In a 70‑kg adult with 30% total body surface area burns and no cardiac, renal, or hepatic disease, how should fluid resuscitation be initiated and calculated?

Fluid Resuscitation in Burns: Initial Management for 30% TBSA

Immediate Initial Bolus

Administer 20 mL/kg of Ringer's Lactate (1,400 mL for this 70-kg patient) intravenously within the first hour, regardless of precise burn assessment. 1, 2, 3

• This initial bolus addresses early hypovolemic shock and should not be delayed while calculating precise TBSA 2
• Use Ringer's Lactate or Hartmann's solution as first-line crystalloid; avoid normal saline due to increased risk of hyperchloremic metabolic acidosis and acute kidney injury 1, 2, 3

Calculate 24-Hour Fluid Requirements Using Parkland Formula

For this 70-kg adult with 30% TBSA burns, calculate total 24-hour fluid requirement as 2-4 mL/kg × 70 kg × 30% TBSA = 4,200-8,400 mL of Ringer's Lactate. 1, 2

Fluid Distribution Timeline

• First 8 hours (from time of burn injury): Administer half of the calculated 24-hour volume (2,100-4,200 mL) 1, 2, 3
• Next 16 hours: Administer the remaining half (2,100-4,200 mL) 1, 2, 3
• Start with 2 mL/kg/%TBSA (lower end) to reduce overall resuscitation volumes and prevent fluid creep 4
• Use 4 mL/kg/%TBSA (upper end) if full-thickness burns or inhalation injury present 2, 3

Critical Caveat on Timing

The 8-hour and 16-hour periods are calculated from the time of burn injury, not from hospital arrival 1, 2. If the patient arrives 2 hours post-burn, the first half must be delivered over the remaining 6 hours.

Titrate Fluids to Urine Output

Target urine output of 0.5-1 mL/kg/hour (35-70 mL/hour for this 70-kg patient) as the primary resuscitation endpoint. 1, 2, 3

• Urine output is the simplest and fastest parameter for guiding fluid adjustments 2
• Adjust infusion rates hourly based on urine output; do not rigidly adhere to formulas 1, 2
• Monitor arterial lactate concentration as an additional marker of adequate resuscitation 1, 2

Advanced Monitoring Considerations

• If oliguria or hemodynamic instability persists despite adequate fluid rates, consider advanced hemodynamic monitoring with echocardiography, cardiac output monitoring, or central venous pressure 1, 2
• Transpulmonary thermodilution may detect early hypovolemia but is not routinely recommended 4, 5

Consider Albumin Supplementation

For burns ≥30% TBSA, initiate 5% human albumin between 8-12 hours post-burn if crystalloid rates exceed expected targets. 1, 6, 4

• Target serum albumin levels >30 g/L with doses of 1-2 g/kg/day 1
• Albumin reduces total crystalloid volumes, improves input-to-output ratio, and decreases abdominal compartment syndrome from 15.4% to 2.8% 1, 6
• Albumin is particularly beneficial in older patients with larger, deeper burns and higher organ dysfunction scores 6
• When high-quality studies are analyzed, albumin significantly reduces mortality (OR=0.34,95% CI 0.19-0.58, P<0.001) 1

Avoid Fluid Creep

Over-resuscitation occurs in 76% of burn resuscitations, with patients receiving an average of 6.3 mL/kg/%TBSA—well above Parkland targets. 2, 3

• Complications of fluid creep include compartment syndrome, pulmonary edema, intestinal edema, and acute kidney injury 1, 2
• Once adequate urine output is achieved, do not continue excessive fluid rates 2
• Monitor intra-abdominal pressure, especially if albumin is not used 1, 4

Special Considerations

Inhalation Injury

• Inhalation injury increases fluid requirements by approximately 45% (from 3.98 to 5.76 mL/kg/%TBSA) 7
• Assess for circumoral burns, oropharyngeal burns, and carbonaceous sputum 1

Circumferential Burns

• Monitor for compartment syndrome in circumferential third-degree burns 1, 3
• Consider escharotomy within 48 hours if circulatory impairment develops, ideally performed at a burn center 1, 3

Burn Center Transfer

• Contact a burn specialist immediately to determine need for transfer 1, 3
• Burns involving face, hands, feet, genitals, or full-thickness compromise require specialized care 1, 3

Assessment Accuracy

Use the Lund-Browder chart, not the Rule of Nines, for TBSA assessment. 1, 2

• The Rule of Nines overestimates TBSA in 70-94% of cases, leading to fluid over-administration 1, 2
• Reassess TBSA during initial management to prevent overtriage and undertriage 1