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ADMINISTRATION
1. Introduction:
The most urgent need is preventing irreversible shock by replacing lost fluids and
electrolytes. Survival of burn victims depends on adequate fluid resuscitation.
Intravenous lines and an indwelling catheter must be in place before implementing fluid
resuscitation. Baseline weight and laboratory test results are obtained as well. These
parameters must be monitored closely in the immediate post-burn (resuscitation) period.
Controversy continues regarding the definition of adequate resuscitation and the optimal
fluid type for resuscitation. Refinement of resuscitation techniques remains an active area
of burn research.
2. Fluid Replacement Therapy:
The total volume and rate of intravenous fluid replacement are gauged by the patients
response.
The adequacy of fluid resuscitation is determined by following urine output totals,
an index of renal perfusion.
Output totals of 30 to 50 mL/hour have been used as goals. Other indicators of
adequate fluid replacement are a systolic blood pressure exceeding
100 mm Hg and/or a pulse rate less than 110/minute.
Additional gauges of fluid requirements and response to fluid resuscitation
include hematocrit and hemoglobin and serum sodium levels.
If the hematocrit and the hemoglobin levels decrease or if the urinary output
exceeds 50 mL/hour, the rate of intravenous fluid administration may be
decreased.
The goal is to maintain serum sodium levels in the normal range during fluid
replacement.
injury occurred is also very important in calculating estimated fluid needs. Formulas must
be adjusted so that initiation of fluid replacement reflects the time of injury. Resuscitation
formulas are approximations only and are individualized to meet the requirements of each
patient.
only in the presence of marked hypotension, not low urine output. Typical fluid rate
changes should involve an increase or decrease in flow rate by no more than 25% to 33%.
The following example illustrates use of the formula in a 70-kg (168-lb) patient with a
50% TBSA burn:
1. Consensus formula: 2 to 4 mL/kg/% TBSA
2. 2 70 50 7,000 mL/24 hours
3. Plan to administer: First 8 hours 3,500 mL, or 437 mL/ hour; next 16 hours 3,500
mL, or 219 mL/hour
The rationale for this replacement method is that by increasing serum osmolality,
fluid will be pulled back into the vascular space from the interstitial space. Reduced
systemic and pulmonary edema has been reported after administering hypertonic
solutions.
Circulation
Obtain IV access anywhere possible
Fluid requirements increase with greater severity of burn (larger % TBSA, increase
depth, inhalation injury, associate injuries - see above)
Fluid requirements decrease with less severe burn (may be less than calculated rate)
Isotonic
Cheap
Easily stored
Resuscitation formulas:
Fluid calculation
Parkland formula:
4 x 100 x 80 = 32,000 ml
Give 1/2 in first 8 hours = 16,000 ml in first 8 hours
Starting rate = 2,000 ml/hour
Adult basal fluid rate = 1500 x body surface area (BSA) (for 24 hrs)
May use
weight %
TBSA burned
3. Glucose (5% in water): 2,000 mL for insensible loss
Day 1: Half to be given in first 8 hours; remaining half over next 16 hours
Day 2: Half of previous days colloids and electrolytes; all of insensible fluid replacement
Maximum of 10,000 mL over 24 hours. Second- and third-degree (partial- and fullthickness) burns exceeding 50% TBSA are calculated on the basis of 50% TBSA.
Brooke Army Formula
1. Colloids: 0.5 mL kg
body weight %
TBSA burned
2. Electrolytes (lactated Ringers solution): 1.5 mL kg
body weight %
TBSA burned
3. Glucose (5% in water): 2,000 mL for insensible loss
Day 1: Half to be given in first 8 hours; remaining half over next 16 hours
Day 2: Half of colloids; half of electrolytes; all of insensible fluid replacement.
Second- and third-degree (partial- and full-thickness) burns exceeding 50% TBSA are
calculated on the basis of 50% TBSA.
Parkland/Baxter Formula
Lactated Ringers solution: 4 mL kg
body weight %
TBSA burned
Day 1: Half to be given in first 8 hours; half to be given over next 16 hours
Day 2: Varies. Colloid is added.
Hypertonic Saline Solution
Concentrated solutions of sodium chloride (NaCl) and lactate with concentration of 250
300 mEq of sodium per liter, administered at a rate sufficient to maintain a desired
volume of urinary output. Do not increase the infusion rate during the first 8 postburn
hours. Serum sodium levels must be monitored closely. Goal: Increase serum sodium
level and osmolality to reduce edema and prevent pulmonary complications.
FLUID ADMINISTRATION:
of 0.5 mmol/kg/% burn and the total volume of fluid required (excluding the replacement
of excessive evaporative losses) has a magnitude of between 2 and 4 ml/kg/% burn. The
actual volume required can be minimized by the inclusion of colloid or by using a
hypertonic salt solution.
Conclusion:
Controversy continues regarding the definition of adequate resuscitation and the
optimal fluid type for resuscitation. Refinement of resuscitation techniques remains an
active area of burn research.
Bibliography:
(i) Sole, (2001), Introduction to Critical Care Nursing, Elsevier saunders
publications: US.
(ii) Black. Joyce. M, Jane Hokanson Hawksetal, (2001), Medical Surgical
Nursing,clinical management for positive outcomes,vol 2,2001,W.B Saunders
company ,Philadelphia
(iii) Smeltzerc.suzanne,Bareg.Brenda,Hinkle l.Janice et. al, (2008) Textbook of
medical surgical nursing, 11th ed,vol11,lippincott Williams & Wilkins, New Delhi
(iv) Medical Surgical Nursing, made Incredibly Easy, 2nd edition, South Asian
Edition,New Delhi,2008
(v) Phipps Wlma J,Long Barbara C, Medical Surgical Nursing, 7th ed,B.I
Publicattions private limited, New Delhi
(vi) Lippincott manual, (2001), Manual of nursing practice, 7th edition, lippincott
Williams and wilkins publication:Philadelphia
(vii) Fernald. L.D & Fernald P.S, (2001), Munns Introduction to Psychology, (5th ed),
New Delhi: AITBS Publishers, Pp: 397-424