Fluid resuscitation is critical for burn patients to prevent hypovolemic shock and maintain organ perfusion. The document outlines the steps for fluid resuscitation, which include securing IV access, estimating burn size using methods like the Rule of Nine, calculating resuscitation fluid needs using formulas like Parkland, monitoring urine output and other parameters, and adjusting fluid rates based on monitoring. The goal is to support circulation with enough fluid while avoiding complications of under or over-resuscitation.

1. F L U I D
R E S U S C I TAT I O N
I N B U R N
PAT I E N T S
By- Dr. Sanyogita Naik
Head of Department Anaesthesiology
B.J.M.C and Sassoon General Hospital,
Pune.

2. INTRODUCTION
• Burns greater than 20% TBSA are associated with increased
permeability and intravascular volume deficits that are most
severe in the first 24 hours post injury .
• Optimal fluid resuscitation aims to support organ perfusion with
the least amount of fluid .
• Proper fluid management is critical to the survival of patients with
extensive burns.
• Fluid resuscitation of any burn patient should be aimed at
maintaining tissue perfusion and organ function while avoiding the
complications of inadequate or excessive fluid therapy .
• The damaging effect of burn shock may be mitigated or prevented
by physiologically based early management of patients with major
burn injury.

3. HOST RESPONSE TO BURN
INJURY
• Massive tissue injury from burns often elicits a
profound host response , resulting in a number of
physiologic and cellular changes which are as
follows:
• A marked decrease in cardiac output , accompanied
by an increase in peripheral vascular resistance.
• An intravascular hypovolemia ensues which is slow
and progressive.It is characterized by massive fluid
shifts from capillary leak and resultant tissue edema
formation .
• The combined hypovolemic and distributive burn
shock requires sustained replacement to avoid organ
hypoperfusion and cell death.

4. GOALS OF RESUSCITATION
• Prevention of hypovolemic shock
• Maintenance of adequate tissue
perfusion and organ function while
avoiding complication of over
resuscitation and under resuscitation.

5. RESUSCITATION FLUIDS
Colloids :
Albumin , dextran ,
hexastarch
Crystalloids :
NS , RL , D5%
,Hypertonic saline

6. Crystalloids Colloids
Half life of 30-60 minutes Half life of several hours or days
Three times the volume needed for
replacement
Replaces fluid volume for volume
Excessive can cause peripheral and
pulmonary edema
Excessive use can precipitate
cardiac failure
Molecules are small enough to freely
cross capillary walls , so less fluid
remains in the intravascular spaces
Molecules too large to cross
capillary walls,so fluid remains in
intravascular spaces longer
Inexpensive Expensive than crystalloids
Non – allergic Risk of anaphylactic reactions

7. RESUSCITATION
METHODOLGY
B E G I N S W I T H T H E A R R I VA L
O F T H E PAT I E N T

8. STEP 1 : SECURE AN I.V
LINE

9. PERIPHERAL
VENOUS
CATHETER
A peripheral venous
catheter ( PVC ),
peripheral venous line or
peripheral venous access
catheter is a catheter
(small, flexible tube)
placed into a peripheral
vein for venous access to
administer intravenous
therapy such as
medication fluids.

10. PER IPHER ALLY
INSER TED
CENTR AL
CATH ETER
Peripherally inserted central
catheter , less commonly called
a percutaneous indwelling
central catheter, is a form
of intravenous access that can
be used for a prolonged period
of time .
It is a catheter that enters the
body through the skin
(percutaneously) at a peripheral
site, extends to the superior
vena cava (a central venous
trunk), and stays in place (dwells
within the veins) for days or
weeks.

11. C E N T R A L
VE N O U S LI N E
A central venous catheter
(CVC), also known as a
central line, central venous
line,is a catheter placed into a
large vein It is a form of
venous access
These catheters are
commonly placed in veins
in the neck(internal jugular
vein), chest (subclavian
vein or axillary vein)

12. VEN O U S C U T
D O W N
Venous cutdown is an
emergency procedure in
which the vein is exposed
surgically and then
a cannula is inserted into the
vein under direct vision. It is
used to get vascular
access in trauma and hypov
olemic shock patients when
peripheral cannulation is
difficult or impossible.
The saphenous vein is most
commonly used.

13. STEP 2 :NOTE WEIGHT OF
THE PATIENT

14. STEP 3 : ESTIMATION OF
BURN

15. R U L E O F
N I N E
The most common
method used to
estimate the extent
of burns.
The system is
based on anatomic
regions ,each
representing
approxmiately 9%
of the TBSA
(total body surface
area)

16. L U N D A N D
B R O W D ER
M ET H O D
It recognizes the
surface area of
various anatomic
parts, especially the
head and leg as it is
according to the age
of the patient.
It divides the body
into very small area
and provide an
estimate proportion
of TBSA burned.

17. PA L M ER
M ET H O D
In patients with
scattered burns, the
palmer method may be
used to estimate the
extent of burns.
The size of the
patient’s hand,
including the fingers is
approxmiately 1%of
that patient’s TBSA.

18. STEP 4 : CALCULATE
RESUSCITATION FLUID

19. 1.PARKLAND FORMULA
Resuscitation fluid needs : first 24 hours
4 ml R Lx kg body weight x % burn
• First half of volume over first 8 hours , second half following
16 hours
Resuscitation fluid needs : second 24 hours
• Colloid are added
• No crystalloids
• Glucose in water is added in amounts required to maintain a
urinary output of 0.5-1ml /hour in adults and 1ml/hour in
children.

20. FORMULA FIRST 24 HOURS NEXT 24 HOURS
1. EVANS CRYSTALLOIDS : 1ml Crystalloids : 0.5 ml/kg
FORMULA[1952] /kg/% burn /%burn
+ Colloids : 0.5ml/kg/%
Colloids : 1ml /kg/% burn
burn +2000ml of glucose in
+ water
2000ml glucose in
water
2.BROOKE FORMULA RL : 1.5ml /kg/%burn RL : 0.5ml/kg/% burn
Colloids : 0.5 ml /kg Colloids : 0.25 ml/kg/%
/%burn burn
+ +
2000ml glucose in 2000 ml glucose in water
water
3. MODIFIED BROOKE NO COLLOIDS Colloids : 0.3-0.5 ml/kg/%
RL : 2ml / kg /% burn in burn and no crystalloids
adults & .
3ml /kg /% burn in Glucose in water is
children added in the amounts

21. FORMULAS DEVELOPED FOR
CHILDREN
Galveston • Initial 24 hours : RL
5000ml/m2 burn +2000ml /m2
total
[1/2 of total fluid to be given over
8hours and rest in next 16 hours.
Shriner’s
cincinnati
• 4ml RL / Kg / % burn + 1.5 L /
m2 BSA for first 8 hours
• 50m Eq NaHCO3+RL solution
in next 8 hrs
• 5% albumin in LR solution in

22. STEP 5 : START
RESUSCITATION

23. MONITORING OF
RESUSCITAT ION

24. 1. URINARY OUTPUT
• The hourly urinary output obtained by use of an
indwelling bladder catheter is the most readily
available and generally reliable guide to resuscitation
adequacy in patients with normal renal function
Adults : 0.5 ml /kg /hour[or 30-50 ml/hour]
Young children[weighing <30 kg] :1ml /kg/hour
Pediatric [weighing > 30 kg , upto age 17] : 0.5 ml /
kg / hour
Adult patients with high voltage electrical injuries with
evidence of myoglobinuria :75-100 ml / hour until
urine clears.

25. • The expected output should be based on
ideal body weight , not actual pre – burn
weight [I . e the patient who weighs 200 kg
does not need to have urinary output of 100
ml per hour ]
• Fluid infusion rate should be increased or
decreased by up to one – third , if the urinary
output falls below or exceeds the desired
level by more than one –third every hour.

26. A . MANAGEMENT OF
OLIGURIA
• Verify that the catheter is functioning well , Oliguria
can be caused by mechanical obstruction , such as
intermittent urinary catheter kinking or dislodgement
from the bladder .
• Oliguria in association with inadequate fluid
adminsteration. The rate of resuscitation fluid infusion
should be increased to achieve target urine output .
• Older patients with chronic hypertension may become
oligouric if blood pressure falls below their usual range.

27. B . MANAGEMENT OF
MYOGLOBINURIA AND DARK ,
RED TINGED URINE
• Administration of fluids at a rate sufficient to maintain a
urinary output of 1.0-1.5 ml /kg /hour in the adult will
often produce clearing of the heme pigments with
significant rapidity to eliminate the need of diuretic.
• Persistence of dark red tinged urine may indicate
compartment syndrome.
• Administration of a diuretic or the osmotic effect of
glycosuria precludes the subsequent use of hourly
urinary output as a guide to fluid therapy ; other indices
of volume replacement adequacy must be relied upon.

28. 2.BLOOD PRESSURE
• Early hypovolemia and hypotension can be a
manifestation of associated hemorrhage due to
trauma.It is important to recognize and treat
hemorrhage in cases of combined burn /trauma
injuries.
• Blood pressure cuff measurement in can be misleading
in the burned limb where progressive edema is present.
• Intra arterial monitoring of blood pressure may be
unreliable in patients with massive burns because of
peripheral vasoconstriction and hemoconcentration.
• In patient with massive burns ,it is important to place
more emphasis on markers of organ perfusion such as
urine output.

29. 3.HEART RATE
• A rate of 110-120 beats per minute is common
in adult patients who , appear to be adequately
resuscitated.
• A persistent severe tachycardia [>140 beats
per minute]is often a sign of treated pain
,agitation, severe hypovolemia or a
combination of all.
• The levels of tachycardia in pediatric patients
should be assessed on the basis of age related
normal heart rate.

30. 4.HEMATOCRIT AND
HEMOGLOBIN
• In massive burns , hemoglobin and hematocrit levels may
rise as high as 20g/dl and 60% respectively during
resuscitation .This typically corrects ,as intravascular volume
is restored over time ,When these values do not correct, it
suggests that the patient remains under-resuscitated.
• Whole blood or packed red cells should not be used for
resuscitation unless the patient is anemic due to pre-existing
disease or blood loss from associated mechanical trauma at
the time of injury. In that case , transfusion of blood products
should be individualized.

31. 5.SERUM
ELECTROLYTES
• Baseline serum chemistries should be
obtained in patient with serious burns.
• The treatment of hyperkalemia and other
electrolyte abnormalities should be
coordinated with the burn center physicians.

32. S
U
M
M
A
R
Y
• In burns greater than 20%
TBSA, fluid resuscitation
should be initiated using
estimates based on body size
and surface area burned.
• The goal of resuscitation is to
maintain tissue perfusion and
organ function while avoiding
the complications of
inadequate or excessive
therapy.
• Excessive volumes of
resuscitation fluid can
exaggerate edema formation ,
thereby compromising the
local blood supply.

33. • Inadequate fluid resuscitation may lead to
shock and organ failure.
• Promptly initiated , adequate resuscitation
helps to maintain the plasma volume and
prevent dehydration.
THANK YOU.