Best Fluids for Initial Burn Management
Primary Resuscitation Fluid
Ringer's Lactate (or Hartmann's solution) is the preferred crystalloid for initial burn resuscitation, administered as 20 mL/kg within the first hour, followed by calculated volumes using the Parkland formula (2-4 mL/kg/%TBSA over 24 hours). 1, 2, 3
Why Ringer's Lactate Over Normal Saline
- Ringer's Lactate has electrolyte concentrations closer to plasma and avoids the hyperchloremic metabolic acidosis and increased acute kidney injury risk associated with normal saline (0.9% NaCl). 2, 3
- Normal saline should not be used as the primary resuscitation fluid in burn patients 2
Initial Resuscitation Algorithm
Immediate Administration (First Hour)
- Give 20 mL/kg of Ringer's Lactate IV within the first hour regardless of precise burn size assessment 2, 3
- Do not delay this initial bolus while calculating exact TBSA 3
- This addresses early hypovolemic shock before formal resuscitation calculations 1
Formal Resuscitation (After First Hour)
For adults with burns ≥10% TBSA and children with burns ≥5% TBSA:
- Calculate 24-hour fluid requirements using Parkland formula: 2-4 mL/kg/%TBSA 1, 2, 3
- Administer half of calculated volume in first 8 hours post-burn, remaining half over next 16 hours 1, 2, 3
- Target urine output: 0.5-1 mL/kg/hour 1, 2, 3
Pediatric modifications:
- Children typically require higher volumes (approximately 6 mL/kg/%TBSA over 48 hours) due to higher surface area-to-weight ratio 1, 2, 3
- Modified Parkland formula for children: 3-4 mL/kg/%TBSA for 24 hours 3
Colloid Supplementation: When to Add Albumin
Albumin 5% should be initiated at 8-12 hours post-burn in patients with large burns requiring fluid rates above expected targets, targeting serum albumin levels >30 g/L with doses of 1-2 g/kg/day. 2, 3
Evidence for Albumin Use
- Albumin administration reduces crystalloid volumes, decreases "fluid creep," and may reduce morbidity including organ failure, ARDS, congestive acute kidney injury, and abdominal compartment syndrome 2
- In pediatric burns, early albumin (8-12 hours) reduces crystalloid administration, fluid creep incidence, and hospital length of stay 2
- The FDA indicates albumin for burn therapy beyond 24 hours to maintain plasma colloid osmotic pressure 4
Contraindicated Colloids
- Hydroxyethyl starches (HES) are absolutely contraindicated in burn patients 2, 3
- Gelatins and other synthetic starches should not be used due to negative effects on coagulation and platelet function 2
Special Burn Scenarios Requiring Modified Fluid Management
Electrical Burns
- Require higher fluid volumes (modified Parkland formula: 3-4 mL/kg/%TBSA) due to deeper tissue damage than surface appearance suggests 1
- Target higher urine output (1-2 mL/kg/hour) to prevent myoglobin-induced renal injury from muscle damage 1
- Monitor for myoglobinuria and compartment syndrome 1
Inhalation Injury
- Significantly increases mortality and fluid requirements beyond standard calculations 2, 3
- Look for circumoral burns, oropharyngeal burns, and carbonaceous sputum 2, 5
Full-Thickness Burns
- May require volumes at the higher end of Parkland range and increase risk of wound conversion 3
Critical Monitoring to Avoid "Fluid Creep"
Over-resuscitation occurs in 76% of burn resuscitations, averaging 6.3 mL/kg/%TBSA, and causes significant morbidity including compartment syndrome, pulmonary edema, intestinal edema, and acute kidney injury. 3
Monitoring Parameters
- Urine output is the primary endpoint: target 0.5-1 mL/kg/hour 1, 2, 3
- Do not continue excessive fluid rates once adequate urine output is achieved 3
- Monitor for compartment syndrome in circumferential third-degree burns, which may require escharotomy within 48 hours 1, 2