To help illustrate the principles of burn resuscitation, we have developed a case presentation based on a recent admission to our unit. This was a 61-year-old male, weighing 85 kilograms with a 50% TBSA flame burn, secondary to propane tank explosion in his trailer. On arrival, he was assessed using an ABLS algorithm. He was intubated, had bilateral breath sounds, palpable radial and DP pulses. Secondary survey was notable for superficial and deep partial thickness burns listed to the areas here. As well as full thickness burns to the bilateral shoulders and upper extremities. There is no evidence of an inhalation injury. After a patient is formally debrided, it's not unusual to have the burn size be quite different than the referring hospital's estimate. Superficial or first-degree burns are not included in the total. The Lombroder is a more accurate estimate than either the rule of nines or the Palmer method. The Lombroder, as depicted here, assigns a percentage of burn size to each part of the body and further divides up the area by the depth of the burn. The areas burned are depicted on the diagram according to the depth. Following debridement of the patient, the TBSA was determined to be 56%. As an injury over 20% would qualify as a major burn, this would necessitate a formal resuscitation. We start with the ABA consensus formula, in which the total fluid volume to be administered over 24 hours is determined by the equation 2 mils per kilogram of LR times body mass in kilograms times TBSA. This total volume is then divided in half. The first half is to be administered over the initial 8 hours of admission and the second half is administered over the ensuing 16 hours. For our patient weighing 85 kilograms with a TBSA of 56%, the total fluid volume over 24 hours to be administered is 9,520 mLs. When we divide this by half, we get 4,760 mLs. So 4,760 mLs will be administered over the first 8 hours and 4,760 divided by 8 equals 595 mLs, which means our starting fluid rate will be 595 mLs per hour. We must emphasize this is only a starting point and will be adjusted many times based on assessment of the patient response. In theory, as 4,760 mLs divided by 16 hours is 297.5 mLs per hour, this patient's fluid rate over the remaining 16 hours in the first 24 hours would be around 298 mLs per hour. One other consideration is the use of colloids. While this is not built into the basic recommended guidelines, at our institution, we administer an additional 5% albumin for burns greater than 30% TBSA. This is a weight-based rate that's determined by the equation 0.5 mLs per hour times the mass in kilograms. So for our 85-kilogram patient, his albumin rate would be about 43 mLs per hour and this would supplement the lactated renew rate. Resuscitation is dynamic and should be driven by the patient's hourly urine output and other hemodynamic parameters. The goal urine output is 0.5 to 1 mLs per kilogram per hour, and at our institution, we use a nurse-driven protocol that's shown here. If the urine output is within this range, the fluid rate should remain the same. If the urine output is less than 0.5 mLs per kilogram per hour, the fluid rate should be increased by one-third. Likewise, if the urine output is greater than a milliliter per kilogram per hour, the fluid rate should be decreased by one-third. For our 85-kilogram patient, his goal urine output is 42.5 to 85 mLs per hour. This table demonstrates the actual fluid resuscitation given over the first 24 hours of this patient. The x-axis marks the time from injury in hours. The left y-axis demonstrates the volume of lactated ringer solution in mLs to be administered per hour. This data is in blue. The right y-axis demonstrates the volume of urine output in mLs recorded per hour. This data is in orange and is superimposed. As we calculated, the starting rate of LR for this patient should be 595 mLs per hour. For the first hour of fluid resuscitation, the urine output was only about 10 mLs. Thus, his fluid rate should be increased by a third. With this increase, the patient's fluid rate in the second hour is 785 mLs per hour. His urine output responds appropriately up to 50 mLs per hour, and so he is left on this rate. At hour three, his fluid rate is kept the same, and his urine output increases to 75 mLs per hour. As his urine output is adequate at hour four, his fluid rate remains the same, and urine output now has increased to 100, which is above the 1 mL per kilogram per hour goal. His fluid rate is consequently lowered by a third to 595 mLs per hour. His urine output also begins to taper down to 80 mLs. As this is within our goal, we will maintain this rate. Urine output at the sixth hour climbs up slightly to 90 at 595 mLs per hour, which is above the goal. Thus, the fluid rate is dropped by one third back to 390 mLs. The urine output falls to more appropriate 60 mLs per hour. The fluid rate is maintained at 390 mLs. Urine output is at 50 mLs. At hour nine, there's a steep drop off of urine output to 20 mLs per hour, while the fluid rate is 390. The fluid rate is increased again by a third, and the urine output responds up to 35 mLs close to the patient's lower end of the goal. Urine output remains steady at 590 mLs per hour and doesn't continue to increase. Thus, the fluid rate is increased again to 785, and the urine output increases to 50. Urine output jumps to 100 mLs per hour at hour 13, and the fluid rate is dropped back down to 590, and urine output comes down as well. Adjustments are made over the ensuing hours to titrate fluid rates to the desired urine output. The patient did well and went on to have several operations to excise and graft his deep burns and was discharged to inpatient rehab. As part of our QI process, we critically examine each resuscitation to assess how it went and identify areas for improvement. In this case, the patient received just over 13 liters of fluid during the first 24 hours. If we calculate this resuscitation plan in reverse, it ended up being just below 3 mLs per kilogram per percent, which is not in excess of what we would have predicted. Similarly, he produced 1.6 liters of urine. This ends up equaling 0.79 mL of urine per kilogram per hour, which is in the range of our target 0.5 to 1, suggesting we appropriately responded to his physiologic parameters. Most importantly, he experienced no complications of over-resuscitation.

burn resuscitation

propane tank explosion

fluid resuscitation

ABA consensus formula

urine output