Burn Resuscitation Fluids (Parkland)

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Red flags

• Half of the 24-hour Parkland volume goes in the FIRST 8 hours, the rest over the following 16 hours — a formula is only the starting estimate; titrate hourly to urine output.
• Fluid creep is real and measured: across 48 studies (1980-2015) the mean first-24-hour volume was 5.2 mL/kg/%TBSA against the 4 mL/kg/%TBSA Parkland estimate — about 30 per cent more, with great variability. Saffle linked fluid creep to abdominal compartment syndrome.
• Titrate to urine output: 0.5 mL/kg/h (adult), 1.0 mL/kg/h (child). Adjust the rate 10 to 20 per cent per hour based on output — never chase a high urine output with more fluid.
• Avoid 0.9 per cent saline as the primary resuscitant: in SMART (15,802 critically ill adults) balanced crystalloids beat saline for the composite of death, new renal replacement therapy, or persistent renal dysfunction (14.3 vs 15.4 per cent).
• Abdominal compartment syndrome from over-resuscitation: Ivy recommended bladder pressure measurement once infusion exceeds 0.25 L/kg (or peak airway pressure passes 40 cmH2O); over 25 mmHg with falling pulmonary compliance signals ACS — decompression may be life-saving.
• Burned children have labile glucose — blood glucose can peak at 10 to 20 mmol/L within 1 to 4 hours of injury and then fall during dextrose-saline infusion. Monitor glucose and titrate children to a urine output of 1.0 mL/kg/h.
• Albumin: in ABRUPT2, lactated Ringer's plus 5 per cent albumin significantly reduced fluid requirements in the first 48 hours with no difference in mortality or acute kidney injury; the ABRUPT observational study started albumin within 12 hours only in patients with the highest crystalloid requirements.