2

Special Considerations

• Inhalation injury significantly increases mortality and fluid requirements—assess for circumoral burns, oropharyngeal burns, and carbonaceous sputum 4
• Electrical burns often cause deeper tissue damage than apparent on surface examination and may require higher fluid volumes 4
• Contact a burn specialist early to determine need for transfer to a burn center 2, 4