How do I calculate fluid resuscitation using the Parkland (Baxter) formula for adult and pediatric burn patients, including dose, timing, urine output targets, and adjustments for inhalation injury, edema, cardiac or renal disease, and age?

Parkland Formula for Burn Resuscitation

Immediate Initial Bolus

Administer 20 mL/kg of Ringer's Lactate or Hartmann's solution intravenously within the first hour to all burn patients, regardless of burn size, before calculating precise total body surface area (TBSA). 1, 2

Adult Parkland Formula (Burns ≥10% TBSA)

Calculate total 24-hour fluid requirement as: 2–4 mL/kg × body weight (kg) × %TBSA burned. 1

Timing and Administration

• Administer 50% of the calculated volume in the first 8 hours from the time of injury (not from arrival) 1, 2
• Administer the remaining 50% over the next 16 hours 1, 2
• Time zero starts at the moment of burn injury, not hospital arrival 1

Dose Selection Within the Range

• Use 4 mL/kg (upper end) for: 1, 2
  • Full-thickness burns
  • Inhalation injury
  • Electrical burns (deeper tissue damage than surface appearance suggests)
• Use 2 mL/kg (lower end) for superficial partial-thickness burns 1

Pediatric Modified Parkland Formula (Burns ≥10% TBSA)

Calculate total 24-hour fluid requirement as: 3–4 mL/kg × body weight (kg) × %TBSA burned. 2, 3

Key Pediatric Differences

• Children typically require approximately 6 mL/kg/%TBSA over the first 48 hours 1, 3
• Add baseline maintenance fluids (using Holliday-Segar 4-2-1 rule) to the Parkland-derived volume 1
• Use the same timing: 50% in first 8 hours, 50% over next 16 hours 2, 3

Fluid Choice

Use Ringer's Lactate or Hartmann's solution exclusively as the resuscitation crystalloid. 1, 2

• Avoid 0.9% NaCl due to risk of hyperchloremic acidosis and acute kidney injury 2
• Hydroxyethyl starches (HES) are absolutely contraindicated 1, 4

Urine Output Targets

Target urine output of 0.5–1 mL/kg/hour in both adults and children as the primary resuscitation endpoint. 1, 2, 3

• Urine output is the simplest and fastest parameter to monitor 1, 3
• Titrate fluid rates up or down every hour based on urine output, not rigidly following the formula 1

Critical Adjustments and Special Circumstances

Inhalation Injury

• Significantly increases mortality and fluid requirements 1, 2
• Use the upper end of the Parkland range (4 mL/kg) 1

Full-Thickness Burns

• Increase risk of wound conversion and require volumes at the higher end (4 mL/kg/%TBSA) 2, 5
• Studies show full-thickness burns require 47% more fluid than predicted 5

Electrical Burns

• Cause deeper tissue damage than surface examination suggests 1
• Require higher fluid volumes than the surface burn would predict 1

Cardiac or Renal Disease

• Monitor for fluid overload more aggressively using advanced hemodynamic monitoring 1
• Consider earlier albumin supplementation (see below) 1

Age Considerations

• Age does not independently modify the negative effects of deviating from Parkland 6
• Elderly patients still follow the same formula but require closer monitoring for complications 6

Avoiding "Fluid Creep" (Over-Resuscitation)

Over-resuscitation occurs in 76% of burn resuscitations, averaging 6.3 mL/kg/%TBSA, and significantly increases mortality. 1, 7

Complications of Over-Resuscitation

• Compartment syndrome (abdominal, extremity) 1, 2
• Pulmonary edema 1, 2
• Intestinal edema 1, 2
• Acute kidney injury 1

Prevention Strategies

• Titrate fluid rates down aggressively once urine output reaches 0.5 mL/kg/hour 7
• Do not accept urine outputs >1 mL/kg/hour as acceptable; reduce infusion rates 7
• Recent evidence shows over-infusion increases mortality while under-infusion does not significantly affect mortality: "less is better than more" 6
• After adjusting for patient characteristics, only positive deviation from Parkland (over-resuscitation) remains a significant mortality risk factor 6

Colloid Supplementation

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

• Target serum albumin level >30 g/L 1
• Use only in patients exceeding the upper Parkland limit despite adequate urine output 1

TBSA Assessment

Use the Lund-Browder chart (pediatric version for children) as the gold standard for TBSA calculation. 1, 2

• Never use the Rule of Nines, as it overestimates TBSA in 70–94% of cases, leading to fluid over-administration 1
• Reassess TBSA during initial management to prevent both overtriage and undertriage 1

Common Pitfalls to Avoid

• Do not delay the initial 20 mL/kg bolus while calculating precise TBSA 1
• Do not rigidly adhere to formulas; adjust hourly based on urine output and clinical response 1, 8
• Do not continue excessive fluid rates once adequate urine output (0.5–1 mL/kg/hour) is achieved 1, 7
• Do not accept urine outputs >1 mL/kg/hour as normal; this indicates over-resuscitation 7
• Pre-hospital and emergency department fluid administration often provides nearly 40% of the 24-hour Parkland volume before burn center arrival; account for this in ongoing calculations 7
• No fluid resuscitation formula has been rigorously validated or shown superiority over others; they provide only initial estimates 1