What is the initial fluid of choice for adult and pediatric burn patients with varying total body surface area (TBSA) burned?

Initial Fluid for Burn Resuscitation

Ringer's Lactate (or Hartmann's solution) is the fluid of choice for both adult and pediatric burn patients, administered as balanced crystalloid solution. 1, 2

Immediate Initial Bolus

• All burn patients should receive 20 mL/kg of balanced crystalloid solution intravenously within the first hour, regardless of precise burn size assessment 1, 2
• This initial bolus addresses early hypovolemic shock and should not be delayed while calculating precise TBSA 1, 2
• Ringer's Lactate or Hartmann's solution are preferred over 0.9% NaCl because they have electrolyte concentrations closer to plasma and avoid hyperchloremic acidosis and acute kidney injury 1, 2

Ongoing Resuscitation for Adults (≥10% TBSA)

Use the Parkland Formula: 2-4 mL/kg/% TBSA over 24 hours 1, 3

• The 2024 American Burn Association guidelines specifically recommend initiating resuscitation at 2 mL/kg/% TBSA to reduce overall resuscitation fluid volumes 3
• Administer half of the calculated volume in the first 8 hours post-burn (calculated from time of injury, not time of presentation), and the remaining half over the next 16 hours 1, 2
• Use the higher end of the range (4 mL/kg/% TBSA) for full-thickness burns, as these increase risk of wound conversion and may require larger volumes 1, 2

Ongoing Resuscitation for Children (≥10% TBSA)

Use the Modified Parkland Formula: 3-4 mL/kg/% TBSA over 24 hours 1, 2, 4

• Children require higher total fluid intake than adults, with retrospective studies showing approximately 6 mL/kg/% TBSA over the first 48 hours 5, 1, 4
• The higher body surface area/weight ratio in children makes adult formulas inadequate 5, 4
• Use 4 mL/kg/% TBSA for deep partial-thickness or full-thickness burns 1, 4
• Administer half in the first 8 hours and half over the next 16 hours, same timing as adults 2, 4

Titration and Monitoring

Target urine output of 0.5-1 mL/kg/hour is the primary endpoint for adjusting fluid rates 5, 1, 2

• Urine output is the easiest and fastest parameter to monitor and should guide ongoing fluid administration 5, 1
• Adjust infusion rates based on clinical and hemodynamic parameters as soon as possible to avoid both under-resuscitation and "fluid creep" 5, 1
• Additional monitoring may include arterial lactate, echocardiography, or cardiac output monitoring in patients with hemodynamic instability or persistent oliguria 5

Albumin Supplementation

Consider 5% albumin starting at 8-12 hours post-burn in patients with large burns requiring fluid rates above expected targets 1, 6, 3

• The 2024 American Burn Association recommends albumin use, especially in patients with larger burns, to lower resuscitation volumes and improve urine output 3
• Target serum albumin level >30 g/L 1
• Early albumin use (within first 24 hours) is associated with decreased mortality, fewer ventilator days, and less vasopressor use in difficult-to-resuscitate patients 6
• Hydroxyethyl starches (HES) are contraindicated in burn patients 1

Critical Pitfalls to Avoid

Over-resuscitation ("fluid creep") occurs in 76% of resuscitations, averaging 6.3 mL/kg/% TBSA, and causes significant morbidity 1, 2

• Complications include compartment syndrome, pulmonary edema, intestinal edema, and acute kidney injury 1, 2
• Do not continue excessive fluid rates once adequate urine output is achieved 1
• Inhalation injury significantly increases fluid requirements and mortality 1, 2
• Electrical burns cause deeper tissue damage than surface examination suggests and may require higher fluid volumes 1

Special Considerations

• For burns <10% TBSA in adults or <10% TBSA in children, formal fluid resuscitation formulas are typically not required 2, 7
• The Rule of Tens is best suited for prehospital phase but has only been validated in silico 5, 8
• Use the Lund-Browder chart (not Rule of Nines) for TBSA assessment, as Rule of Nines overestimates TBSA in 70-94% of cases 1, 2